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Patients suffering from atrial fibrillation (AF) and severe aortic stenosis thus undergoing transcatheter aortic valve implantation (TAVI) have a worse prognosis than those in sinus rhythm. One of the reasons of this is related to the augmented bleeding risk associated with oral anticoagulation (OAC). Left atrial appendage occlusion (LAAO) represents a therapeutic choice to avoid this drug intake and to reduce this kind of adverse outcome. So, a combined procedure of TAVI and LAAO could be an option for TAVI candidates with AF to omit the need for OAC. The clinical case concerns an 85-year-old man with hypertension and dyslipidemia with a history of recent syncope and permanent atrial fibrillation in therapy with antithrombotic drug. Brain MRI performed during hospitalization showed numerous hemosiderin deposits with microhemorrhagic foci thus contraindicating oral anticoagulation. Severe aortic stenosis has also been found to the transthoracic echocardiogram with a mean gradient of 35 mmHg and confirmed by transesophageal echocardiogram with a planimetric area of 0.8 sq.cm. Furthermore, given the finding of significative left circumflex artery disease, after Heart Team discussion and the execution of CT scan that demonstrated the feasibility of transcatheter approach, it was decided to perform in a single session percutaneous coronary intervention (PCI) plus TAVI plus left atrial appendage closure (LAAO). This kind of approach allowed a quick recovery to the patient after a short period of hospitalization. After six months from interventional procedure his NYHA (New York Heart Association Functional Classification) status improved abutting on I/II class. As described above, it can be deduced that combined approach (TAVI+LAAO) is feasible for certain kind of patients thus avoiding surgical approach and long hospitalization. Furthermore, multimodality imaging is of critical importance to plan a complex procedure and an accurate step-by-step pre-procedural strategical planning is the key for procedural success.

Percutaneous closure of a patent forame ovale (PFO) is indicated in selected patients with a confirmed cryptogenic stroke, transient ischemic attack (TIA), or systemic embolism and an estimated high probability of a casual role of the PFO as assessed by clinical, anatomical and imaging features. This procedure is usually undertaken from the femoral vein. In this case, the patient was affected by vena cava agenesis with a compensatory enlargement of azygos vein. We performed the percutaneous closure of the PFO using a 9F jugular vein access. We advanced a straight guide trough the foramen with a Multipurpose 6F catheter supported by a Destino Oscor 8F. Then we changed the straight guide with an Amplatz Super-Stiff 0.035" guide in the left ventricle, on which a Mullins 9F trans-septal catheter was advanced. Finally we delivered an Amplatzer Multifenestrated Septal Occluder "Cribriform" 25/25 mm. In our case, it was impossible to perform the PFO closure procedure using the classic femoral vein access due to the inferior vena cava agenesis. Performing PFO closure using the right internal jugular venous approach was technically challenging but safe and it is possible using standard equipment normally present in the Catheterization Laboratory. In rare cases of an indication for PFO closure and lack of access through the femoral veins, alternative techniques using on the shelf materials help in overcoming the challenging anatomies. The use of steerable catheter is critical for engaging the foramen ovale with unfavourable angulation. The procedure with nitinol double disk devices is safe and effective.

Il diabete mellito aumenta tra 2 e 4 volte il rischio di complicanze cardiovascolari maggiori e richiede, pertanto, strategie precoci e aggressive di prevenzione cardiovascolare primaria che dovrebbero comprendere, oltre all’educazione a uno stile di vita sano, l’uso delle statine e di farmaci ipoglicemizzanti con effetti cardioprotettivi. Nell’ambito della prevenzione cardiovascolare primaria assistiamo da anni al dibattito sull’efficacia e la sicurezza dell’aspirina a basse dosi. Nonostante le evidenze non del tutto incoraggianti questo farmaco viene ampiamente prescritto ai soggetti diabetici, spesso in maniera impropria. Lo scopo di questo articolo e quello di fornire una rassegna critica delle evidenze e delle raccomandazioni sull’uso dell’aspirina in prevenzione cardiovascolare primaria nei diabetici e di proporre un approccio ragionato alla prescrizione di questo farmaco.

Patients with diabetes have a prothrombotic state and a 2 to 4 times higher risk of cardiovascular events than those without diabetes. Aspirin is the cornerstone of treatment in patients withcardiovascular disease, irrespective of diabetes status, being able to confer a 19% relative risk reduction per year in serious vascular events compared with placebo at long-term follow-up (6.7% vs 8.2% per year, p 0.0001). Data regarding the benefit-risk ratio of aspirin prescribed to patients with diabetes without established cardiovascular disease are less convincing, especially when compared to other preventive strategies. Of note, in primary prevention trials, aspirin allocation yielded a significant 12% proportional reduction in serious vascular events, irrespective of diabetes status, corresponding to a small annual absolute risk reduction (0.06% per year). However, in everyday clinical practice aspirin is still largely prescribed by both diabetologists and cardiologists. In this article, we provide eight questions and answers corroborated by available evidence on the use of aspirin for primary prevention of cardiovascular disease in diabetes.

Aims Anatomic knowledge of the tricuspid valve (TV) is the first step in the management of patients with tricuspid regurgitation (TR) who are candidates for transcatheter tricuspid valve intervention (TTVI). Echocardiography is undoubtedly the first approach in assessing the aetiology and severity of TR and the size and function of the right chambers. Computed tomography (CT) provides a detailed morphological visualization of the cardiac structures owing to acquisition of 3D data with high spatial resolution. These findings may undoubtedly help in decision-making progress for novel transcatheter therapies. The purpose of the present study was to assess the geometrical changes of the TV complex using CT images, in patients suffering from functional TR and lead-induced TR. Methods The study population consisted of 21 consecutive patients with symptomatic severe TR referred to Policlinico Universitario Campus Biomedico between November 2020 and October 2021. Patients were prospectively included in the study only if they presented severe TR, diagnosed by echocardiography and underwent cardiac CT study dedicated to the right-chambers. The reconstructions were transferred to an external workstation for off-line image analysis. The following measurements were reported: tricuspid annulus area, perimeter, septal–lateral and antero-posterior diameters. Commissures were identified as antero-septal (AS), postero-septal (PS) and anteroposterior (AP). Were measured the inferior vena cava ostium to tricuspid valve centroid distance, anatomic regurgitant orifice area (AROA) and its position respect to the centroid, and the right chambers. Results All 21 patients underwent CT scan using Siemens SOMATOM Definition AS 128 Slice CT Machine. The measurements were calculated off-line using the 3mensio workstation. In our study population, the annulus resulted enlarged in the annulus area, perimeter, septal-lateral and anterior-posterior dimensions. Measurements did not differ significantly, except for the septal-lateral diameter that was smaller in systole (52.80 ± 7.28 mm vs. 47.83 ± 6.83 mm (P=0.027). Also, distances between the commissures were similar except for the AP-AS distance that was shorter in systole (45.26 ± 3.48 mm vs. 42.13 ± 3.73, P=0.007). The AROA resulted to be central in 7 patients, the IVC ostium to TV centroid distance was 23±3 mm. Right chambers and IVC resulted very enlarged in all patients. Conclusions CT provides a complete morphologic imaging of the heart structures, thanks to a high spatial resolution with excellent capacity to define the endocardial border and allows acquisition of three-dimensional data with high spatial resolution of the TV and provides valuable information about the geometric variations of the tricuspid complex in patients with TR. Image quality for analysis should be optimized with specific CT acquisition protocols that focus on the right ventricles.

Aims The natural history of tricuspid valve (TV) regurgitation is characterized by dismal prognosis and high in-hospital mortality when treated with isolated TV surgery. Although the anatomy and the imaging of the TV are very challenging, the edge-to-edge repair with the TriClip (Abbott Vascular, Santa Clara, CA) showed promising results. We report preliminary results of our experience with the TriClip System in a cohort of ‘real life’ patients with functional tricuspid regurgitation (TR). Methods and results From January to September 2021, 30 consecutive patients with severe TR has been screened, 8 underwent transcatheter TriClip repair. The anatomical feasibility was established according to a complete transesophageal echocardiogram (TEE) and a dedicated CT scan for the right cardiac chambers. All the echocardiographic projections focused on right ventricle were used during the procedure, with the aim of optimizing the visualization of the catheters and device with respect to the anatomical structures of the tricuspid valve complex. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy. In-hospital and 30-day clinical and echocardiographic outcomes were recorded. The annulus septo-lateral diameter was enlarged in all cases, and functional TR was present in all patients. In two patients, the pacemaker lead interfered with leaflets coaptation. TR jet was predominantly central. The implant and procedural success were achieved in all cases, implanting one device in five patients and two in three patients. The final TR grade was 2+ in four patients and and 1+ in the others. All patients were extubated in the catheterization laboratory. There were no procedural or in-hospital adverse events. At 30-day follow-up, we observed significant improvement in clinical and echocardiographic outcomes. Conclusions In our experience, 26% of screened patients were selected for the procedure. Favourable anatomical findings for the TV edge-to-edge repair were the following: moderate leaflet tethering (coaptation depth

Aims Severe tricuspid valve regurgitation (TVR) is critically associated with an increased risk of morbidity and mortality, surgical treatment is limited by high perioperative risk. In these patients, transcatheter edge to edge valve repair (TEER) is progressively recognized as an effective treatment strategy. The aim of this work is to report the single centre experience procedural results and clinical outcomes in ‘real-world’ patients suffering TVR treated with the TriClip™ device (Abbott Vascular, Santa Clara, California). Methods From January up to July 2021, we screened 30 patients with severe TR, among which 8 were treated with TEER. All patients underwent cardiac computerized tomography and both transesophageal and transthoracic echocardiography, with the purpose to identify a dedicated grasping strategy. TEER was performed through right common femoral vein access, advancing a 24 F steerable guiding catheter (SGC) in the right atrium. Following, the TriClip delivery system was advanced and positioned over the valve centroid and, once oriented, the clip was opened. Under fluoroscopic and transesophageal monitoring, the clip was advanced in the right ventricle and pulled back to grasp the target leaflets. Following echocardiographic control, the clip was released. Results Procedural success, defined as a significative reduction of the regurgitation’s severity, was achieved in all patients. No procedural or in-hospital adverse events were reported. At 30 days follow-up, all patients were alive and no further hospitalizations occurred. Conclusions In our single centre experience, TEER appeared to be a valid and feasible therapeutic option in patients with severe TVR. Multicentre prospective studies are mostly needed to assess the long terms outcomes of TEER in these patients, with the purpose to introduce in the clinical practice a valid alternative to the highly risk surgical option.

BACKGROUND The detection of epidural space is usually performed by the technique of loss of resistance (LOR) without technological support, although there are few commercial options. In this work, we aimed to assess the feasibility of a new, non-invasive, mechatronic system for LOR detection in clinical settings. The system allows monitoring the pressure exerted on the syringe plunger by the clinician during the puncture. The LOR is related to the mentioned pressure. METHODS Pressure exerted on the syringe plunger by an expert anesthesiologist was monitored using the proposed system. 58 epidural punctures were performed on 34 patients using six configurations with different sensitivities and ranges of measurements. The system capability in LOR detection was evaluated comparing the LOR detected by the system with the feedback provided by the clinician. The procedure time was estimated using the system and without its use. RESULTS The detection of LOR is strongly related to the system configuration; it ranged from 93.3% to 27.7%, while 3 configurations never detected it. The procedure time showed a non-significant increase (p=0.56) using the proposed system (average time 71 s vs. 62 s). CONCLUSIONS The proposed mechatronic system successfully detected the LOR in the large part of cases using the configurations characterized by the best trade-off between system sensitivity and range of measurements. A non-significant increment of the procedure time is related to the use of the system.

The performance of a precise and safe peripheral nerve blockade (PNB) can currently rely on the aid of the ultrasounds and nerve stimulators. The injection pressure monitoring may be beneficial to perform a safer procedure. This review focuses on the pressures measured during PNB among studies conducted on animal, and human models. From a deep research among the PubMed/MEDLINE database for all reports published in English between January 2004 and November 2018, we selected 15 original papers. We excluded those that were reviews, case-reports, recommendations and correspondences, that did not match with object of our study. We highlighted the available systems for monitoring injection pressures and classified the reports on the basis of the model used for the respective study (animals, humans, in vitro). Intraneural injections were associated with lower pressures than perineural ones. High injection pressures registered at the needle tip were associated with an increased risk of nerve damage. To date, a precise cut-off pressure value has not yet emerged from the literature for a safe PNBs, but based on the recent literature, it can be stated that the threshold of 15 psi is an acceptable value under which a perineural injection can be performed during a PNB to achieve a safer procedure. So it is desirable to make further studies in order to assess them. In the future, the monitoring of the pressure could allow the use of a minimal quantity of anesthetic, empowering the safety of the nerve blocks. Moreover, the sensitive system should not be invasive and it should not hinder the job of the anesthetists.

This study focuses on the development of a noninvasive system for monitoring the force exerted by the anesthesiologist on the syringe during peripheral nerve blocks (PNBs). During this procedure, local anesthetic solutions are injected around a specific peripheral nerve. The injection pressure, and in turn the force exerted by the anesthesiologist may be related to the efficacy and safety of PNBs. The proposed system is based on i) a mechanical part fixed to the syringe used for the injection; ii) three piezoresistive force sensors which measure the force exerted by the anesthesiologist to inject the anesthetic solution. Indeed, the clinician performs the PNB by pushing with three fingers on three different parts of the syringe; iii) a custom printed circuit board, which pre-processes, collects and transmits the relevant signals.During the calibration of the three sensors, the clinical scenario has been mimicked by interposing the finger of a volunteer between the indenter of the testing machine and the active area of each sensor. These experiments provide the calibration curve of the system (for each sensor), which allows estimating the force exerted by the anesthesiologist during the injection of the anesthetic solution during PNB. Finally, the system has been tested on a patient undergoing PNB on adductor canal. During the whole experiment, the system was able to correctly follow the force exerted by the three fingertips of the clinician. These results are promising, but they can be considered just a first step toward the development of a system for supporting the clinician during PNB.