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Introduction The diagnosis of constrictive pericarditis can be challenging through conventional imaging. Novel imaging techniques have been proposed to improve it. Clinical Case A 74-year-old man with a previous diagnosis of heart failure with preserved ejection fraction and permanent atrial fibrillation (AF) was admitted because of worsening dyspnea, peripheral edema, and ascites refractory to diuretics therapy. ECG revealed low QRS voltages and AF with normal heart rate and laboratory exams detected increased values of BNP and hepatic stasis indices; blood count and CRP were normal. Echocardiography revealed mildly reduced bi-ventricular pump function (left ventricular ejection fraction = 52%, right ventricular fractional area change = 25%) and slightly increased wall thickness. Atria were moderately dilated (left and right atrium 46 and 44 ml/mq, respectively) and mitral and tricuspid annuli were dilated too. There was inferior vena cava plethora, moderate atriogenic tricuspid regurgitation and mild-to-moderate atriogenic mitral regurgitation. A paradoxical interventricular septal motion and significant respiratory changes on trans-mitral (>25%) and trans-tricuspid (>30%) pulsed Doppler were noted; however, there was no "annulus reversus" (lateral and septal e’ 13 and 11 cm/sec, respectively) at TDI analysis. In contrast, 2D-speckle-tracking global longitudinal strain showed impaired deformation ​​of the lateral segments with relative sparing of the septal segments. The latter pattern has been recently described as "strain reversus" or "hot septum sign". The findings were suspected of constrictive pericarditis, but a chest Computed Tomography excluded pericardial calcifications. Cardiac magnetic resonance (CMR) was then performed revealing a "septal shift" at cine-real time sequences analysis. The pericardium was slightly thickened (4-5 mm) with widespread late gadolinium enhancement but without signs of acute inflammation at T2-weighted imaging. Tricuspid regurgitation was confirmed to be "moderate" after phase-contrast imaging. Cardiac catheterization finally revealed normal coronary arteries and confirmed the diagnosis of constrictive pericarditis (square root sign, equalization of bi-ventricular end-diastolic pressures). The patient underwent pericardiectomy and tricuspid and mitral valve repair and was asymptomatic at 6-months follow-up. Conclusions Constrictive pericarditis represents a potentially reversible cause of heart failure but can be easily missed through conventional imaging. In the present case, advanced echocardiography and CMR were essential to come up with an accurate diagnosis, guiding the patient's clinical management with excellent outcome.

Ventricular assist devices (VADs) are considered the standard of care for end-stage heart failure (HF) patients. Despite increasing confidence in the technology, evidence data, endorsement by scientific societies and guidelines, the number of implants reached a steady state and is not increasing at the expected pace. This is most likely related to complications that are still burdening the technology and consequently excluding the most needy, ill, and fragile population. In this manuscript we are reporting a single-center experience in a very fragile, elderly and end-stage HF population, with a superficial, partial support device: the CircuLite Synergy. The patients were included in the pre-CE mark clinical study and consequently the device underwent technical adjustment during the support, based on the complications recorded. At our institution were implanted 6 patients overall: 3 patients survived to discharge and 2 survived up to 5 years. Most of the complications recorded were due to patients' frailty and overall clinical conditions. The initial experience with the CircuLite Synergy device is proving that a more "superficial" device might be more tolerable in an elderly, frail population. Partial support has proven hemodynamically efficacious and efficient in relieving heart failure symptoms, improving medical therapy tolerability, and improving quality of life. Unfortunately, the technology was not made available due to financial uncertainty and poor management, but we hope that once the concept has been proved someone will collect the legacy.

Aims Repetitive Levosimendan treatment in advanced heart failure patients has not been investigated yet via myocardial work indices (MWI), which could more accurately detect the effects of this both inotropic and vasodilatory drug. The aims of this study were (1) to describe variations of myocardial work indices, as a consequence of repetitive Levosimendan infusions and (2) to assess the prognostic value of myocardial work parameters in these patients. Methods and results Fourteen patients with advanced heart failure treated with intermittent in-hospital levosimendan infusions were prospectively included. Clinical, laboratory, and echocardiographic assessment were performed before and after every Levosimendan infusion. The primary endpoint was a composite of any episode of decompensated HF, urgent HF rehospitalization, cardiogenic shock, cardiac arrest and cardiovascular death at 4–6 weeks follow-up after each planned infusion. During follow-up (mean: 150 ± 99 days) a total of 37 infusions were performed and a total of 11 cardiovascular events occurred. Global constructive work (GCW), global work efficiency (GWE), and global work index (GWI) increased after Levosimendan infusion in 62.2%, 73.0%, and 70.3% of cases, with significant differences between patients with and without outcomes [delta GCW: −7.36 mmHg% (134.12) vs. 113.81 mmHg% (204.41), P = 0.007; delta GWE: −3.27% (8.38) vs. 4.30% (5.58), P = 0.002]. Delta value of GWE showed the largest area under curve (AUC: 0.82, 95% CI: 0.64–1.00, P = 0.002) for outcome prediction with a cut-off point of 0.5%. Independent prognostic value of GWE variation was confirmed in multivariable regression models (OR: 0.825, 95% CI: 0.702–0.970, P = 0.02). Conclusions GWE and GCW provided incremental and independent prognostic value at short-term follow-up over traditional echocardiographic parameters. The differentiation of patients into ‘workers’, whose GWE improved after Levosimendan infusion, and ‘non-workers’, who failed to improve their GWE, permitted to identify patients at higher risk of forthcoming cardiovascular events. Monitoring these patients with MWI may have relevant clinical implications.

Rapid deployment aortic valve prostheses have become a common solution for aortic valve replacement. While >mild prognostic paravalvular leaks are not infrequent, their treatment is not yet clear. We report the case of an 82-year-old man that presented with acute heart failure. Previously implanted rapid deployment bioprosthetic aortic valve (Intuity Elite, Edwards Lifesciences, Irvine, California) presented a significant paravalvular leak that seemed to be secondary to valve underexpansion. Percutaneous balloon post dilation was performed and resulted in better expansion of the valve and its sealing skirt with a significant reduction of the leak.

The Agent paclitaxel-coated balloon is a new drug-coated balloon (DCB) with few available real-world data. Our study sought to assess the safety and efficacy of the Agent DCB during percutaneous coronary intervention (PCI) in different coronary lesion types in a prospective registry.All patients undergoing PCI with the Agent DCB at three Italian centers between September 2014 and March 2018 were included in this registry. Major adverse cardiac event (MACE) rate was defined as the composite of cardiac death, recurrent non-fatal myocardial infarction (MI), and target-lesion revascularization (TLR). Procedural success was also evaluated. Among the 354 patients included in the registry (450 lesions treated with 508 DCBs), Agent DCBs were used for the treatment of in-stent restenosis (ISR) in 34%, small-vessel disease (SVD) in 29%, bifurcation lesions in 26%, and "stent-like result" (SLR) lesions obtained after balloon predilation in 11%. The implantation of Agent DCBs was safe and had a high DCB lesion success rate of 92%. One-year MACE rate was 5.7% in the overall population. A higher MACE rate was observed in the ISR group (8.3%) vs the SVD group (3.6%; P=.03), with a trend toward higher event rates vs both BL (3.7%; P=.09) and SLR patients (5.5%; P=.54).The use of Agent DCBs during PCI appears safe and effective in a large real-world registry. These results were maintained in all subgroups, with a slightly higher trend of events rates in the ISR setting, consistent with the higher-risk nature of this patient subset.

Tricuspid regurgitation (TR) has a considerable prevalence in the overall population, that further increases in selected categories of patients. Three morphologic types of TR prevail, namely primary, secondary and atrial TR, mostly, but not always, occurring in different subsets of patients. Recent evidences demonstrate a negative impact of TR on outcomes, irrespective of etiology and even when less than severe in grading. Unfortunately, current surgical standards are void of strong prospective evidence of positive impact on clinical outcomes. While on one hand recent advances in diagnosis and risk stratification of patients with TR are shedding light onto the population that may benefit from intervention and its appropriate timing, on the other hand the arrival on stage of percutaneous treatment options is widening even more the therapeutic options for such population. In this review we will address and discuss the available evidence on the prognostic impact of TR in different clinical contexts encountered in practice.

The aim of this study was to determine the utility of rapid atrial pacing immediately after transcatheter aortic valve replacement (TAVR) to predict the need for permanent pacemaker implantation (PPI).Risk stratification for patients without high-grade atrioventricular block (AVB) after TAVR is imprecise and based on anatomic considerations, electrocardiographic characteristics, and clinical suspicion. A more reliable assessment is necessary to minimize inpatient rhythm monitoring and/or reduce unnecessary PPI.Consecutive patients undergoing TAVR at 2 centers were included. After valve implantation in patients without pacemakers who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Rapid atrial pacing was performed from 70 to 120 beats/min, and patients were assessed for the development of Wenckebach AVB. Patients were then followed for clinical outcomes, including PPI.A total of 284 patients were included. Of these, 130 (45.8%) developed Wenckebach AVB. There was a higher rate of PPI within 30 days of TAVR among the patients who developed Wenckebach AVB (13.1% vs. 1.3%; p 0.001), with a negative predictive value for PPI in the group without Wenckebach AVB of 98.7%. A greater percentage of patients receiving self-expanding valves required PPI than those receiving a balloon-expandable valves (15.9% vs. 3.7%; p = 0.001), though these rates were still relatively low among patients who did not develop Wenckebach AVB (2.9% and 0.8%).Atrial pacing post-TAVR is easily performed and can help identify patients who may benefit from extended rhythm monitoring. Patients who did not develop pacing-induced Wenckebach AVB demonstrated an extremely low likelihood of PPI.

BACKGROUND The role of C2238/atrial natriuretic peptide (ANP) minor allele, at the T2238C ANP gene variant, as a predisposing risk factor for acute cardiovascular events, has been previously reported. We aimed at evaluating, by a retrospective approach, the long-term impact of C2238/ANP-minor allele carrier status toward the risk of recurrent acute coronary syndromes (re-ACS) in an Italian cohort of ischemic heart disease patients. METHODS A total of 379 patients (males = 80.5%; mean age = 62.5 ± 9.2 years) presenting with ACS were retrospectively analyzed. Mean follow-up was 5.1 ± 3.5 years (range 1-26 years). Occurrence of new episodes of unstable angina, non-ST-segment elevation myocardial infarction and STE myocardial infarction over the years was recorded and compared between subjects not carrying and carrying C2238/ANP-minor allele. RESULTS At univariate analysis, C2238/ANP-minor allele carrier status and treatment with beta-blocker, aspirin and statin were associated with risk of re-ACS. Multivariate analysis confirmed that hypercholesterolemia (P

Percutaneous coronary angioplasty celebrated its 40th anniversary and gained an established role thanks to its remarkable results. The progressive development of techniques and materials together with a better understanding about the pharmacological treatment of patients with coronary artery disease contributed to this success. Nowadays percutaneous treatments have become a valid alternative to coronary artery bypass graft surgery in many patients. In this article we will highlight practical "tips and tricks" to improve the performance and the results of percutaneous coronary interventions.

Hypertension causes target organ damage (TOD) that involves vasculature, heart, brain and kidneys. Complex biochemical, hormonal and hemodynamic mechanisms are involved in the pathogenesis of TOD. Common to all these processes is an increased bioavailability of reactive oxygen species (ROS). Both in vitro and in vivo studies explored the role of mitochondrial oxidative stress as a mechanism involved in the pathogenesis of TOD in hypertension, especially focusing on atherosclerosis, heart disease, renal failure, cerebrovascular disease. Both dysfunction of mitochondrial proteins, such as uncoupling protein-2 (UCP2), superoxide dismutase (SOD) 2, peroxisome proliferator-activated receptor γ coactivator 1-α (PGC-1α), calcium channels, and the interaction between mitochondria and other sources of ROS, such as NADPH oxidase, play an important role in the development of endothelial dysfunction, cardiac hypertrophy, renal and cerebral damage in hypertension. Commonly used anti-hypertensive drugs have shown protective effects against mitochondrial-dependent oxidative stress. Notably, few mitochondrial proteins can be considered therapeutic targets on their own. In fact, antioxidant therapies specifically targeted at mitochondria represent promising strategies to reduce mitochondrial dysfunction and related hypertensive TOD. In the present article, we discuss the role of mitochondrial oxidative stress as a contributing factor to hypertensive TOD development. We also provide an overview of mitochondria-based treatment strategies that may reveal useful to prevent TOD and reduce its progression.

1. IntroductionRenovascular hypertension is one of the most common forms ofsecondary hypertension, and its prevalence is estimated between 1and 5% in the general hypertensive population [1]. Amongst theseconditions, renal artery stenosis (RAS), defined as N50% stenosis of therenalarterylumen,representsoneoftheleadingcausesofrenovascularhypertension.Itisfrequentlyrelatedtothepresenceofrenalatheroscle-rosis (predominantly in elderly individuals), fibro-muscular dysplasia(FMD) and arteritis (more often in young women). Compared to otherclinical conditions, FMD shows different aetiology, as well as differentclinical presentation, prognosis and therapeutic options [2].We describe here an atypical clinical presentation of RAS due toFMD occurred in a young otherwise healthy woman, then analysingthe diagnostic and therapeutic work-out.2. Clinical case reportA 46-year-old woman had an acute hospital admission for 3-dayworsening dyspnoea on mild efforts (New York Health Association[NYHA] classes II–III) and dry cough by 3 weeks. In her medical historysmokinghabit,familyhistoryforcoronaryarterydiseaseandoccasionalepisodes of severe and pulsing headache, resolved with non-steroidalanti-inflammatory drug assumption (indomethacin), were reported.AttheadmissiontoEmergencyDepartment,thephysicalexaminationshowed a normal female phenotype with gallop rhythm, no detectableheart or vascular (including abdominal) bruits, and pulsating peripheralarteries. Slight swelling jugular and ankle oedema with decreasedbreath sounds at the bilateral lung bases were also described. Clinicblood pressure (BP) levels were 185/100 mm Hg, and heart rate was92bpm.The12-leadelectrocardiogramshowedasinusrhythm,biatrialenlargement signs and left ventricular hypertrophy, according toCornellvoltagecriteria(Fig.1).ThechestX-rayshowedbilateralpleuraleffusions and partial atelectasis of the lower lobes. Echocardiographicexamination confirmed the presence of concentric left ventricle hyper-trophy (left ventricular mass indexed for height^2.7 80.98 g/m^2.7,relative wall thickness 0.54), biatrial enlargement, mild reduction ofleft ventricular ejection fraction reduction (45%), and restrictive fillingat transvalvular Doppler assessment (E/A ratio 2.07). Moderate mitraland mild tricuspid regurgitations with slight increase of pulmonaryarterypressure,mildpericardialeffusionandanenlargementofinferiorvena cava, that was partially collapsible during inspiration, were alsodescribed.Haematological tests reported a slight hypokalaemia (2.9 mmol/l)with creatinine value of 1.5 mg/dl and estimated (Cockroft–Gaultformula) glomerular filtration rate (GFR) of 40 ml/min, slight anaemia(12.1 g/dl of haemoglobin) and increased levels of pro-BNP levels(11,886 pg/ml). The urine collection analysis revealed a slight protein-uria (266 mg/24 h). Also, thyroid hormonal profile and autoimmunityscreening with anti-double strand DNA, Anti Nuclear (ANA), andExtractable Nuclear Antigens (ENA) antibodies dosages did not showabnormal values.The patient was initially treated with intravenous infusion ofcentrally-acting alpha2-adrenergic agonist (clonidine) and potassiumsupplement with progressive BP reductions. In addition, antihyperten-sive treatment with angiotensin-converting enzyme inhibitors (ACEIs),beta-blockers (BBs), calcium channel blockers (CCBs), loop diureticsand spironolactone was started and titrated, with further BP reductionswithout achieving effective BP control [3].After admission to the Cardiology Division, sudden worsening ofrenal function (creatinine value of 2.2 mg/dl and estimated GFR of25 ml/min) was observed, paralleled by increased serum potassiumlevels (5.7 mmol/l) and worsened control of clinic BP levels, despiteoptimal antihypertensive therapy. In view of the clinical suspicion ofrenovascular hypertension, antihypertensive therapy was modified, by

Cardiorenal syndrome is a frequently encountered clinical condition when the dysfunction of either the heart or kidneys amplifies the failure progression of the other organ. Complex biochemical, hormonal and hemodynamic mechanisms underlie the development of cardiorenal syndrome. Both in vitro and experimental studies have identified several dysregulated pathways in heart failure and in chronic kidney disease that lead to increased oxidative stress. A decrease in mitochondrial oxidative metabolism has been reported in cardiomyocytes during heart failure. This is balanced by a compensatory increase in glucose uptake and glycolysis with consequent decrease in myocardial ATP content. In the kidneys, both NADPH oxidase and mitochondrial metabolism are important sources of TGF-β1-induced cellular ROS. NOX-dependent oxidative activation of transcription factors such as NF-kB and c-jun leads to increased expression of renal target genes (phospholipaseA2, MCP-1 and CSF-1, COX-2), thus contributing to renal interstitial fibrosis and inflammation. In the present article, we postulate that, besides contributing to both cardiac and renal dysfunction, increased oxidative stress may also play a crucial role in cardiorenal syndrome development and progression. In particular, an imbalance between the renin-angiotensin-aldosterone system, the sympathetic nervous system, and inflammation may favour cardiorenal syndrome through an excessive oxidative stress production. This article also discusses novel therapeutic strategies for their potential use in the treatment of patients affected by cardiorenal syndrome.

BACKGROUND High blood pressure (BP) levels expose patients treated with percutaneous coronary interventions (PCI) to very high risk of 10-year cardiovascular morbidity and mortality. OBJECTIVE To investigate the role of BP levels at the time of PCI on the risk of in-stent restenosis (ISR). METHODS We retrospectively included 796 patients previously treated with PCI, who underwent repeated angiography for recurrent angina or reversible myocardial ischemia. Patients were stratified into either case (n = 354) and control (n = 442) groups in the presence or absence of ISR (defined as in-stent diameter stenosis ≥50%). BP levels were measured at the time of first and second procedures. Normal BP levels were defined for

Background: Hypertension represents a major cardiovascular risk factor with relevant consequences on morbidity and mortality in the general population. An optimal control of blood pressure (BP) is far from being achieved. Aim: The objective of this study was to explore awareness of BP levels, prevalence of risk factors and status of hypertension control in a sample of the Italian general population. Methods: Subjects aged 18 years or older were enrolled on a voluntary basis during the 7th and 8th World Hypertension Days at our hospital centre, S. Andrea Hospital in Rome, and at other hospitals throughout the Italian Lazio region. Along with BP measurement, a short questionnaire was completed at the time of the interview. Results: Of 1165 individuals enrolled into the analysis, 71.7% were aware of their BP levels (82.5% among hypertensive patients). Within the whole cohort, 31.9% of subjects were under antihypertensive treatment, while the overall rate of subjects found to be hypertensive patients at our visit was 52.9% (n = 616). Among hypertensive patients taking antihypertensive drugs, 47.1% had controlled BP values with the remaining 52.9% showing uncontrolled hypertension. Mean systolic blood pressure (SBP) was 138.2±20.7mmHg and mean diastolic blood pressure (DBP) was 80.4±11.3mmHg in subjects receiving antihypertensive treatment. Among older hypertensive patients (71–94 years of age), only 76.9% were under treatment. Hypertensive males were more frequently treated than females in all age groups (p = 0.001). Smoking habit negatively affected efficacy of antihypertensive therapy in the age groups of 48–53 and 54–62 years (p = 0.008 and p = 0.01, respectively). Diabetic patients had higher mean SBP values than non-diabetic subjects (137.3±22.1 vs 129.3±18.2mmHg, p = 0.02). Conclusion: The results of our survey strongly support the need for a continuing educational effort aimed at providing correct advertisement of healthy lifestyles and awareness of adequate BP control. Based on our observations, particular attention has to be paid to women, younger subjects, elderly subjects and diabetic patients in order to reach appropriate BP control and reduction of cardiovascular risk in these subject categories.

s 153 Clinica Medica, Department of Medical and Surgical Sciences, University of Brescia, Brescia, Italy Clinica Chirurgica, Department of Medical and Surgical Sciences, University of Brescia, Brescia, Italy Chair of Ophthalmology, University of Brescia, Brescia, Italy Chair of Ophthalmology, University of Molise, Campobasso, Italy Chair of Ophthalmology, University of Ferrara, Ferrara, Italy Structural alterations of subcutaneous small resistance arteries, as indicated by an increased media to lumen (M/L) ratio, are frequently present in hypertensive and/or diabetic patients, and may represent the earliest alteration observed. In addition, M/L of small arteries evaluated by micromyography has a strong prognostic significance; however its extensive evaluation is limited by the invasivity of the assessment, since a biopsy of subcutaneous fat is needed. Non-invasive measurement of wall to lumen (W/L) of retinal arterioles using scanning laser doppler flowmetry (SLDF) has been recently introduced (Harazny J et al, Hypertension 2007; 50:623-629). However, this new technique was never compared with micromyographic measurement, considered the gold standard approach. Methods and Results: We have investigated 37 subjects and patients. Twenty-three of them were hypertensives and 14 normotensives. Blood pressure values were 139/88 17/10 mmHg and 125/71 17/12 mm Hg, respectively (p