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The hybrid strategy allows for a complete myocardial revascularization in patients with multivessel coronary artery disease and a high frailty index. These patients, due to their old age and multi-comorbidities, are evaluated with inadequate tools for their clinical complexity and destined to an incomplete revascularization for increased surgical or procedural risk. Hybrid revascularization enables to use the best techniques resulting from the surgical and percutaneous approach defining a tailored strategy for the patient. In the frail patient, this strategy is associated with favorable outcomes and a lower exposure to periprocedural complications.

Cardiovascular disease and cancer are the leading causes of mortality worldwide. We report our experience in a cancer patient with acute coronary syndrome successfully treated by hybrid revascularization, i.e. off-pump coronary artery bypass grafting, followed by surgical removal of the tumor and percutaneous coronary intervention. The concomitant presence of cancer and acute coronary syndrome is not rare, ranging from 1.9% to 4.2%. Usually, the most life-threatening disease should be treated first, more frequently coronary artery disease. There are several therapeutic approaches to patients with cancer and coronary artery disease and cancer, including percutaneous coronary intervention, surgical treatment of cancer, or coronary artery bypass grafting. Each of these options should consider the severity of cardiac disease, the stage of malignancy and the clinical conditions of the patient.

In recent years, the remarkable progress achieved in terms of survival after myocardial infarction have led to an increased incidence of chronic heart failure in survivors. This phenomenon is due to the still incomplete knowledge we possess about the complex pathophysiological mechanisms that regulate the response of cardiac tissue to ischemic injury. These involve various cell types such as fibroblasts, cells of the immune system, endothelial cells, cardiomyocytes and stem cells, as well as a myriad of mediators belonging to the system of cytokines and not only. In parallel with the latest findings on post-infarct remodeling, new potential therapeutic targets are arising to halt the progression of disease. After the evaluation of the results obtained from gene therapy and stem cells, in this part we evaluate micro-RNA, post-translational modification and microspheres based therapy.

Iron supplementation is essential for the treatment of anemia in the chronic kidney disease (CKD) population. Liposomial iron is a preparation of ferric pyrophosphate carried within a phospholipidic membrane. Compared to other oral formulations, it is well absorbed from the gut and demonstrates high bioavailability together with a lower incidence of side effects. The aim of our study was to evaluate the effectiveness of treatment with liposomial iron compared to intravenous iron in a CKD population with anemia and iron deficiency. Our study is a single-center, prospective, randomized, fourth-phase study. Enrollment for the study began in October 2011 and CKD 3, 4 and 5 patients were randomized to receive either intravenous iron or liposomial iron in a 1:2 ratio. The primary outcome was set as the increase of hemoglobin from baseline. The secondary outcomes were the reduction of erythropoietin dosage by at least 25% in patients treated with erythropoiesis-stimulating agents and an increase in serum ferritin of 100 ng/ml from baseline values. In the preliminary study, 21 patients were analyzed, 14 of whom were treated with oral liposomial iron and 7 with intravenous iron. The observed increase of hemoglobin at 8 weeks compared to baseline was similar in both groups but was significant in the liposomial group only.

Patent foramen ovale (PFO) is a flap-like opening between the primum and secundum atrial septum at the level of the fossa ovalis that may persist after birth. There is increasing evidence that PFO is the culprit in paradoxical embolic events in patients with ischemic stroke. Although medical or percutaneous treatment of PFO remains controversial, nowadays percutaneous treatment is widespread in clinical practice. Transesophageal echocardiography (TEE) is the gold standard in the diagnosis of PFO. This article describes how PFO is detected and how it needs to be properly described by echocardiography. PFO dimensions and the degree of right-to-left shunt should be measured. Moreover, septum primum and septum secundum characteristics, the association with an aneurysm of a fossa ovalis or with other atrial defects should be described as well as the presence of an atrial thrombus, a Chiari network or an Eustachian valve. Such information is of extreme value to predict embolic events and may influence further management.

Retrospective research carried out by 29 General Practitioners in their databases, in order to evaluate the prevalence of gastro-esophageal reflux disease in its different clinical outbreaks and the incidence of new diagnosis in the last quinquennium, the diagnostic approach through instrumental examinations (endoscopy) or empirical tests (PPI test), and the therapeutical aspects, in particular concerning the usage of PPI. The prevalence has been of 3.82%, while the data concerning the incidence have pointed out a progressive increase of the diagnosis in the last quinquennium, specially for the atypical outbreaks. Moreover, it has been noted a likely excessive use of endoscopy, in the follow up as well, while less used is the IPP test. Gastroesophageal reflux disease is the most important item in the expenditure for the usage of IPP.

The progressive loss of cardiomyocytes by different injuries (first of all by ischemia), associated with an insufficient endogenous repair process, is one of the main factors of heart failure development, a real health problem in western countries. In the last decade, cell transplantation in the heart of stem cells with myogenic and angiogenic potential, by intrinsic capability of cellular differentiation and paracrine favorable effects, represents a promising therapy for heart failure, producing a real myocardial regeneration. Early clinical results have been obtained from phase I studies with autologous adult stem cells such as skeletal myoblasts and bone marrow mononuclear cells. The easy cellular availability, the lack of need for immunosuppression and the absent likelihood of tumor formation after cell transplantation are important advantages of these cells, which allow to overcome the apparent ethical dilemma associated with the use of fetal/embryonic cells. Three percutaneous cell delivery methods have been added to the initial surgical transepicardial approach: transendocardial, intracoronary and coronary transvenous injection. The aim of this review was to describe advantages, limitations and techniques about each transcatheter delivery approach to cardiac tissue repair, in the light of current knowledge, investigating possible application fields in different left ventricular dysfunction settings.

Endothelium is not a mere monolayer of cells separating flowing blood and vascular wall, but plays a key role in maintenance of vascular homeostasis. Nitric oxide is the principal mediator of endothelial function; it is a potent vasodilator, it inhibits platelet aggregation, vascular smooth muscle cell migration and proliferation, and monocytes adhesion. Cardiovascular risk factors promote development of endothelial dysfunction, characterized by impairment of endothelium-dependent vasodilation (EDV) and by pro-coagulant/pro-inflammatory endothelial activities. The assessment of EDV is a common parameter for testing endothelial function. EDV in the coronary arteries is angiographically evaluated by measurement of the vessel response to endothelial agonists, such as acetylcholine. A non-invasive technique for the detection of EDV employs the ultrasound evaluation of flow-mediated dilation (FMD) of the brachial artery following reactive hyperemia. A close relation between FMD and coronary vasomotor response to acetylcholine has been demonstrated. Endothelial dysfunction in the coronary circulation may precede development of angiographically evident coronary atherosclerosis; endothelial dysfunction has been also associated with a higher prevalence of coronary artery disease and resulted predictive of future cardiovascular events; recently, it has been associated with a higher risk of restenosis after coronary stent implantation. Endothelial dysfunction is actually considered a reversible phenomenon; drug therapies with ACE-inhibitors, angiotensin receptor blockers, statins, antioxidants agents have shown a beneficial effect on endothelial function.

Myocardial injury during coronary intervention occurs in 10-40% of cases and is often characterized by a slight increase in the markers of myocardial necrosis, without symptoms, electrocardiographic changes or impairment of cardiac function. However, even small increases in creatine kinase (CK)-MB levels are an expression of a true and detectable infarction and may be associated with a higher follow-up mortality. The cause of CK-MB elevation in case of procedural complications is obvious; however, most cases of minor CK-MB elevation occur in patients with uncomplicated procedures with excellent final angiographic results. It has been suggested that the main mechanism explaining the occurrence of myocardial necrosis during otherwise successful coronary intervention may be distal microembolization of plaque components, an enhanced inflammatory state or total plaque burden and/or instability. Different treatments have been proposed to prevent myocardial injury during coronary intervention, including nitrate infusion, intracoronary beta-blockers, adenosine and IIb/IIa inhibitors, but none of these (apart from the use of IIb/IIIa inhibitors) have been routinely introduced into clinical practice. Previous observational studies suggested a beneficial effect of pre-treatment with statins in this setting; the ARMYDA (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) trial is the first prospective, randomized, placebo-controlled study, evaluating the effects of 7-day therapy with 40 mg/day of atorvastatin on post-procedural release of markers of myocardial damage in patients with stable angina undergoing percutaneous intervention. In this study therapy with atorvastatin was associated with an 80% risk reduction in the occurrence of periprocedural myocardial infarction, as well as with a significant reduction in post-intervention peak levels of all markers of myocardial damage. The mechanisms underlying the beneficial effects of atorvastatin may be an inflammatory action reducing myocardial injury necrosis due to microembolization, an improvement in endothelial function on microcirculation, and direct myocardial protection.

Background: Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia and circulatory arrest. Endovascular repair is an attractive, less invasive alternative that may change our therapeutic approach. The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms and to address the new problems in this area., Methods: In the last 5 years, we treated 21 patients for aortic arch pathology with an "off-pump" endovascular repair (18 men, 3 women, mean age 71.4 +/- 7.2 years). We used 26 stent grafts (5 Gore Excluder TAG, 3 Endomed Endofit, 6 Medtronic Talent, 12 Cook Zenith TX1) with a mean of 1.2 graft/patient. Proximal fixation of endograft was achieved by means of aortic "de-branching" in 11 cases. In 10 cases the left subclavian artery was intentionally covered without revascularization. Follow-up included clinical examination, chest X-ray and computed tomography at discharge and at 6-month intervals thereafter., Results: Technical success was 85% (18/21). There was one in-hospital death (4.7%) due to endograft migration. We observed 2 cases of type I endoleak (9.5%). One surgical conversion was performed 2 weeks after the procedure, because of total collapse of the stent graft with rupture of three stents. No complications related to the coverage of the left subclavian artery were observed. At a mean follow-up of 18.7 +/- 12.8 months, no mortality or morbidity including new-onset endoleak, stent-graft migration and thrombosis of supra-aortic grafts were recorded., Conclusions: Endovascular treatment of aortic arch pathology is feasible even in elderly patients. However, accurate placement in the arch and aneurysm sealing with the currently available devices, may be challenging due to the involvement of supra-aortic vessels, the anatomical curvature of the arch, the high blood flow, and substantial movement of the aorta with each heartbeat.

The aim of this study to assess the in vitro behaviour of different pin shapes in response to identical techniques and to compare the results. It is concluded that cylindrical pins give the best mechanical results though the conical pin may be preferable for certain root conformations.