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One of the most common complications of tricuspid valve replacement is atrioventricular block (AVB), often requiring permanent pacing. The endocardial pacemaker lead, placed in the right ventricle, may sometimes interfere with the implanted prosthesis, causing its early dysfunction and the need for alternative sites of pacing. To the best of our knowledge, we present the first case of a successful combined percutaneous procedure consisting of the implantation of two leads in the coronary sinus for univentricular bifocal pacing and a transcatheter tricuspid valve-in-valve implantation in a young patient with severe dysfunction of the tricuspid bioprosthesis, requiring permanent pacing for a postsurgical complete atrioventricular block.

Aim: Micra AV represents a leadless endocardial pacing system able to detect atrial contractions providing atrioventricular synchrony. A reduction of myocardial contractility may be detected in case of first-degree atrioventricular block (AVB). Materials & methods: In six patients with first-degree AVB (PQ interval ≥220 msec) was evaluated the left ventricle global longitudinal strain (LV GLS) by speckle tracking (ST) echocardiography during single-lead atrial sensing ventricular pacing (VDD) stimulation as compared with spontaneous rhythm (SR), 24-48 h after Micra AV implantation. Results: A statistically significant difference between the two modalities was observed (LV GLS during SR: -14.7% [interquartile range (IQR) 5.5], LV GLS during VDD pacing: -16.1% [IQR 5.2]; p value = 0.041). Conclusion: Our preliminary results suggest an improvement of myocardial contractility with VDD pacing as compared with SR.

There is an increasing awareness on the association between mitral valve prolapse (MVP) and sudden cardiac death. Mitral annular disjunction (MAD) is a phenotypic risk feature that can help in risk stratification. We present a case of a 58-year-old woman who experienced an out-of-hospital cardiac arrest caused by ventricular fibrillation interrupted by a direct current shock. No coronary lesions were documented. Echocardiogram showed myxomatous MVP. Nonsustained ventricular tachycardia have been registered during hospital stay. Interestingly, cardiac magnetic resonance revealed MAD and a late gadolinium enhancement area in inferior wall. Finally, a defibrillator has been implanted. For arrhythmic risk stratification of MVP with MAD, multimodality imaging is the diagnostic tool to find out the disease behind many cardiac arrests of unknown cause.

Atrial myxomas are primary cardiac tumors which may cause ischemic stroke. The authors present a case of a 51-year-old man admitted to the emergency department with right-sided hemiplegia and aphasia caused by ischemic stroke. 2D and 3D transesophageal echocardiography showed an atrial myxoma described as a large mass in the left atrium attached to the interatrial septum. In the end, surgical excision of the myxoma was performed 48 h after diagnosis. Nowadays, specific guidelines concerning the correct time for surgical excision of the myxoma are lacking. The authors highlight the utmost role of echocardiography to promptly characterize a cardiac mass and the importance of discuss about the timing of cardiac surgery.

Hypereosinophilic syndrome can lead to acute myocarditis with a potentially severe systolic dysfunction and serious complications. A 75-year-old patient suffering from Hepatitis C virus (HCV) related-hepatitis came to our observation for idiopatic hypereosinophilic syndrome and acute severe cardiac systolic dysfunction without coronaropathy. Cardiac magnetic resonance showed a 'patchy' subendocardial and intramyocardial late gadolinium enhancement pattern often seen in eosinophilic myocarditis (EM). Assuming EM, appropriate corticosteroid therapy was initiated and it led to clinical remission. Despite endomyocardial biopsy (EMB) is the diagnostic gold standard for EM, in this case only a noninvasive integrated imaging approach was successfully attempted. Given an adequate clinical context, in our opinion EM can be correctly recognized without EMB and so promptly and safely treated with corticosteroids, even when an underling mild HCV-hepatitis is present.

Endocarditis of a prosthetic heart valve is a life-threatening condition that is associated with high morbidity and mortality. Perivalvular extension in infective endocarditis includes complications such as periannular or intramyocardial abscesses, pseudoaneurysms and fistulae. The incidence of perivalvular extension ranges from 10 to 30% in native valve endocarditis and 30 to 55% in prosthetic aortic-valve endocarditis. Herein, we describe a case of a 66-year-old man who presented endocarditis of a prosthetic aortic valve complicated by infective pseudoaneurysm with localization next to the right coronary sinus of Valsalva. Moreover, we underscore the importance of the diagnostic imaging tools options and surgical timing.

Aim: The aim of this study was to determine the role of NT-proBNP in predicting the outcome of septic patients and to evaluate possible correlations between NT-ProBNP and haemodynamics in sepsis., Methods: Forty consecutive patients with severe sepsis were prospectively evaluated. Patients were treated with the gold standard therapy for sepsis. NT-BNP levels, endotoxin activity (EA), SOFA score and SAPS II score, cardiac index (CI), mean arterial pressure (MAP) and pulmonary arterial pressure (PAP) were evaluated at admission and after 72 hours. Survival was evaluated at 28 days after admission., Results: At 4-week follow-up, 22 patients had died (55%). Survival was not associated with age, gender, baseline EA and treatment, while it was associated with NT-proBNP levels at admission and after 72 hours. NT-proBNP>1,000 pg/ml at 72 hours was a robust independent predictor of survival. The area under the curve (AUC) of NT-proBNP at admission was 0.73 and 0.99 after 72 hours. At 72 hours, AUC for SOFA score was 0.94, for SAPS II score 1, for EA 0.73. Levels of NT-proBNP>1,000 pg/ml at 72 hours were associated with an adverse outcome (sensitivity 95.5%, specificity 94.4%). NT-proBNP at 72 hours correlated with CI, MAP and PAP (P<0.01, <0.01,<0.05 respectively)., Conclusions: Increased NT-proBNP levels at 72 hours could predict mortality at 28 days in patients with septic shock and are correlated with haemodynamics.