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The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.

The number of elderly patients admitted to cardiac intensive care units (CICU) is significantly increasing. Nowadays, novel diagnostic and therapeutic tools allow to treat the vast majority of cardiac acute diseases, nonetheless care of elderly patients requires a careful clinical evaluation. A favorable proportion of cost-effectiveness is warranted, aimed at avoiding futile procedures or treatments. On the other hand, the availability of minimally invasive procedures carries forward old limits to treatments in elderly patients in CICU. It appears evident that age cannot per se represent a limit in the care of elderly people. The present review gives insights in the management of the most common cardiovascular disease settings in elderly patients in the CICUs, thus providing important tools in complex decision-making.

Cardio-oncology is now part of the standard clinical approach for patients with cancer and cannot be overlooked anymore. While its scientific background is solid and its clinical relevance is well known, its application in daily practice varies greatly among hospitals. To provide the best cardio-oncology care to cancer patients and to make cardio-oncology's clinical use uniform, we developed a shared multidisciplinary proposal for a dedicated clinical pathway. Our proposition presents the minimum requirements needed to which this path caters for, identifies patient categories to be entered into the path, highlights the role of a specific inter-hospital clinical and imaging network and indicates follow-up strategies during and after oncological treatments. The proposed pathway is based on some key elements and is easily adaptable to different hospitals with minimal changes.

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients’ condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01–18.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival.

Percutaneous treatment of heavily calcified coronary lesions still represents a challenge for interventional cardiology, with higher risk of immediate complications, late failure due to stent underexpansion and malapposition, and consequently poor clinical outcome. Good characterisation of calcium distribution with multimodal imaging is important to improve the successful treatment of these lesions. The use of traditional or new dedicated devices for the treatment of calcified lesions allows better lesion preparation; therefore, it is important that we know the different mechanisms and technical features of these devices.

Heavily calcified lesions may be difficult to dilate adequately with conventional balloons and stents, which causes frequent periprocedural complications and higher rates of target lesion revascularisation (TLR). High-pressure non-compliant balloon angioplasty may be of insufficient force to modify calcium and, even when successful, may be limited in its ability to modify the entire calcified lesion. Scoring and cutting balloons hold theoretical value but data to support their efficacy are lacking and, because of their high lesion crossing profile, they often fail to reach the target lesion. Rotational and orbital atherectomy target superficial calcium; however, deep calcium, which may still impact on vessel expansion and luminal gain, is not affected. Intravascular lithotripsy (IVL), based on lithotripsy for renal calculi, is a new technology which uses sonic pressure waves to disrupt calcium with minimal impact to soft tissue. Energy is delivered via a balloon catheter, analogous to contemporary balloon catheters, with transmission through diluted ionic contrast in a semi-compliant balloon inflated at low pressure with sufficient diameter to achieve contact with the vessel wall. With coronary and peripheral balloons approved in Europe, peripheral balloons approved in the USA and multiple new trials beginning, we review the indications for these recently introduced devices, summarise the clinical outcomes of the available trials and describe the design of ongoing studies.

The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists (ANMCO), reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure. Data deriving from a national survey in Italian hospitals about IABP use are also provided.

Cardiogenic shock is a clinical syndrome characterized by hypotension and hypoperfusion due to the inability of the heart to provide adequate cardiac output. It is an infrequent clinical condition still burdened by high mortality rates. In patients with cardiogenic shock rapid diagnosis, multiparameter monitoring and timely therapeutic strategies with pharmacological agents or mechanical circulatory support are necessary to provide adequate peripheral tissue perfusion and to improve outcome. Recent investigations reported lower mortality rates to be associated with clinical pathways based on a well-organized network, and on admission in high-volume specialized hospitals (Shock Center) with a dedicated multidisciplinary team (Shock Team). The aim of this clinical pathway for cardiogenic shock is to describe the best organization to ensure to Tuscan citizens an equal access to care independently of the site where they suffer from cardiogenic shock.

The article reviews the rate of embolic risk in permanent and paroxysmal atrial fibrillation reported in the current literature. The data analyzed suggest that the embolic risk in the two forms of atrial fibrillation is different and therefore careful clinical judgment is needed to offer patients tailored anticoagulation treatments.

The Cardioband system is a transcatheter direct annuloplasty device that is implanted in patients with severe symptomatic functional mitral regurgitation (MR) due to annulus dilatation and high surgical risk. This device covers the posterior two-thirds of the annulus, from the anterolateral to the posteromedial commissure, implanted in close proximity of the left circumflex artery, atrioventricular (AV) conduction system, and coronary sinus. We present the case of an 80-year-old-gentleman with prohibitive surgical risk, treated with Cardioband implantation for functional MR with an evident P1-P2 cleft and P2-P3 indentation, a relative contraindication to MitraClip implantation. We achieved procedural success with significative mitral annulus reduction (30% anteroposterior reduction from 37 to 26 mm) and MR reduction (from grade 4 to grade 1-2). A late onset Mobitz 2 AV block developed after 26 hr and evolved to complete AV block in the following day, requiring definitive biventricular pacemaker (PM). Less than 200 Cardioband implantations have been performed but, to our knowledge, this is the first reported AV block, possibly facilitated by the pre-existing bifascicular block, suggesting the opportunity of prolonged ECG monitoring after Cardioband like any other mechanical transcatheter structural intervention possibly affecting the AV conduction system.

In recent years, transcatheter aortic valve replacement (TAVR) and percutaneous mechanical circulatory support (MCS) systems have seen a widespread diffusion. These devices require the insertion of large femoral sheaths in a population of patients often presenting with calcific peripheral artery disease. Small and severely calcified iliac vessels are associated with increased risk of vascular complications or strategy changes such as the use of an alternative subclavian or transapical approach for TAVR or a conversion to surgery. Intravascular lithotripsy (IVL) technology applies mechanical pressure waves to modify vessel calcifications. It has been applied both in coronary and peripheral calcific disease with promising results. The use in vessel preparation before the insertion of large sheaths is an emerging application of this device. After case reports and presentations of isolated cases, two multicenter registries collected 42 and 12 patients treated with peripheral IVL before TAVR and MCS insertion. In most cases, the largest balloons were used in the iliac arteries with success achieved directly or using a separate insertion sheath in all cases. Low-pressure dilatation during energy delivery avoided dissections or vessel ruptures with no need of postprocedural stent implantation or emergency surgical repair. IVL can successfully modify the arterial compliance and facilitate transfemoral delivery of TAVR or MCS in patients with calcified iliofemoral vessels, reducing the need for alternative TAVR access routes and allowing to perform high-risk coronary procedures with adequate support.

In patients with severe cardiac dysfunction refractory to conventional therapies, extracorporeal membrane oxygenation used in veno-arterious modality can provide temporary circulatory assistance (extracorporeal life support, ECLS). Since it is an invasive and complex technique, its use is potentially burdened by severe complications, thus requiring careful nursing and medical care during intensive cardiac care unit stay. The use of ECLS requires specific skills such as knowledge of protective mechanical invasive ventilation, specific echocardiographic evaluation, accurate monitoring of hemodynamics and laboratory tests. A patient on ECLS is at high risk of thrombotic and hemorrhagic complications that could be fatal, hence specific pro- and anti-hemostatic therapy is needed. Moreover, the knowledge of some peculiar aspects of ECLS system and management can help doctors to avoid several complications such as limb ischemia, left ventricular overload and regional perfusion discrepancy. In conclusion, careful management by adequately trained personnel is required.

Near-infrared spectroscopy (NIRS) is a new intracoronary imaging technique that detects and quantifies cholesterol-rich atherosclerotic plaques. NIRS can be combined with intravascular ultrasound to provide morphological information together with a chemogram of the atherosclerotic plaques. This technique has been used for characterization of unstable plaques, showing a nearly universal presence of high lipid content in patients with ST elevation myocardial infarction or acute coronary syndromes, for prediction of embolization risk and for assessing the effects of cholesterol-lowering therapy. The main potential advantage of NIRS is the identification of vulnerable plaques at high risk, to be targeted by local treatment and more aggressive preventive measures.

In the last years, non-invasive imaging with multidetector computed tomography on one side and echocardiography with Doppler-based estimation of cardiac pressures and gradients on the other have largely replaced invasive measurements and angiographic studies of great vessels in the catheterization laboratory. Multidetector computed tomography has become a widely used diagnostic method of screening but coronary angiography remains the gold standard for assessment of epicardial coronary vessels in patients with chest pain and a high risk of coronary disease, acute coronary syndrome, or patients waiting for cardiac surgery. Coronary angiography, unlike all other non-invasive imaging techniques, permits a percutaneous myocardial revascularization to be performed immediately. Ventriculography and aortography can be used to confirm information obtained from non-invasive techniques. In the last years, transradial access has become the preferred vascular access for coronary angiography in most catheterization laboratories, leading to a major decrease of vascular complications.

When TAVR is performed with transfemoral percutaneous approach, local anesthesia, no routine post-procedural intensive care admission, an early discharge (

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) represents a therapeutic option in patients with refractory cardiogenic shock (RCS). This strategy is limited to a restricted number of centres with capabilities for implanting VA ECMO and management patients on this support. We report on the initial experience of our ECMO referral centre for patients with RCS.We retrospectively analysed our ECMO data registry for RCS of 14 patients treated with VA ECMO, consecutively admitted to our intensive cardiac care unit (ICCU), which is an ECMO referral centre.Six patients (6/14, 42%) came from peripheral centres, four were transferred to our ICCU directly. During ICCU stay, four patients died (28.5%) due to multi-organ failure, seven showed a complete recovery while one underwent cardiac transplantation. The remaining two patients died while waiting for cardiac transplantation because of cerebral haemorrhage. The 30-day overall mortality rate was 42.8%, all survivors showed a good neurologic outcome.In our series, the survival rate of RCS patients supported by VA ECMO is high (57%) and the transfer of RCS patients is feasible and safe. Our data support that a network for RCS is needed to transfer patients in well experienced centres even on ECMO support.

Cardiogenic shock (CS) is a rare disease that needs a rapid and multiparameter diagnosis and a timely, aggressive and multidisciplinary goal-oriented treatment. Recently published epidemiological studies and registries underline how SC represents an infrequent clinical entity still burdened by high mortality rates, substantially unchanged over the years. Currently, only few patients with CS are treated with circulatory assistance in dedicated centers. Some consensus documents and expert recommendations emphasize the importance of early diagnosis of CS, immediate pharmacological support, and treatment of precipitating causes, and stress the need for hospitalization in high-volume intensive care centers. The aim of this review is to show the instructions for the creation of a SC network, emphasizing the necessary elements, in agreement with available resources and existing health regulations for giving the same care opportunities to all the patients.

Fractional flow reserve (FFR) is considered the gold standard for functional assessment of coronary stenosis in stable coronary artery disease. The use of FFR enables an ischemia-guided revascularization with improvement of clinical outcomes in a cost-effective fashion. Both clinical and interventional cardiologists should be aware of the advantages and potential pitfalls of this technique. We focus on FFR with the aim to provide the clinical cardiologist with information on indications and technical aspects to confirm a correct execution of FFR in different coronary anatomical settings.

The DESolve (Elixir Medical Corporation, Sunnyvale, California, USA) is a poly-L lactide-based polymer scaffold coated with the antiproliferative and anti-inflammatory drug novolimus. The scaffold biodegrades within one year with a complete resorption in two years and in vitro bench test have shown the ability to supply the necessary radial strength to support the vessel for the critical 3- to 4-month period after implant. The DESolve showed the unique self-correction property, which may reduce the incidence of minor malapposition after deployment. Overexpansion with DESolve is safe since a high capability resistance to fracture has been demonstrated with this scaffold. The aim of this review is to provide a comprehensive overview of the available preclinical and clinical data regarding the DESolve.

Successful percutaneous coronary intervention of chronic total occlusions (CTO) is associated with favorable clinical outcomes in selected subsets of patients. The success rate of CTO interventions greatly increased over the last decades, thanks to the development of dedicated materials and interventional strategies. Nevertheless, CTO interventions are still challenging with higher complication rates and lower success rates compared to standard percutaneous coronary interventions. Dedicated CTO operators are warranted in order to minimize the rate of complications and to achieve a success rate near to 90%. This state of the art paper is aimed to provide updated evidences on the clinical benefit of CTO recanalization and to describe specific interventional techniques for CTO recanalization.

tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr 2010;23:351–69. [3] Udink ten Cate FE, Schmidt BE, Sudholt H, Wilmes C, Sreeram N. Speckle tracking echocardiography in childhood myocarditis: spontaneous reversal of severe left ventricular rotational abnormalities during follow-up. Int J Cardiol 2011;151:257–60. [4] Takahashi K, Al Naami G, Thompson R, Inage A, Mackie AS, Smallhorn JF. Normal rotational, torsion and untwisting data in children, adolescents and young adults. J Am Soc Echocardiogr 2010;23:286–93. [5] Markus KA, Mavinkurve-Groothuis MA, Barends M, et al. Reference values for myocardial two-dimensional strain echocardiography in a healthy pediatric and young adult cohort. J Am Soc Echocardiogr 2011;24:625–36.

2016 can be hardly described as a year of revolutions in interventional cardiology. Still multiple randomized studies supported the 3 to 5 year efficacy of metallic drug eluting stents in left main disease, cast doubts on long-term outcome after fully biodegradable stents, discouraged routine thrombectomy during primary PCI, gave a mixed message on the importance of physiological guidance of coronary revascularization, helpful for non-culprit lesions in STEMI, questionable for multivessel disease in allcomers, and defeated the paradigm that a fully arterial surgical revascularization delivers better clinical outcome. ### Revascularization vs. medical therapy We start this review of transcatheter interventions with a trial where bypass surgery rather than stent-assisted angioplasty was used and compared with medical therapy. STICH1 (Surgical Treatment for Ischemic Heart Failure) compared optimal medical therapy (OMT) and surgical revascularization with coronary artery by-pass grafting (CABG) in 1215 patients with left ventricular ejection fraction (LVEF) ≤35%. The negative results at 4.8 years of the original presentation in 2010 (death from any cause in 41% of patients in OMT and 36% in the CABG group, P = 0.12) justified the conservative attitude of our heart failure colleagues towards myocardial revascularization. In 2010–2013, in USA only 17.5% of 67 161 patients hospitalized for new onset heart failure underwent testing for ischemic CAD during the index hospitalization.2 The highlight of the European Society of Cardiology Congress 2016 in Rome was the presentation of the results at 9.8 years of STICHES3 (Surgical Treatment for Ischemic Heart Failure Extension Study), showing progressive divergence of the curves for mortality (66.0% in OMT group vs. 58.9% in the CABG group, P = 0.02) and cardiovascular mortality (49.3% vs. 40.5%, respectively, P = 0.006), with a significant difference in favour of the surgical arm. In the CABG group, the NNT to prevent one death was 14, though mortality was high in both groups. This trial has implications …

Hyperlactataemia is commonly used as a diagnostic and prognostic tool in intensive care settings. Recent studies documented that serial lactate measurements over time (or lactate clearance), may be clinically more reliable than lactate absolute value for risk stratification in different pathological conditions. While the negative prognostic role of hyperlactataemia in several critical ill diseases (such as sepsis and trauma) is well established, data in patients with acute cardiac conditions (i.e. acute coronary syndromes) are scarce and controversial. The present paper provides an overview of the current available evidence on the clinical role of lactic acid levels and lactate clearance in acute cardiac settings (acute coronary syndromes, cardiogenic shock, cardiac surgery), focusing on its prognostic role.