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Sudden cardiac death is a leading cause of mortality, claiming millions of lives every year. Recent advances in cardiac arrhythmia mapping have demonstrated that the ventricular epicardial region has a critical arrhythmogenic role in some inherited cardiogenetic diseases. Historically, electroanatomic abnormalities have been identified in the ventricular epicardium of patients with arrhythmogenic right ventricular cardiomyopathy. More recently, epicardial pathological substrates have been identified also in electrical disease (Brugada syndrome, early repolarization syndrome) and currently in long QT syndrome. In light of these findings, the epicardial area has emerged as an important determinant in sudden cardiac death-related cardiomyopathies.

OBJECTIVES Aim of this study was to evaluate arrhythmic burden of patients with Barlow’s disease and significant mitral regurgitation (MR) and assess the impact of mitral repair on ventricular arrhythmias (VA) in this group of subjects. METHODS We prospectively included 88 consecutive patients with Barlow’s disease referred to our Institution from February 2021 to May 2022. All enrolled patients underwent 24-h Holter monitoring before surgery. Sixty-three of them completed 3 months echocardiographic and Holter follow-up. Significant arrhythmic burden was defined as ≥1% premature ventricular beats/24 h or at least one episode of non-sustained ventricular tachycardia (VT), VT or ventricular fibrillation. RESULTS At baseline, 29 patients (33%) were arrhythmogenic (AR), while 59 (67%) were not [non-arrhythmogenic (NAR)]. AR subjects tended to be more often females with history of palpitations. Sixty-three patients completed 3-months follow-up. Twenty of them (31.7%) were AR at baseline and 43 (68.3%) were not. Among AR patients, 9 (45%) remained AR after mitral surgery, while 11 (55%) became NAR. Considering NAR subjects at baseline, after mitral valve repair 8 (18.6%) evolved into AR, while 35 (81.4%) remained NAR. A higher prevalence of pre-operative MAD was found among patients experiencing VA reduction if compared with patients who remained arrhythmogenic (63.6% vs 11.1%, P = 0.028). CONCLUSIONS In our experience, one-third of Barlow’s patients referred for mitral surgery showed a significant arrhythmic burden. Almost half of the subjects arrhythmogenic at baseline were free from significant VA after mitral repair. However, a minority (18.6%) of subjects without arrhythmic burden at baseline experienced significant VA at follow-up.

In contemporary Cardiac Intensive Care Unit (CICU), bedside intra-aortic balloon pump (IABP) insertion under echocardiographic guidance may be an attractive option for selected patients with cardiogenic shock (CS). Currently available data on this approach are limited.This study aimed to assess the feasibility and safety of bedside IABP insertion, as compared to fluoroscopic-guided insertion in the Catheterization Laboratory (CathLab), and to describe the clinical features of patients receiving bedside IABP insertion using a standardized technique in real-world CICU practice.We prospectively evaluated all patients admitted the CICU who received transfemoral IABP between June 2020 and October 2021. The overall study cohort was divided according to implant strategy in bedside and CathLab groups. The primary outcome was correct radiographic IABP positioning at the first bedside chest X-ray obtained after insertion. Secondary outcomes included IABP-related complications.Among 115 patients, bedside IABP insertion was performed in 35 (30.4%) cases, mainly presenting with CS-related to acute decompensated heart failure (ADHF) (68.6 vs 33.8%; p 0.001), with lower LVEF, higher proportion of right ventricular involvement and higher need of inotropes/vasopressors, compared to those receiving CathLab insertion. Bedside IABP insertion resulted feasible and safe, with similar rates of correct IABP positioning (82.9 vs. 82.5%; p = 0.963) and IABP-related major vascular complications (5.7 vs. 5.0%; p = 0.874), as compared to CathLab positioning.This study suggests the feasibility and safety of bedside IABP insertion, which could be of relevant interest in patients with ADHF-related CS who may not need coronary angiography or other urgent CathLab procedures.

Aims The procedural planning of transcatheter mitral valve replacement (TMVR) requires a specific imaging assessment to establish patient eligibility. Computed tomography (CT) is considered the reference method. In this setting, data regarding the role of transoesophageal echocardiography (TOE) are lacking. We evaluated the feasibility and reliability of a comprehensive 3D-TOE screening in TMVR candidates. Methods and results We performed a retrospective observational study including 72 consecutive patients who underwent a pre-procedural CT and 3D-TOE for TMVR evaluation. The measurements of mitral annulus (MA), length of anterior mitral leaflet (AML), native left ventricular outflow tract (LVOT), and predicted neo-LVOT acquired with CT and 3D-TOE were compared using a novel semi-automated software for post processing analysis (3 mensio Structural Heart 10.1—3mSH, Pie Medical Imaging, Bilthoven, Netherlands). The final suitability decision was given by the valve manufacturer based on CT measurements and clinical conditions. Among 72 patients screened, all patients had adequate image quality for 3D-TOE analysis. 3D-TOE and CT measurements for AML length (r = 0.97), MA area (r = 0.90), perimeter (r = 0.68), anteroposterior (r = 0.88), and posteromedial-anterolateral (r = 0.74) diameters were found highly correlated, as well as for native LVOT (r = 0.86) and predicted neo-LVOT areas (r = 0.96) (all P-values Conclusion 3D-TOE appraisements showed good correlations with CT measurements and high accuracy to predict TMVR screening success.

The procedural planning of transcatheter mitral valve replacement (TMVR) requires a specific imaging assessment to establish patient eligibility. Computed tomography (CT) is considered the reference method. In this setting, data regarding the role of transesophageal echocardiography (TEE) are lacking. Aims To evaluate the feasibility and reliability of a comprehensive 3D-TEE screening in TMVR candidates. Methods we performed a retrospective observational study including 72 consecutive patients who underwent a pre-procedural CT and 3D-TEE for TMVR evaluation. The measurements of mitral annulus (MA), length of anterior mitral leaflet (AML), native left ventricular outflow tract (LVOT) and predicted neo-LVOT acquired with CT and 3DTEE were compared using a novel semi-automated software for post processing analysis (3mensio Structural Heart 10.1 - 3mSH, Pie Medical Imaging, Bilthoven, Netherlands). The final suitability decision was given by the valve manufacturer based on CT measurements and clinical conditions. Results Among 72 patients screened, all patients had adequate image quality for 3D-TEE analysis. 3D-TEE and CT measurements for AML length (r=0.97), MA area (r=0.90), perimeter (r=0.68), anteroposterior (r=0.88) and posteromedial-anterolateral (r=0.74) diameters were found highly correlated, as well as for native LVOT (r=0.86) and predicted neo-LVOT areas (r=0.96) (all P -values Conclusions 3D-TEE appraisements showed good correlations with CT measurements and high accuracy to predict TMVR screening success. Central Illustration. Mitral annulus segmentation and neo-LVOT area measurement performed by means of the 3mensio software (Pie Medical Imaging, Bilthoven, Netherlands) in a step-by-step fashion by TEE and CT imaging. After the virtual simulation of a valve implantation, the minimal systolic neo-LVOT area is manually measured by planimetry on a plane orthogonal to the centerline.

Short-coupled idiopathic ventricular fibrillation (SC-IVF) is a rare, life-threatening arrhythmia, accountable for 5–10% of out-of-hospital cardiac arrests (OHCA). Catheter ablation of the short-coupled premature ventricular contraction (PVC) that triggers VF has been shown to prevent VF recurrences in outdated case series. Aim To evaluate the clinical outcome and summarize the recent experience of 3D electrophysiological mapping and radiofrequency catheter ablation (RFCA) of SC-IVFs in a tertiary high-volume referral centre. Methods from January 2016, we enrolled all consecutive patients diagnosed with SC-IVF and treated by RFCA. Structural heart disease was excluded in all patients by means of echocardiography, cardiac magnetic resonance, coronary angiography, and exercise test. Brugada syndrome and long QT syndrome were excluded by Ajmaline and Epinephrine tests, respectively. The CARTO system was used to construct detailed 3D electroanatomic maps of the right and left ventricle. Mapping and ablation were performed with a standard 3.5- irrigated tip catheter. The PVCs were localized by mapping the earliest bipolar electrogram relative to the onset of the ectopic surface QRS (confirmed by QS complex in the unipolar configuration). Pace mapping was used in patients with infrequent PVCs. The origin of PVCs from fascicles/Purkinje network was indicated by initial sharp potentials preceding the ectopic QRS complex. The procedural end point was the abolition of all clinical PVCs. Outcome (freedom from SC-PVCs and VF episodes) was assessed by Holter monitoring and defibrillator memory interrogation. Results eleven consecutive patients [8 men, 3 women; median age 41 (± 5 years)] were enrolled. 10/11 patients (91%) were asymptomatic prior the index VF event, while 1 patient (9%) experienced recurrent syncope. An aborted OHCA was the index event in all patients. Arrhythmic storm was observed at the index presentation in 2 patients (18%). No patient had family history of sudden cardiac death. All patients were implanted with an ICD after the index event. The delay in SC-IVF diagnosis was 3 (± 2 years) from the index event. 2 patients (18%) had ≥ 2 SC-PVC morphologies. The mean coupling interval (CI) of the SC-PVCs ranged from 230 to 330 msec (mean 303 ± 26 msec). The CI/QT ratio ranged from 0.6 to 1 (mean 0.81 ± 0.15). 10 patients underwent RFCA for recurrent VF/ICD shocks and 1 patient for refractory electrical storm. RFCA was based on activation mapping, pace-mapping, and both in 1 (9%), 1 (9%), and 9 (82%) patients, respectively. The sites of ablation were LV Purkinje, RV Purkinje, RV non-Purkinje (RV outflow tract and tricuspid annulus), and LV non-Purkinje (LV Summit) in 3 (27%), 4 (36%), 3 (27%), and 1 (9%) patient, respectively. The first ablation was acutely successful in all patients. 1 patient experienced recurrence of SC-PVCs and VF episodes after 5 days from the first ablation and underwent a second RFCA. There were no peri-procedural complications. After a median follow-up of 22 months (ranging from 6 to 39 months) all patients were free from sustained ventricular arrhythmia recurrences: 10 patients (91%) were free from VF and PVCs; 1 patient (9%) had recurrent SC-PVCs without VF episodes. Conclusions this retrospective study explored the effectiveness of RFCA combined with the advanced electroanatomic mapping in a current cohort of patients with history of OHCA diagnosed with SC-IVF. RFCA of SC-PVCs was safe and highly effective in abolishing VF episodes in all patients.

Background Acute heart failure (AHF) with left ventricle (LV) dysfunction is characterized by a condition of afterload mismatch without preload reserve. LV ejection fraction (LVEF) and stroke volume (SV) become thus dependent on the afterload. Owing to its arteriolar vasodilator properties, sodium nitroprusside (SNP) may reduce LV afterload and result particularly beneficial in this setting, improving LV ejection and ventriculo-arterial coupling (VAC). Hypothesis We aimed to assess the effect of SNP on LV afterload (arterial elastance, Ea), LV contractility (end-systolic elastance, Ees) and VAC (Ea/Ees ratio) in AHF patients. Methods Patients with AHF receiving SNP were prospectively enrolled and underwent Ea and Ees estimation with a single-beat echocardiographic method, before and after SNP infusion. The method was described by Chen et al (J Am Coll Cardiol, 2001) and Kelly et al (Circulation, 1992). Echocardiography was analyzed by a physician blinded to the images timing. Results A total of 36 AHF patients [69% male, age 70 (68, 76) years] received SNP infusion and were enrolled. Patients were admitted for acute coronary syndrome (47%) and for worsening heart failure (53%). SNP median dose was low: 0.30 (0.21-0.57) mcg/kg/min. SNP led to a trend to SBP reduction [140 (131-150) vs 158 (140-168) mmHg; p=0.002]. Heart rate did not change: 84 (75, 92) vs 83 (72, 94) bpm; p=0.800. Afterload (Ea) was reduced following SNP infusion: 2.2 (1.9, 2.7) vs 2.8 (2.4, 3.4) mmHg/mL; p Conclusion In this report on consecutive AHF, low-dose SNP did not significantly affect VAC but led to a significant reduction in LV afterload and to a significant increase in SV and LVEF.

Background Intra-Aortic Balloon Pump (IABP) efficacy is critically affected by the inflation/deflation timing. Balloon deflation may cause a sucking effect, and a steal phenomenon on carotid flow. Delaying IABP deflation reduces the degree of this flow reversal, but at the same time exposes patients to the risk of increased proto-systolic afterload with detrimental effects on the LV. Hypothesis To investigate the effects of a delayed IABP deflation timing on cerebral blood flow and LV hemodynamics. Methods We prospectively evaluated 20 consecutive patients who received transfemoral IABP for cardiogenic shock (CS). Central aortic pressures (augmented diastolic [ADP], end-diastolic [EDP], assisted systolic [ASP] and mean aortic [MAP] pressures) were recorded from the IABP console simultaneously with ultrasound data. First ultrasound and haemodynamic measurements were collected during conventional IABP deflation timing (balloon deflation completed before onset of LV systole by automated ECG gating). Then, IABP deflation was manually delayed to the beginning of the QRS (early LV systole). After adjustment, counterpulsation was performed for a minimum of 2 minutes to achieve steady hemodynamics, then the same ultrasound and haemodynamic measurements were recollected. Results Mean age was 67±13 years, LVEF was 25±11%. At the carotid ultrasound, the delayed deflation increased the net forward velocity time integral (VTI) in the common carotid artery (18±9 vs 15±8 cm; p=0.001), by reducing the end-diastolic backward VTI (1±1 vs 4±2 cm; p Conclusions In our cohort, a delayed IABP deflation strategy, evaluated by a multi-parametric yet relatively simple approach, demonstrated to be safe and was associated with both an increase cerebral perfusion and an improvement in cardiac mechanics.

During transcatheter edge-to-edge repair (TEER), the reduction of functional mitral regurgitation (FMR) severity, compared with baseline evaluation, is not uncommon. Because the procedural strategies are mainly guided by the location and severity of the regurgitant jets, intraprocedural downgrading (ID) of regurgitation severity could affect the procedural strategy and the results. The aim of this study was to evaluate the prevalence of ID during TEER and to compare early and midterm outcomes in patients with and without ID. All patients with moderate-to-severe or severe FMR who underwent TEER in San Raffaele Hospital between 2018 and 2020 were evaluated in this single-center, retrospective study. ID was defined as mild (1+) or moderate (2+) regurgitation degree during intraprocedural evaluation. The outcomes, assessed at discharge and at 2 years of follow-up, were all-cause mortality, heart failure hospitalization, and recurrence of mitral regurgitation2+. The final study cohort included 55 patients: 42% presented with ID. At discharge, 85.5% of patients achieved regurgitation reduction to 2+ or less: 100% in patients with ID versus 75% in patients without ID, p0.009. At 2 years, no significant difference in the incidence of all-cause mortality, heart failure hospitalization, and the recurrence of mitral regurgitation2+ between patients with ID or without ID was found. In conclusion, ID is frequent during TEER in FMR. No baseline characteristics were found to identify this group of patients. In patients with ID, the combination of live intraprocedural imaging and baseline ambulatory assessment of regurgitant jets seems effective in the procedural guiding to achieve a successful and durable mitral repair.

Aims The planning of transcatheter mitral valve replacement (TMVR) requires cardiac imaging assessment to establish patient eligibility according to mitral valve anatomy, device characteristics and risk of left ventricular outflow tract (LVOT) obstruction. In this setting, computed tomography (CT) is considered the reference method. Although recent studies demonstrated that three-dimensional transesophageal echocardiographic (3D-TEE) assessment of mitral anatomy presents a good agreement compared to CT, its potential role in the TMVR planning has never been fully evaluated. To test feasibility and reliability of a comprehensive 3D-TEE screening in candidates for TMVR. Methods We performed a single-centre retrospective observational study including 59 consecutive patients referred to our centre for TMVR due to high surgical risk, who performed a pre procedural CT and 3D-TEE screening. The measurements of mitral annulus (MA), native LVOT and predicted Neo-LVOT, assessed with CT and 3D-TEE were collected in order to evaluate their concordance in the assessment of TMVR eligibility. The final suitability decision was given by the valve manufacturer based on CT measurements and then compared with the screening results obtained with 3D-TEE evaluation. 3D-TEE measurements were obtained with a post processing analysis using a novel automated software platform (3mensio Structural Heart 10.1 - 3mSH, Pie Medical Imaging, Bilthoven, Netherlands). Results Excellent correlation was found between 3D-TEE and CT measurements for MA area (r =0.85), antero-posterior diameters (r= 0.81), native LVOT (r=0.82) and Neo-LVOT areas (r=0.95) (all P-values 0.80. Conclusions 3D-TEE appraisements of MA dimensions, native LVOT and Neo-LVOT are feasible in patients candidate for TMVR, showing good correlations with CT measurements and high accuracy to predict TMVR screening success.

Aims Infection by SARS‐CoV‐2 may result in a systemic disease and a proportion of patients ranging 15%–44% experienced cardiac injury (CI) diagnosed by abnormal troponin levels. The aim of the present study was to analyse the clinical characteristics of a large series of hospitalized patients for COVID‐19 in order to identify predisposing and/or protective factors of CI and the outcome. Methods and results This is an observational, retrospective study on patients hospitalized in two Italian centres (San Raffaele Hospital and Cremona Hospital) for COVID‐19 and at least one high‐sensitivity cardiac troponin (hs‐cTnt) measurement during hospitalization. CI was defined if at least one hs‐cTnt value was above the 99th percentile. The primary end‐point was the occurrence of CI during hospitalization. We included 750 patients (median age 67, IQR 56–77 years; 69% males), of whom 46.9% had history of hypertension, 14.7% of chronic coronary disease and 22.3% of chronic kidney disease (CKD). Abnormal troponin levels (median troponin 74, IQR 34–147 ng/l) were detected in 390 patients (52%) during the hospitalization. At multivariable analysis age, CKD, cancer, C‐reactive protein (CRP) levels were independently associated with CI. Independent predictors of very high troponin levels were chronic kidney disease and CRP levels. Patients with CI showed higher rate of all‐cause mortality (40.0% vs. 9.1%, p = 0.001) compared to those without CI. Conclusion This large, multicentre Italian study confirmed the high prevalence of CI and its prognostic role in hospitalized patients with COVID‐19, highlighting the leading role of systemic inflammation for the occurrence of CI.

Study Objective To evaluate safety and effectiveness of the combination of hysteroscopic endometrial focal resection with levonorgestrel-releasing intrauterine device (LNG-IUD) for International Federation of Gynecology and Obstetrics stage IA G1 early endometrial cancer (EEC) and atypical endometrial hyperplasia (AEH) in young women to preserve their fertility. Design Retrospective case series (Canadian Task Force classification II-3). Setting University Federico II, Naples, Italy. Patients The medical records of 69 consecutive patients treated from 2007 to 2017 with diagnosis of EEC (n = 14) or AEH (n = 55) meeting inclusion criteria were reviewed. Interventions Patients with focal EEC were treated by hysteroscopic resection of the lesion according to Mazzon's technique; patients with AEH were treated by superficial endometrial resection, preserving the basal layer of the endometrium. An LNG-IUD was inserted in all patients after surgery. Patients were followed for 24 months with serial hysteroscopic biopsies. Measurements and Main Results Rates of response, live birth, and recurrence were assessed. Of the 14 patients with EEC, 11 (78.6%) achieved a complete response, 2 (18.2%) of whom had subsequent relapse, 1 (7.1%) showed partial response, whereas 2 (14.3%) were nonresponders (1 stable disease and 1 progression). Of the 55 patients with AEH, 51 (92.7%) achieved a complete response, 2 (3.9%) of whom had subsequent relapse, 3 (5.5%) showed partial response, whereas only 1 (1.8%) was nonresponder with stable disease. Among 25 patients who had removed the LNG-IUD, 10 (40%) gave birth after natural conception in the last 12 months of follow-up. Conclusion The combination of hysteroscopic resection with an LNG-IUD as fertility-sparing treatment of EEC and AEH showed similar response and live birth rates compared with those reported in literature for progestins alone, but with considerably lower relapse rate. We advocate the use of this combined approach as an alternative fertility-sparing option in patients with ECC and AEH.

Funding Acknowledgements Type of funding sources: None. Aims and Methods Aim of this study was to assess the feasibility of a bolus-free, low-dose levosimendan infusion for acute decompensated heart failure (ADHF) with hypoperfusion. All consecutive patients who received levosimendan without intravenous bolus at our Department for ADHF in the last 6 months were included in this is a single-center retrospective study. To avoid abrupt drop in blood pressure, all patients started infusion at 0.01 mcg/kg/min, and gradual titration was achieved, up to 0.1 mcg/kg/min. Continuous variables are reported as medians (IQR), categorical as proportions. Paired measures were compared with the Wilcoxon signed-rank test. p-value was set at 5%. Analyses were performed using RStudio v1.3. Results We included 26 patients [males 84.6%; age 72 (59-76) years]. Patients had severe LV dysfunction [LVEF of 20 (20-25)%] and moderate/severe RV dysfunction in 46.2%. Most patients were admitted for cardiogenic shock (26.9%) or low-output state (61.5%); baseline serum lactate was 1.6 (1.2-3.2) mmol/L. Etiology was ACS in 26.9% patients, worsening HF in 53.8%, and valvular disease in 26.9%. All patients required inotropes: 73.1% required adrenaline [max dose 0.10 (0.05-0.15) mcg/kg/min]; 50.0% required noradrenaline [max dose 0.10 (0.05-0.18) mcg/kg/min]; 26.9% received levosimendan alone [max dose 0.05 (0.03-0.10) mcg/kg/min]. Levosimendan was used in combination with adrenaline in 69.2%, after 3 (0-4) days of adrenaline initiation. Duration of levosimendan infusion was 3 (1-4) days. MCS was pursued in 69.2% [57.7% IABP, 15.4% Impella CP, and 3.8% VA-ECMO]. Oro-tracheal intubation was required in 50.0%, CVVHDF was required in 11.5% patients. No patient required levosimendan interruption for hypotension/arrhythmia. In-hospital mortality was 7.7%. One patients underwent successful LVAD implantation, and one patient was referred for HTx. Invasive hemodynamic data, before and during levosimendan, was available for 7 patients. Initiation of levosimendan led to a non-significant drop in SVR [14.8 (13.3-16.9) vs 19.5 (14.6-25.4) WU; p = 0.093], but SBP was unchanged (p = 0.470). Left ventricular systolic performance was improved: CI [2.6 (2.4-2.7) vs 2.2 (2.0-2.3) Lt/min/m²; p = 0.016]; CPO [0.9 (0.8-1.0) vs 0.8 (0.8-0.9) W; p = 0.031]. Mean PAP (p = 0.297), and PCWP (p = 0.149) remained unchanged. Notably, no significant adjustments in diuretic (p = 0.422) or adrenaline (p = 0.999) doses, IABP counterpulsation ratio (p = 0.999), or Impella flow (p = 0.999) were recorded between these longitudinal assessments. As a result of improved myocardial function, LVEF increased from admission to discharge [20 (20-25) vs 25 (20-32)%; p = 0.024]. Discussion This preliminary study reports on a bolus-free, low-intensity levosimendan regimen for ADHF with hypoperfusion. Levosimendan improved indexes of myocardial performance. In this cohort, levosimendan often required concomitant inopressor and was started at a very low dose to avoid abrupt drop in blood pressure. Abstract Figure 1

Background: Myocardial injury (MI) can be detected during the acute phase of Coronavirus disease 19 (COVID-19) and is associated with a dismal prognosis. Recent imaging studies described the persistence of cardiac abnormalities after the recovery. The aim of the study was to investigate the spectrum of cardiac abnormalities at mid-term follow-up in patients recovered from COVID-19 using clinical assessment, laboratory tests, and imaging evaluation with comprehensive echocardiography. Methods: This is an observational, cross-sectional study assessing an unselected cohort of consecutive patients recovered from COVID-19. MI was defined by elevated plasma levels of high sensitive troponin T (hsTnT). At the follow-up, a complete examination including echocardiography was performed. Results: The 123 patients included were divided into two groups according to the presence of MI during hospitalization: group A (without MI) and group B (with MI). After a median of 85 days, group B patients were more frequently symptomatic for dyspnea and had significantly higher values of hsTnT and N-Terminal prohormone of Brain Natriuretic Peptide (NT-proBNP), compared to Group A. No differences between the two groups in left nor right ventricle dimension and ejection fraction were found. However, in group B a significant reduction of mean left ventricle global longitudinal strain was observed (-15.7±.7vs -18.1±.3 in group A, p&nbsp

Mitral regurgitation is the most prevalent valve disease worldwide. Percutaneous mitral valve interventions are emerging as alternative options for high-risk patients with severe mitral regurgitation not eligible for conventional surgery. Accurate patient selection is based on a detailed pre-procedural multimodality imaging evaluation. Morphology and functional anatomy of the mitral valve should be evaluated to determine the feasibility of treatments and to identify the best therapeutic approach. The procedures are guided by fluoroscopy, transoesophageal echocardiography and fusion imaging, ensuring a continuous communication between the interventionalist and the imaging specialist. The present review will cover the pre-procedural planning and the intra-procedural guidance of the most used transcatheter approaches in the setting of native mitral valve regurgitation: edge to edge repair, percutaneous direct and indirect annuloplasty, transapical beating-heart chordal implantation and transcatheter mitral valve replacement.

Allele frequencies for the 15 autosomal STR loci included in the AmpFlSTR((R)) IdentifilerTM PCR Amplification Kit panel from Applied Biosystems (D3S1358, vWA, FGA, D8S1179, D21S11, D18S51, D5S818, D13S317, D7S820, TH01, TPOX, CSF1PO, D19S433, D2S1338, D16S539) and several statistical parameters were estimated from a sample of 103 unrelated individuals, mostly Shia and Sunni Arabs, living in most of central and southern Iraq provinces. We compared the allele frequency spectrum detected in the Iraqi population to allele frequencies from 11 other data sets from published studies of individuals from Turkey, Iraqi-Kurdistan, Saudi Arabia, Arab Emarates, Oman, Iran, Syria, and Jordan. Significant global differences in allele frequencies were detected in 9 of the 11 comparisons following sequential Bonferroni corrections. Comparisons with the two independent panels from Saudi Arabia were not significant after applying Bonferroni corrections, however, low P-values (P0.05) associated with these two contrasts nonetheless suggested that at least slight genetic differences between populations may exist.