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Background: The natural history of tricuspid valve regurgitation (TR) is characterized by poor prognosis and high in-hospital mortality when treated with isolated surgery. We report the preliminary echocardiographic and procedural results of a prospective cohort of symptomatic patients with high to prohibitive surgical risk and at least severe TR who underwent transcatheter edge-to-edge repair through the TriClipTM system. Methods: From June 2020 to March 2022, 27 consecutive patients were screened, and 13 underwent transcatheter TriClipTM repair. In-hospital, 30-day and six-month clinical and echocardiographic outcomes were collected. Results: Nine patients had severe, three massive and one baseline torrential TR. Sustained TR reduction of ≥1 grade was achieved in all patients, of which 90% reached a moderate TR or less. On transthoracic echocardiographic examination, there were significant reductions in vena contracta width (p < 0.001), effective regurgitant orifice area (p < 0.001) and regurgitant volume (p < 0.001) between baseline and hospital discharge. We also observed a significant reduction in tricuspid annulus diameter (p < 0.001), right ventricular basal diameter (p = 0.001) and right atrial area (p = 0.026). Conclusion: Treatment with the edge-to-edge TriClip device is safe and effective. The resulting echocardiographic improvements indicate tricuspid valve leaflet approximation does not just significantly reduce the grade of TR but also affects adjacent structures and improves right ventricular afterload adaptation.

Gli studenti dovrebbero già possedere all'inizio del loro percorso universitario buone competenze di scrittura, ma spesso incontrano notevoli difficoltà, dovute essenzialmente a due motivi: il primo riguarda l'eterogeneità delle scuole secondarie di provenienza; il secondo, l'ambito universitario, nel quale la capacità di scrittura è assunta come acquisita in via definitiva, e non più insegnata né esercitata. Diventa sempre più necessario promuovere percorsi di attenzione e riflessione sull'uso della lingua scritta, in modo da rendere gli studenti consapevoli del suo valore comunicativo, legato alla partecipazione alla vita sociale e intellettuale, all'assunzione di responsabilità, all'impegno a mantenere un'attitudine critica verso se stessi e gli altri. Questo volume evidenzia il valore della scrittura come elaborazione intellettuale, il tema dell'autoregolazione dell'apprendimento, il ruolo del pensiero creativo e critico nei curricoli universitari e l'importanza del saggio argomentativo come tipologia testuale che permette una valutazione accurata della competenza in lingua scritta. Per condurre questa rilevazione le autrici presentano anche una guida operativa, costruita proprio in base alle particolari esigenze dell'università, utilizzabile come base per la formulazione di un piano didattico di intervento.

Functional mitral regurgitation (FMR) and tricuspid regurgitation (FTR) occur due to cardiac remodeling in the presence of structurally normal valve apparatus. Two main mechanisms are involved, distinguishing an atrial functional form (when annulus dilatation is predominant) and a ventricular form (when ventricular remodeling and dysfunction predominate). Both affect the prognosis of patients with heart failure (HF) across the entire spectrum of left ventricle ejection fraction (LVEF), including preserved (HFpEF), mildly reduced (HFmrEF), or reduced (HFrEF). Currently, data on the management of functional valve regurgitation in the various HF phenotypes are limited. This review summarizes the epidemiology, pathophysiology, and treatment of FMR and FTR within the different patterns of HF, as defined by LVEF.

Background: Computed tomography (CT) is the recommended imaging technique for defining the anatomical suitability for current transcatheter technologies and planning tricuspid valve (TV) intervention. The aim of the Tricuspid Regurgitation IMAging (TRIMA) study was to assess the geometrical characteristics of the TV complex using novel CT parameters. Methods: This prospective, single-center study enrolled 22 consecutive patients with severe tricuspid regurgitation, who underwent a cardiac CT study dedicated to the right chambers. The following variables were obtained: annulus area and perimeter, septal-lateral and antero-posterior diameters, tenting height, and anatomical regurgitant orifice area. Moreover, the following novel annular parameters were assessed: distance between commissures, distance between TV centroid and commissures, and angles between centroid and commissures. Results: A significant phasic variability during the cardiac cycle existed for all variables except for eccentricity, angles, and distance between the postero-septal and antero-posterior commissure and distance between the centroid and antero-posterior commissure. There was a significant relationship between the TV annulus area and novel annular parameters, except for annular angles. Additionally, novel annular variables were found to predict the annulus area. Conclusions: These novel additional variables may provide an initial platform from which the complexity of the TV annular morphology can continue to be better understood for further improving transcatheter therapies.

Background: Cardiac computed tomography (CT) provides important insights into the geometrical configuration of the tricuspid valve (TV). The purpose of the present study was to assess the geometrical changes of TV in patients with functional tricuspid regurgitation (TR) using novel CT scan parameters and to correlate these findings with echocardiography. Methods: This single-center study enrolled 86 patients undergoing cardiac CT and divided them into two groups according to the presence or not of severe TR (43 patients with TR ≥ 3+ and 43 controls). The measurements collected were as follows: TV annulus area and perimeter, septal-lateral and antero-posterior annulus diameters, eccentricity, distance between commissures, segment between the geometrical centroid and commissures, and the angles of commissures. Results: We found a significant correlation between all annulus measurements and the grade of TR, except in regard to angles. TR ≥ 3+ patients had significantly larger TV annulus area and perimeter, larger septal-lateral, and antero-posterior annulus dimensions, as well as larger commissural distance and centroid-commissural distance. In patients with TR ≥ 3+ and controls, the eccentricity index predicted a circular shape and an oval shape of the annulus, respectively. Conclusions: These novel CT variables focusing on commissures increase the anatomical understanding of the TV apparatus and the TV geometrical changes in patients with severe functional TR.

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

Nowadays, severe symptomatic tricuspid regurgitation (TR) affects millions of persons worldwide. However, the benefit of surgical correction of isolated secondary TR remains controversial because of the increased risk of periprocedural mortality and morbidity. In recent years, novel transcatheter tricuspid valve interventions (TTVI) were developed to treat TR, so that TTVI is currently considered in symptomatic, inoperable, anatomically eligible patients. TTVI can be divided into these five domains: edge-to-edge leaflet repair, tricuspid annuloplasty, caval implants, spacer, and total valve replacement. Each transcatheter intervention needs specific imaging protocols for assessing the anatomical feasibility and consequentially predicting the procedural success. This review summarizes the available multimodality imaging tools for screening patients with TR, and identifies anatomical characteristics to choose the best option for the patient.

RATIONALE Marfan syndrome is a rare cause of heart failure due to primary or secondary cardiomyopathy. Recently, sacubitril/valsartan-an angiotensin receptor blocker-neprilysin inhibitor-has been added in clinical practice as a standard therapy for heart failure. To our knowledge, there are no data on sacubitril/valsartan's effects on cardiovascular outcomes in patients with Marfan syndrome. PATIENT CONCERNS A 24-year-old man was admitted to our Internal Medicine Department due to dyspnea, ascites, and leg swelling. Arterial blood gas analysis revealed severe hypoxemia with respiratory and metabolic alkalosis. Hilar congestion was highlighted on chest x-ray. DIAGNOSES Recurrent acute decompensated heart failure with reduced ejection fraction despite optimal medical therapy in Marfan-related cardiomyopathy. INTERVENTIONS AND OUTCOMES Sacubitril/valsartan was added to optimal medical therapy after hemodynamic stabilization allowing progressive clinical, laboratoristic, and echocardiographic improvement. Patient maintained a free survival from heart failure and a good quality of life until 9-month follow-up. LESSONS Sacubitril/valsartan should be effective on pathophysiologic mechanisms and cardiovascular outcomes of Marfan syndrome-related cardiovascular complications.

Nephropathic subjects show an increased tendency to develop cardiovascular diseases, mainly as the consequence of several risk factors including increased oxidative stress, inflammation, physical inactivity, anemia, vascular calcification, and endothelial dysfunction. The alterations in lipid metabolism represent a relatively lesser important cause of genesis and progression of atherosclerosis. Unfortunately, in these patients the atherogenic potential of dyslipidemia may depend more on apolipoproteins than on lipid abnormalities, and may not always be recognized by measurement of plasma lipids alone. The aim of this review was therefore to analyze the main lipid alterations that can occur in nephropathic patients, as well as their causes and their effects on the cardiovascular system. The clinical evidence and recommendations for the use of lipid-regulating drugs in patients with chronic kidney disease, nephrotic syndrome, in patients undergoing hemo- and peritoneal dialysis and in transplanted patients was also reviewed. Moreover, we analyzed the link between dyslipidemia and kidney disease onset and progression and the role of statins in preventing it.

The small 25 kDa peptide, neutrophil gelatinase-associated lipocalin (NGAL), first known as an antibacterial factor of natural immunity, and an acute phase protein, is currently one of the most interesting and enigmatic proteins involved in the process of tumor development. The aim of the present review is to point out the main contradictory, sometimes even paradoxical, effects attributed to NGAL in human neoplasias. For instance, acting as an intracellular iron carrier and protecting MMP9 from proteolytic degradation, NGAL has a clear pro-tumoral effect, as has already been observed in different tumors (e.g. breast, stomach, oesophagus, brain) in humans. Moreover, in thyroid carcinomas, NGAL is strongly induced by NF-kB, an important factor involved both in tumor growth and in the link between chronic inflammation and neoplastic development. However, on the contrary, some studies have demonstrated that NGAL can inhibit the pro-neoplastic factor HIF-1alpha, FA-Kinase phosphorylation and also VEGF synthesis, thus suggesting that, in alternative conditions, NGAL also, paradoxically, has an anti-tumoral and anti-metastatic effect in neoplasias of, for example, the colon, ovary and pancreas. Finally, in the field of clinical oncology, attention is currently focused on the potential use of NGAL levels in making an early diagnosis, establishing a prognosis and predicting response to different treatments.

Background Anderson-Fabry disease (FD) is caused by a deficit of the α-galactosidase A enzyme which leads to the accumulation of complex sphingolipids, especially globotriaosylceramide (Gb3), in all the cells of the body, causing the onset of a multi-systemic disease with poor prognosis in adulthood. In this article, we describe two alternative methods for screening the GLA gene which codes for the α-galactosidase A enzyme in subjects with probable FD in order to test analysis strategies which include or rely on initial pre-screening. Findings We analyzed 740 samples using EcoTILLING, comparing two mismatch-specificendonucleases, CEL I and ENDO-1, while conducting a parallel screening of the same samples using HRM (High Resolution Melting). Afterwards, all samples were subjected to direct sequencing. Overall, we identified 12 different genetic variations: -10C>T, -12G>A, -30G>A, IVS2-76_80del5, D165H, C172Y, IVS4+16A>G, IVS4 +68 A>G, c.718_719delAA, D313Y, IVS6-22C>T, G395A. This was consistent with the high genetic heterogeneity found in FD patients and carriers. All of the mutations were detected by HRM, whereas 17% of the mutations were not found by EcoTILLING. The results obtained by EcoTILLING comparing the CEL I and ENDO-1 endonucleases were perfectly overlapping. Conclusion On the basis of its simplicity, flexibility, repeatability, and sensitivity, we believe thatHRM analysis of the GLA gene is a reliable presequencing screening tool. This method can be applied to any genomic feature to identify known and unknown genetic alterations, and it is ideal for conducting screening and population studies.