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Background Cardiac dysfunction, mainly assessed by biomarker alterations, has been described in COVID-19 infection. However, there are still areas of uncertainty regarding its effective role in disease evolution. Aim of this study was to evaluate early echocardiographic parameters in COVID pneumonia and their association with severity disease and prognosis. Methods An echocardiographic examination was performed within 72 h from admission in 64 consecutive patients hospitalized for COVID-19 pneumonia in our medium-intensity care unit, from March 30th to May 15th 2020. Six patients were excluded for inadequate acoustic window. Results Fifty-eight consecutive patients were finally enrolled, with a median age of 58 years. Twenty-two (38%) were classifiable as severe COVID-19 disease. Eight out of 58 patients experienced adverse evolution (six died, two were admitted to ICU and received mechanical ventilation), all of them in the severe pneumonia group. Severe pneumonia patients showed higher troponin, IL-6 and d-Dimer values. No significant new onset alterations of left and right ventricular systolic function parameters were observed. Patients with severe pneumonia showed higher mean estimated systolic pulmonary artery pressure (sPAP) (30.7 ± 5.2 mmHg vs 26.2 ± 4.3 mmHg, p = 0.006), even if in the normality range values. No differences in echocardiographic parameters were retrieved in patients with adverse events with respect to those with favorable clinical course. Conclusion A mild sPAP increase in severe pneumonia patients with respect to those with milder disease was the only significant finding at early echocardiographic examination, without other signs of new onset major cardiac dysfunction. Future studies are needed to deepen the knowledge regarding minor cardiac functional perturbation in the evolution of a complex systemic disorder, in which the respiratory involvement appears as the main character, at least in non-ICU patients.

Myocardial strain assessed with speckle tracking echocardiography is a sensitive marker of cardiac dysfunction. Both left-ventricular global longitudinal strain (LV-GLS) and right ventricular longitudinal strain (RV-LS) were affected by severe SARS-CoV-2 infection. However, data about cardiac involvement in patients with asymptomatic/mild Coronavirus disease-19 (COVID-19) is still lacking.To evaluate myocardial function using LV-GLS and RV-LS in patients with previous asymptomatic/mild COVID-19.Forty young adults without previously known comorbidities/cardiovascular risk factors and with a confirmed diagnosis of asymptomatic or paucisymptomatic SARS-CoV-2 infection were retrospectively included. A 2D-transthoracic echocardiogram with speckle tracking analysis was performed at least 3 months after the diagnosis. Forty healthy subjects, matched for age, sex, and body surface area in a 1:1 ratio were used as the control group.Left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE) and RV-LS were comparable between the two groups. LV-GLS was significantly lower in the cases compared to the control group (-22.7 ± 1.6% vs. -25.7 ± 2.3%; p.001). Moreover, the prevalence of regional peak systolic strain below -16% in at least two segments was three times higher in patients with previous COVID-19 compared to controls (30% vs. 10%, p = .02). In multivariable logistic regression, previous COVID-19 infection was independently associated with reduced LV-GLS values (p.001).SARS-CoV-2 infection may affect left ventricular deformation in 30% of young adult patients despite an asymptomatic or only mildly symptomatic acute illness. Speckle-tracking echocardiography could help early identification of patients with subclinical cardiac involvement, with potential repercussions on risk stratification and management.

We report the case of a healthy 35‐year‐old woman who had experienced a flu‐like syndrome during the week before childbirth and heart failure symptoms 10 days before the current hospitalization and presented to our emergency department with clinical signs of congestive heart failure, echocardiographic evidence of a severely dilated and hypokinetic heart, laboratory evidence of SARS‐CoV‐2 disease, and radiologic findings consistent with both virus‐related pneumonia and heart failure. Early cardiac magnetic resonance was crucial for the diagnosis of postpartum cardiomyopathy and for the exclusion of virus‐related myocarditis, allowing us to decide on a prudent and supportive clinical approach.

Background MitraClip system is a device for percutaneous edge-to-edge repair of the mitral valve in symptomatic patients with severe mitral regurgitation (MR) not eligible for surgery, but frequently heart failure symptoms remain substantial on mid-term follow-up. Recently, right ventricular (RV) to pulmonary arterial (PA) coupling has emerged as a relevant prognostic predictor in heart failure but little is known about its prognostic role in patients after MitraClip implantation. Purpose To identify echocardiographic predictors of clinical outcome after MitraClip procedure, with a particular focus on RV-PA coupling. Methods We retrospectively analyzed the data of patients with severe MR who underwent MitraClip implantation between April 2015 and October 2019 at our Institution. Echocardiographic data were assessed at baseline, 3 and 12 months after the procedure; RV to PA coupling was assessed using the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). Functional class was assessed at 12 months of follow-up. Significance level was set to 0.05 and SPSS was used for statistical analysis. Results 41 patients were included (age 77.1±7.3, 71% male, BMI 25.8±5.5). MR was primary, functional and mixed in 22, 76 and 2% of patients, respectively. 1/2/3 mitraclips were implanted in 39/56/5% of patients, respectively. Echocardiographic data at baseline, at 3 and 12 months follow-up are shown in Table. NYHA class at 12 months significantly correlated with TAPSE and PASP at 3 months follow-up echocardiogram (beta coefficient −0.83 and 0.78 respectively). On the contrary, NYHA class did not show a correlation with left ventricular ejection fraction (LVEF) or residual MR grade. At 12 months 44% of patients showed an improvement in NYHA class; these patients had a better TAPSE (22.7±1.3 vs 19.4±4.6 mm), a lower PASP (37.9±10.2 vs 48.5±12.9 mmHg) and a better TAPSE/PASP (0.61±0.2 vs 0.42±0.2) compared to patients who did not improve their functional class, while LVEF and residual MR did not differ. Conclusion In this sample of significant MR undergoing repair with MitraClip System, patients with functional class improvement at 12 months follow-up showed a better RV-coupling without difference in LV function and residual MR. Funding Acknowledgement Type of funding sources: None. Table 1

SYNOPSIS Coronavirus disease 2019 (COVID-19) could have a direct or indirect effect on the cardiovascular system. To detect cardiac involvement, trans-thoracic echocardiography (TTE), as a widely available and cost-effective tool, is highly recommended and can provide important information that can affect the clinical management of COVID-19 patients. Despite that, considering the risk of equipment contamination and personnel exposure, mainly focused echocardiographic evaluations instead of complete examination are recommended and the use of portable devices easy to disinfect with offline reporting is highly suggested. Accordingly, cardiac imaging examination should be considered only when it could change the clinical management or be lifesaving for the patients. COVID-19, through different mechanisms, could affect different sections of the heart and it is useful to analyze them separately during an echocardiographic examination. Regarding the left ventricle, the SARS-CoV-2 infection could lead to acute myocardial infarction, tako-tsubo syndrome and in particular acute myocarditis. The impairment of the pulmonary circulation and the higher prevalence of pulmonary embolism in these patients explain and correlate with some pathological findings as right ventricular systolic dysfunction and direct or indirect signs of pulmonary hypertension, which could easily be assessed by echocardiography and with notable prognostic meaning. Some reports also described acute pericarditis and cardiac effusion during SARS-COV-2 infection and echocardiography is the first recommended diagnostic tool to evaluate the pericardial involvement, especially to exclude signs of cardiac tamponade that rapidly deteriorate the clinical state of the patients. However, available echocardiographic data on COVID-19 patients are scarce and actually does not provide definite evidence and more studies are certainly needed to better evaluate this topic.

Aims: Mitral valve reoperations due to failing bioprostheses, in patients affected by multiple comorbidities, are associated with high morbidity and mortality. Transcatheter techniques may evolve as complementary approaches to surgery in these patients at high risk for surgery. Methods and results: We describe a case of Direct Flow 25 mm transcatheter valve implantation as valve-in-valve in a degenerated mitral bioprosthesis through a transapical approach in a 63-year-old man affected by dilated cardiomyopathy. The patient was affected by Carpentier-Edwards 29 mm severe regurgitation. The 25 mm Direct Flow bioprosthesis was advanced through the mitral bioprosthesis into the left atrium and then positioned using the three independent positioning wires. Transoesophageal echocardiography evidenced normal Direct Flow function with no paravalvular regurgitation and a low transmitral gradient of 4 mmHg. Conclusions: Our successful experience, characterised by a Heart Team approach and multidisciplinary patient care, demonstrated the technical feasibility and procedural safety of Direct Flow valve-in-valve mitral implantation.

Changes in the incidence, clinical features and microbiology of infective endocarditis (IE) observed in a single center in Italy were compared between the period 2003-2010 and 2011-2015.All cases of IE, defined as definite or possible according to the modified Duke criteria, observed at the 'L. Sacco' Hospital in Milan, Italy between 2003 and 2015 were retrospectively reviewed.366 episodes of IE were identified in 325 patients. The mean number of incident IE over the period 2003-2015 was 1.43 (range: 0.6-2.1) cases per 1000 admissions, with a significantly increasing trend from a mean of 1.28-1.72 cases per 1000 admissions/year in 2003-2010 and 2011-2015, respectively (+34%; p = .04). Staphylococci remain the leading pathogens causing IE (29%) with a relative increase of methicillin-resistant Staphylococcus aureus between the two periods. Streptococci and enterococci account for 26% and 18% of IE, respectively. We found an increase in the proportion of cases due to enterococci (from 14% in 2003-2010 to 22% in 2011-2015). The rate of in-hospital mortality was 19%, similar in the two periods studied.The incidence of IE continuously increased in our cohort over the past decade and, along with the aging of the population, a raise in the incidence of health care-associated infections and a change in the distribution of prevalent pathogens were observed. Surgery was independently associated with higher in-hospital survival (AOR, 95% CI: 0.38, 0.19-0.74; p = .005). A constant surveillance is required to guide the optimal management of the changing epidemiology of IE.

Transcatheter aortic valve implantation has emerged as a valuable option to treat patients with symptomatic severe aortic stenosis, who are not being considered for surgery because of significant comorbidities. Concerns exist over treating patients who have previously undergone mitral valve surgery for possible interference between the percutaneous aortic valve and the mitral prosthesis or ring.At our centre, from May 2008 to December 2012, 172 patients (76 male) with severe symptomatic aortic stenosis were eligible for transcatheter aortic valve implant. Nine patients, affected by severe aortic stenosis, had previously undergone mitral valve surgery (4 mono-leaflet, 3 bileaflet, 1 bioprosthesis, 1 mitral ring); they were considered high-risk surgical candidates following joint evaluation by cardiac surgeons and cardiologist and had undergone TAVI.Seven patients underwent standard femoral retrograde CoreValve(®) (Medtronic Inc., Minneapolis, USA) implantation, two patients underwent a direct aortic implantation through a mini-thoracotomy. All patients experienced immediate improvement of their haemodynamic status. No deformation of the nitinol tubing of the CoreValve, nor distortion or malfunction of the mechanical valve or mitral ring, occurred as assessed by echographical and fluoroscopic evaluation. No major postoperative complications occurred. In all patients , echocardiography indicated normal valve function during follow-up.Our experience confirms the feasibility of CoreValve implantation in patients with mechanical mitral valves or mitral annuloplasty ring.

Contemporary series of postpericardiotomy syndrome (PPS) are lacking. The aim of this study was to evaluate the incidence, time course, features at presentation, risk factors, and prognosis of PPS. The study population consisted of 360 consecutive candidates to cardiac surgery enrolled in a prospective cohort study. PPS was diagnosed in 54 patients (15.0%; mean age 66 ± 12 years, 48.1% women): 79.6% in the first month, 13.0% in the second month, and 7.4% in the third month. Specific symptoms, signs, or features were pleuritic chest pain (55.6%), fever (53.7%), elevated markers of inflammation (74.1%), pericardial effusion (88.9%), and pleural effusion (92.6%). Cardiac tamponade was rare at presentation (1.9%). Female gender (hazard ratio 2.32, 95% confidence interval 1.22 to 4.39, p = 0.010), and pleura incision (hazard ratio 4.31, 95% confidence interval 2.22 to 8.33, p

Aims No drug has been proven efficacious to prevent the post-pericardiotomy syndrome (PPS), but colchicine seems safe and effective for the treatment and prevention of pericarditis. The aim of the COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS) trial is to test the efficacy and safety of colchicine for the primary prevention of the PPS. Methods and results The COPPS study is a multicentre, double-blind, randomized trial. On the third post-operative day, 360 patients (mean age 65.7 ± 12.3 years, 66% males), 180 in each treatment arm, were randomized to receive placebo or colchicine (1.0 mg twice daily for the first day followed by a maintenance dose of 0.5 mg twice daily for 1 month in patients ≥70 kg, and halved doses for patients

Impella Recover 100 is an intravascular microaxial blood pump designed for short-term circulatory support in conditions of reduced left ventricular function. Two-dimensional echocardiography is a consolidated tool to study and monitor patients undergoing circulatory support. Three-dimensional (3D) echocardiography is emerging as a source of more accurate analysis in heart morphology and function. We described the use of 3D echocardiography in a patient who underwent Impella recover 100 support for postcardiotomy shock. 3D echocardiography allowed complete visualization of the pump and provided excellent intraoperative assessment of the complex spatial location into the left ventricle.

We describe a case of Direct Flow (Direct Flow Medical Inc, Santa Rosa, CA) transcatheter aortic valve implantation in a patient with a mechanical valve in a mitral position.

Objective Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for surgery. These patients are also often affected by severe iliac–femoral arteriopathy, rendering the trans-femoral approach unusable. We report our experience with the direct-aortic approach to treat these patients. Methods From May 2008 to November 2013 two hundred and thirty-two patients (131 female, 56%) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were evaluated for TAVI at our department. Of these patients, 202 were deemed eligible for TAVI. Of this group, 50 underwent CoreValve implantation by the direct aortic approach through a right anterior mini-thoracotmy (28 female, 56%), mean age 81.2±6.9. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. Results Twenty-eight (56%) patients were female and 11 (22%) were redo at TAVI. We used a 23-mm CoreValve Evolute in 3 patients (6%), and the most used valve size was the 29mm in 46% of patients. Mean hemodynamic trans-aortic gradient was less than 5mmHg. The paravalvular regurgitation was ≤ grade 1 in 46 patients as assessed by peri-procedural transesophageal echocardiography (TEE). Seven patients (7/43, 16%) required a permanent pacemaker implantation; 30-day mortality was 6% (3 patients). Seven patients (14.8%) died during follow-up. Actuarial survival at 2years is 84.7±5.3%. Conclusions Transcatheter aortic valve implantation with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure.

No data are available in the literature regarding the effectiveness and safety of transcatheter aortic valve implantation in patients who underwent previous mitral valve ring repair. Concerns exist related to the possible interference between the percutaneous aortic valve and the mitral annuloplasty ring. We report our experience with percutaneous aortic self-expandable valve implantation in a 76-year-old woman affected by severe aortic stenosis, previously operated on for "undersized" mitral annuloplasty repair of severe functional mitral regurgitation in dilated cardiomyopathy. No deformation of the nitinol tubing of the CoreValve device (CoreValve, Inc, Irvine, CA), neither distortion nor malfunction nor change of the conformation of the mitral ring occurred. No change in mitral function and regurgitation was evident at echocardiography monitoring, which was performed during the implant.

Left atrial appendage occlusion (LAAO) is a non-pharmacological alternative for stroke prevention in high-risk patients with non-valvular atrial fibrillation. The aim of this real world retrospective registry was to obtain clinical data about procedural success, complications and mid-term outcomes

Background Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for operation; however, these patients are also often affected by severe iliac-femoral arteriopathy that prohibits the transfemoral approach. Methods From May 2008 to January 2012, 400 patients were evaluated for TAVI at our center; of these, 141 patients (64 men; mean age 81.3 ± 8 years) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were eligible for CoreValve (137 patients; Medtronic Inc, MN) or Sapien (Edwards Lifesciences, CA) implantation. Twenty-five patients (all affected by severe peripheral vasculopathy, including five re-do procedures), with a mean The Society of Thoracic Surgeons mortality score 11% ± 6%, underwent CoreValve implantation directly from the ascending aorta through a right anterior minithoracotomy. This case series was reviewed to evaluate the clinical outcomes of these patients. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. Results In all patients after valve deployment, the mean aortic gradient immediately dropped to 5 mm Hg or less, and the angiographic grade aortic insufficiency was 1 or less in 22 patients. One patient was converted to the transfemoral approach due to an extremely fragile aortic wall, but the patient died of abdominal aorta aneurysm rupture on postoperative day 1. Procedural success was obtained in the remaining 24 patients. A left ventricle tear in 1 patient was successfully surgically treated. Four patients required a permanent pacemaker implantation. Thirty-day mortality was 8% (2 patients). All discharged patients improved their New York Heart Association functional class and functional capacity, and echocardiograms demonstrated good valve performance up to 2 years (mean valve gradient, 9 mm Hg). During follow-up, 1 patient died of cachexia and another of bone marrow aplasia. Conclusions TAVI with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure, and has emerged as a valuable alternative route to transapical access.

Background— Inflammation and pericarditis may be contributing factors for postoperative atrial fibrillation (POAF), and both are potentially affected by antiinflammatory drugs and colchicine, which has been shown to be safe and efficacious for the prevention of pericarditis and the postpericardiotomy syndrome (PPS). The aim of the Colchicine for the Prevention of the Post-Pericardiotomy Syndrome (COPPS) POAF substudy was to test the efficacy and safety of colchicine for the prevention of POAF after cardiac surgery. Methods and Results— The COPPS POAF substudy included 336 patients (mean age, 65.7±12.3 years; 69% male) of the COPPS trial, a multicenter, double-blind, randomized trial. Substudy patients were in sinus rhythm before starting the intervention (placebo/colchicine 1.0 mg twice daily starting on postoperative day 3 followed by a maintenance dose of 0.5 mg twice daily for 1 month in patients ≥70 kg, halved doses for patients P =0.021; relative risk reduction, 45%; number needed to treat, 11) with a shorter in-hospital stay (9.4±3.7 versus 10.3±4.3 days; P =0.040) and rehabilitation stay (12.1±6.1 versus 13.9±6.5 days; P =0.009). Side effects were similar in the study groups. Conclusion— Colchicine seems safe and efficacious in the reduction of POAF with the potentiality of halving the complication and reducing the hospital stay. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00128427.

Transcatheter valve implantation into failing surgical mitral bioprosthetic valves have been reported. This strategy avoids performing high-risk repeat cardiac surgery in elderly patients with multiple comorbidities. All these patients have been treated by a transapical approach. We report a case of failing bioprosthetic mitral valve in an 82-year-old woman successfully treated with a 29-mm Edwards SAPIEN balloon expandable bioprosthesis (Edwards Lifesciences, Irvine, CA) with direct left atrial approach through a right anterior thoracotomy. Our experience demonstrates the technical feasibility and safety of this approach. Therefore, mitral valve-in-surgical valve implantation may be a viable treatment alternative in carefully selected patients.

No preventive pharmacologic strategies have been proven efficacious for the prevention of postoperative effusions after cardiac surgery. Colchicine is safe and efficacious for the prevention of pericarditis. On this basis, we realized a substudy of the COPPS trial to assess the efficacy and safety of colchicine for the prevention of postoperative pericardial and pleural effusions.The COPPS is a multicenter, double-blind, randomized trial, where 360 consecutive patients (mean age 65.7 ± 12.3 years, 66% men), 180 in each treatment arm, were randomized on the third postoperative day to receive placebo or colchicine for 1 month (1.0 mg twice daily for the first day, followed by a maintenance dose of 0.5 mg twice daily in patients ≥70 kg, and halved doses for patients70 kg). The incidence of postoperative effusions was evaluated in each study group.Despite similar baseline features, colchicine significantly reduced the incidence of postoperative pericardial (12.8% vs 22.8%, P = .019, relative risk reduction 43.9%, no. of patients needed to treat 10) and pleural effusions (12.2% vs 25.6%, P = .002, relative risk reduction 52.3%, no. of patients needed to treat 8). The rate of side effects (only gastrointestinal intolerance) and drug withdrawal was similar in the study groups with a trend toward an increased rate of both events for colchicine. In multivariable analysis, female gender (hazard ratio 1.76, 95% CI 1.03-3.03, P = .040) and pleura incision (hazard ratio 2.58, 95% CI 1.53-4.53, P.001) were risk factors for postoperative effusions.Colchicine is safe and efficacious for the primary prevention of postoperative effusions after cardiac surgery.

Few data are available on the effects of cardiac resynchronization therapy (CRT) in candidates for cardiac surgery and affected by severe heart failure (HF). The aim of our analysis is to evaluate the percentage of patients who maintain indication for CRT after surgery and the efficacy of CRT in those patients subsequently implanted. We enrolled 124 HF patients with indication both to heart surgery and to CRT. During surgery, an epicardial left ventricular lead was implanted, tunneled to a subclavear pocket, and capped. Afterward, patients were periodically reassessed to confirm indication for CRT. CRT indication was confirmed within 1 month from surgery in 54 patients (group A) and in 33 patients within 6 months (group B). In group A and B, 63% and 71% of patients were considered responders according to an arbitrary five-point increase of left ventricular ejection fraction (LVEF), respectively. The assessment of clinical response at 1 year, based on the definitions proposed by Packer, identified 63% and 80% of responders in group A and B, respectively. Our data show that a remarkable percentage of patients maintain an indication for CRT after cardiac surgery (76%), while in the remaining 24% the lack of an indication is confirmed by a higher LVEF at last follow-up. In combination with surgery, CRT proved to be an effective therapy in those patients who were subsequently implanted. The suggested method is simple, without significant adjunctive risks, and allows easier CRT implantation with stable thresholds.

Impella Recover 100 is an intravascular microaxial blood pump designed for short-term circulatory support in conditions of reduced left ventricular function. Two-dimensional echocardiography is a consolidated tool to study and monitor patients undergoing circulatory support. Three-dimensional (3D) echocardiography is emerging as a source of more accurate analysis in heart morphology and function. We described the use of 3D echocardiography in a patient who underwent Impella recover 100 support for postcardiotomy shock. 3D echocardiography allowed complete visualization of the pump and provided excellent intraoperative assessment of the complex spatial location into the left ventricle.

Axial flow pumps have gained increased acceptance in recent years as a bridge to heart transplantation and, more recently, as destination therapy. As left ventricular (LV) assist device dysfunction will be increasingly prevalent, the aim of our work was to introduce an echocardiographic management protocol as a guide to recognize the causes of pump failure. In this article we describe the echocardiographic approach to 5 episodes of malfunction of an axial flow pump (DeBakey, MicroMed Technology Inc, Houston, Tex) in 4 patients: 4 episodes caused by thrombosis of LV assist device and one caused by abnormal increase of systemic vascular resistance. In our experience, echocardiography played a pivotal role in clinical management of LV assist device failure. It allowed us to: assess patency and position of inflow and outflow cannulae; research the source of thromboembolic material; assess adequate LV filling and unloading; and optimize right ventricular function, volume replacement therapy, and pharmacologic support.