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ObjectiveThe advantage of beta-blockers has been postulated in patients with Takotsubo syndrome (TTS) given the pathophysiological role of catecholamines. We hypothesised that beta-blocker treatment after discharge may improve the long-term clinical outcome in this patient population.MethodsThis was an observational, multicentre study including consecutive patients with TTS diagnosis prospectively enrolled in the Takotsubo Italian Network (TIN) register from January 2007 to December 2018. TTS was diagnosed according to the TIN, Heart Failure Association and InterTAK Diagnostic Criteria. The primary study outcome was the occurrence of all-cause death at the longest available follow-up; secondary outcomes were TTS recurrence, cardiac and non-cardiac death.ResultsThe study population included 825 patients (median age: 72.0 (63.0–78.0) years; 91.9 % female): 488 (59.2%) were discharged on beta-blockers and 337 (40.8%) without beta-blockers. The median follow-up was 24.0 months. The adjusted Cox regression analysis showed a significantly lower risk for all-cause death (adjusted HR: 0.563; 95% CI: 0.356 to 0.889) and non-cardiac death (adjusted HR: 0.525; 95% CI: 0.309 to 0.893) in patients receiving versus those not receiving beta-blockers, but no significant differences in terms of TTS recurrence (adjusted HR: 0.607; 95% CI: 0.311 to 1.187) and cardiac death (adjusted HR: 0.699; 95% CI: 0.284 to 1.722). The positive survival effect of beta-blockers was higher in patients with hypertension than in those without (pinteraction=0.014), and in patients who developed cardiogenic shock during the acute phase than in those who did not (pinteraction=0.047).ConclusionsIn this real-world register population, beta-blockers were associated with a significantly higher long-term survival, particularly in patients with hypertension and in those who developed cardiogenic shock during the acute phase.

Backgrounds Tako-tsubo syndrome (TTS) is a reversible heart failure pathology characterized by transient myocardial left ventricular (LV) dysfunction. Although traditionally considered a benign condition in-hospital complications are frequent in this cohort. Non-invasive myocardial work (MW) parameters are considered as emerging indexes in evaluating global and regional myocardial systolic function. Objective to investigate the potential association of MW compared to standard echocardiography parameters, such as LV ejection fraction (EF) with in-hospital complications, in TTS patients. Methods thirty-eight patients (mean age, 68 ± 12 years, 35 women) with TTS diagnosed with Takotsubo Italian Network criteria were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24 hours from hospital admission. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating into its calculation the non-invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted myocardial work (WMW) were measured. In hospital complications (HC) were defined as a composite of apical LV thrombosis, hypokinetic arrhythmias (HA), supraventricular tachycardia (SVT), acute heart failure (AHF), ventricular tachycardia/fibrillation (VT/VF), cardiogenic shock (CS), respiratory arrest (RA), stroke and cardiac death (CD). The normal values ​​for the echocardiographic parameters are reported in the Table. Odds ratio, sensitivity and specificity were used to quantify the ability of EF and MW (abnormal vs normal values) in predicting HC. Results HC occurred in 16 TTS patients (26% with AHF; 10% with SVT; 8% with CS; 5% with apical LV thrombosis; 5% with HA; 2,6% with RA; 2,6% with stroke; 2% with VT/VF). The MWI and CMW parameters appear to have the best performance in predicting in-hospital complications (odds ratio for having HC: 10.4 (95% confidence interval: 1.2 to 93.3); 8.6 (0.9 to 77.6) respectively, Table), followed by EF (odds ratio 7.0 (0.8 to 64.1)) and WMW (odds ratio 4.8 (0.9 to 26.7)). MWI has the same sensitivity (94%) as CMW and EF, but higher specificity (41% vs 32%). Of note, the highest specificity was obtained by the WMW parameter (41%). Conclusion global and regional myocardial performance is transiently impaired in TTS and significantly associated with HC. Although limited by the low number of patients, these results suggest that myocardial work parameters have a good sensistivity and may have a better performance than the EF value in predicting intra-hospital complications. Larger studies will be necessary to confirm these preliminary results.

Aim The aim of this study was to assess the prevalence and outcome in patients with severe low flow, low gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve intervention (TAVI). Methods Patients with LFLG AS undergoing TAVI from 2013 to 2022 were prospectively collected. Clinical, imaging data and procedural parameters were collected. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient Results The study included 268 patients [81±6 years; 142 (53%) females]; of these, 155 patients (58%) had paradoxical LFLG AS and 113 patients (42%) had LFLG AS with low LVEF. Regarding echocardiography parameters, in the overall population the mean transaortic gradient was 31±6 mmHg, the mean iAVA 0.38±0.08 cm/m2, and the median LVEF 50% (IQR 38-55). Compared with paradoxical LFLG AS, the patients with classical form were characterized by a lower percentage of women (43% vs. 60% p 0.07), worse renal function (46% vs. 30%, p 0.012), and a significantly higher number of cardiovascular disease as coronary artery disease (52% vs. 29%, p At one-year follow-up, the composite outcome was reported in 49 patients (18%), 21 patients (13%) had paradoxical LFLG AS and 28 patients (24%) had classical form. Kaplan-Meier survival free from the composite outcome was significantly lower in patients with classical LFLG AS compared to those paradoxical LFLG AS (Log-Rank 0,022, Figure 1). Conclusion LFLG AS is a complex population with significant incidence of adverse event at one years. Patients with classical LFLG AS have higher number of risk factor and cardiovascular disease and lower survival compared paradoxical form. Figure 1

Aim This study sought to determinate the prevalence, clinical impact, and clinical outcome of significant moderate-to-severe mitral regurgitation (MR) in patients with severe low flow, low gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Methods All consecutive patients with severe LFLG-AS undergoing TAVI in two high-volume Italian centres from 2013 to 2022 were prospectively included. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient 50%. Demographic, clinical, instrumental, and procedural features were systematically collected by using an electronic case report form. MR severity was graded according to the current guidelines, and patients were categorized based on the MR severity at baseline in two groups: mild and moderate-to-severe MR. The primary study outcome was the composite of all-cause mortality and rehospitalization for worsening heart failure (HF) up to 1 year; secondary outcomes were the single components of the primary outcome. Results The study included 268 patients [81±6 years; 142 (53%) females]; moderate-to-severe MR was reported in 57 patients (21%). At baseline moderate-to-severe MR compared to those with mild MR showed statistically significant differences between age (p 0.008), female sex (p 0.007), hypertension (p 0.036), diabetes (p 0.001) atrial fibrillation/flutter (p 0.018) and chronic kidney disease (p 0.012). In the overall population, only one patient died during the hospitalization and at one-year follow-up, the primary outcome was reported in 49 patients (18%); all-cause death occurred in 26 (10%), and HF rehospitalization in 24 (9%). Regarding the two subgroups, Kaplan-Meier curves showed that survival free from the composite outcome was significantly lower in patients with moderate-to-severe MR compared to those with mild MR (Log Rank Conclusion In this study, many patients with LFLG-AS undergoing TAVR had coexisting moderate-to-severe MR. TAVI confirmed a high safety profile, LFLG-AS patients showed a high incidence of adverse events up to 1 year, especially those with coexisting moderate-to-severe MR. Moderate-to-severe MR should be duly considered for better prognostic stratification and clinical management of these particular TAVR patients during follow-up. Figure 1

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.

Short-term mechanical circulatory support (MCS) devices are designed to provide hemodynamic support for a wide range of clinical conditions such as high-risk cardiac surgery or interventional procedures, post-cardiotomy cardiogenic shock, acute decompensated heart failure. Electrical storm (defined as three or more sustained episodes of ventricular fibrillation-VF- in a 24-h period) is a rare but critical complication following revascularization in patients with ischemic heart disease and it is associated with a very high mortality (80-90%) both during the incident alone and during further observation. Here we report the case of a 38-year-old patient affected by coronary artery disease with moderate to severe left ventricular systolic dysfunction (EF 30-35%) who underwent emergency coronary artery bypass grafting (CABG) complicated by electrical storm and severe haemodynamic instability, successfully managed with a novel approach of biventricular mechanical circulatory support with extracorporeal life support (ECLS) in first instance, subsequently switched to Impella CP and ProtekDuo.

BackgroundA high prevalence of cardiovascular risk factors including age, male sex, hypertension, diabetes, and tobacco use, has been reported in patients with Coronavirus disease 2019 (COVID-19) who experienced adverse outcome. The aim of this study was to investigate the relationship between cardiovascular risk factors and in-hospital mortality in patients with COVID-19.MethodsMEDLINE, Cochrane, Web of Sciences, and SCOPUS were searched for retrospective or prospective observational studies reporting data on cardiovascular risk factors and in-hospital mortality in patients with COVID-19.Univariable and multivariable age-adjusted analyses were conducted to evaluate the association between cardiovascular risk factors and the occurrence of in-hospital death.ResultsThe analysis included 45 studies enrolling 18,300 patients. The pooled estimate of in-hospital mortality was 12% (95% CI 9–15%). The univariable meta-regression analysis showed a significant association between age (coefficient: 1.06; 95% CI 1.04–1.09; p ConclusionsThis meta-analysis suggests that older age and diabetes are associated with higher risk of in-hospital mortality in patients infected by SARS-CoV-2. Conversely, male sex, hypertension, and smoking did not independently correlate with fatal outcome.

Background: There is an incomplete understanding of the prevalence and predictors of attainment of low-density lipoprotein cholesterol (LDL-C) goal after myocardial infarction (MI). Aim: To evaluate the prevalence of achievement of LDL-C goal of 70 mg/dL, to identify the baseline features associated with suboptimal lipid control, and to assess the use of LDL-C-lowering drug therapies (LLT) beyond the first year after MI. Methods: The EYESHOT Post-MI was a prospective, cross-sectional, Italian registry, which enrolled patients presenting to cardiologist 1 to 3 years after MI. In this retrospective post-hoc analysis, patients were categorized in 2 groups according to the achievement or not of the LDL-C goal of 70 mg/dL. Univariable and multivariable logistic regression analyses were performed to identify the baseline features associate with LDL-C≥70 mg/dL. Results: The study population included 903 patients (mean age 65.5 ± 11.5 years). Among them, LDL-C was ≥70 mg/dL in 474 (52.5%). Male sex ( P = 0.031), hypertension ( P = 0.024), prior percutaneous coronary intervention ( P = 0.016) and high education level ( P = 0.008) were higher in the LDL-C Conclusions: In patients presenting to cardiologists 1 to 3 years from the last MI event, LDL-C is not under control in a large proportion of patients, particularly in those with a low education level or without hypertension. LLT is underused in this very-high-risk setting.

Aims Aim of the study is to assess the prevalence and in-hospital death in patients with low flow low gradient aortic stenosis (LFLG-AS) and right ventricular dysfunction (RVD) hospitalized for heart failure in a single referral centre. Methods and results Complete demographic, clinical characteristics, and imaging data were collected. Patients with LFLG AS hospitalized for heart failure were prospectively enrolled from 2013 to 2021. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient < 40 mmHg, and stroke volume index Conclusions RVD can be detected in more than one quarter of patient with new diagnosis of LFLG AS and is an independent predictor of all-cause in-hospital death. Quantification of right ventricular systolic function in these complex population give important information in identifying patients and higher risk requiring more aggressive therapy.

Aims Although right ventricular (RV) systolic dysfunction seems to be associated with adverse outcome after transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system, the prognostic value of RV free wall longitudinal strain (RVFWLS) in this setting has not been yet investigated. The aim of this study is to evaluate RVFWLS as predictor of outcome in patients with severe or moderate-to-severe functional MR undergoing TEER and its prognostic role compared with tricuspid annular plane systolic excursion (TAPSE). Methods and results 102 patients [73 (IQR: 66.8–77.0) years, 73 males (71.6%)] were retrospectively selected from March 2012 to February 2021. Echocardiograms were performed by using General Electric machines. RVFWLS was assessed through RV modified apical 4-chamber view, setting the region of interest to minimum size. Values of RVFWLS > −20% were recognized as abnormal. We considered a composite endpoint including rehospitalization for heart failure (HF) and overall death as primary outcome. Secondary outcomes were overall death, cardiac death and rehospitalization for HF. All patients were assessed at the longest available follow-up [median 22.1 (IQR: 9.7–49.3) months]. Baseline clinical and echocardiographic characteristics are listed in Table 1. Primary outcome was found in 60 (58.8%) patients, while secondary outcomes, i.e. overall death, cardiac death and rehospitalization for HF, were found respectively in 50 (50.0%), 31 (30.4%), and 36 (35.3%) patients. Mean TAPSE was 16.7 ± 4.0 mm and mean RVFWLS was −16.9 ± 6.0%. At univariable analysis both TAPSE (HR: 0.907, CI: 0.848–0.970, P-value: 0.004) and RVFWLS (HR: 0.937, CI: 0.897–0.979, P-value: 0.004) were significantly associated with the primary outcome. Kaplan–Meier survival curves showed that patients with TAPSE −20% also showed a lower survival free from the composite outcome compared with patients with RVFWLS ≤ −20% (Log Rank 0.004). Among patients with preserved RV systolic longitudinal function as indicated by TAPSE ≥ 17 mm, subjects with RVFWLS > −20% had a significantly higher incidence of the composite outcome compare with those with RVFWLS ≤ −20% (Log-Rank = 0.008). Conversely, no difference was found among patients with TAPSE Conclusions RV dysfunction assessed either by TAPSE and RVFWLS is associated with poorer outcome in patients with severe or moderate-to-severe functional MR undergoing TEER. Compared with TAPSE, RVFWLS seems to be superior in identifying patients at higher risk of adverse events during follow-up. Our data encourage the use of this speckle tracking-derived echocardiographic parameter in routinely evaluation of patients with functional MR candidate for TEER.

Aims This study sought to determine the prevalence, clinical impact, and in-hospital outcome of moderate to severe mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) hospitalized for heart failure (HF). Methods and results Patients with aortic valve thickness and aortic velocities >2.5 m/s hospitalized for heart failure in a single referral centre were prospectively enrolled from 2013 to 2021. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient Conclusions Moderate to severe MR is frequently detected in patients with LFLG AS and HF. In this peculiar cohort significant MR has a negative impact on outcome and is independently associated with in-hospital mortality.

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.

OBJECTIVES The aim of this study was to describe the prevalence of coronary artery ectasia (CAE) in patients with ST-elevation myocardial infarction (STEMI) and to compare the long-term outcome of subjects with and without CAE undergoing emergent coronary angiography. BACKGROUND The prognostic impact of CAE in STEMI patients has been poorly investigated. METHODS This retrospective, single-center, study included consecutive patients with STEMI undergoing emergent coronary angiography from January 2012 to December 2017. The primary endpoint was the assessment of recurrent myocardial infarction (MI) in patients with versus those without CAE at the longest available follow-up. The propensity score weighting technique was employed to account for potential selection bias between groups. RESULTS From 1,674 patients with STEMI, 154 (9.2%) had an angiographic evidence of CAE; 380 patients were included in the no CAE group. CAE patients were more often males and smokers, and showed a lower prevalence of diabetes than no CAE patients. After percutaneous coronary intervention, the corrected thrombolysis in MI frame count (p

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We aimed at appraising features and outcomes of patients undergoing MitraClip treatment according to their age.We queried the prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) multicenter registry dataset including 19 Italian centers performing MitraClip implantation, distinguishing patients80 vs ≥80 years of age.In total, 1853 patients were included, 751 (40.5%) octogenarians and 1102 (59.5%) non-octogenarians. Several baseline and procedural features were significantly different, including gender, regurgitation etiology, and functional class (all p 0.05). In-hospital outcomes were similarly satisfactory, with death occurring in 18 (2.4%) and 32 (2.9%, p = 0.561), respectively, and improvement in mitral regurgitation in 732 (97.4%) and 1078 (97.8%, p = 0.746), respectively. After a mean follow-up of 15 months, death occurred in 152 (20.2%) and 264 (24.0%), and cardiac death in 85 (11.3%) and 138 (12.5%), respectively (both p 0.05). Rehospitalization for heart failure and the composite of cardiac death or rehospitalization for heart failure were significantly less common in octogenarians: 63 (8.4%) vs 156 (14.2%, p 0.001), and 125 (16.6%) vs 242 (22.0%, p = 0.005), respectively. Multivariable analysis showed that these differences were largely due to confounding features, as after adjustment for baseline, clinical and imaging characteristics no significant difference was found for the above clinical endpoints.Transcatheter mitral valve repair with the MitraClip in carefully selected octogenarians appears feasible and safe, and is associated with favorable clinical outcomes at mid-term follow-up.

BACKGROUND Transcatheter mitral valve repair (TMVR) with the MitraClip device is an established treatment for mitral regurgitation (MR). More than one MitraClip may be implanted if a single one does not reduce MR adequately. We aimed at appraising the outlook of patients undergoing implantation of one, two or multiple MitraClips for TMVR. METHODS Exploiting the ongoing prospective GIse registry Of Transcatheter treatment of mitral valve regurgitaTiOn (GIOTTO) Study dataset, we compared patients, procedural details and outcomes distinguishing those receiving one, two or multiple MitraClips. The primary endpoint was the composite of 1-year cardiac death or rehospitalization for heart failure. Additional endpoints included all cause death, surgical mitral repair, and functional class. Multivariable adjusted Cox proportional hazard analysis was used for confirmatory purposes. RESULTS As many as 1824 patients were included: 718 (39.4%) treated with a single MitraClip, and 940 (51.5%) receiving two MitraClips, and 166 (9.1%) receiving three or more. Significant differences were found for baseline features, including age, female gender, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, prior myocardial infarction, atrial fibrillation, permanent pacemaker, cardiac resynchronization therapy, implantable cardioverter defibrillator, and prior mitral valve repair (all p

Background Takotsubo syndrome (TTS) is an acute cardiac disease increasingly recognized in a variety of clinical scenarios. Heart Failure Association of the ESC classified TTS in primary (occurring in the setting of psychological or emotional trigger or without clear identifiable stressors) and secondary (triggered by physical stressors or other critical illnesses). However, the clinical profile and outcome of these different subtypes is still controversial. Aim of the study To compare baseline features, clinical presentation and in-hospital outcomes in patients with primary or secondary TTS in a single referral center. Methods Overall study population included 210 patients (mean age 66.1±12.2 years, 14 male); 165 and 45 with primary and secondary TTS, respectively; consecutively enrolled from 2012 to 2019 in our center. Clinical, instrumental and laboratory data and in-hospital events were also recorded in both groups. Results Compared to patients with primary TTS, patients with secondary form were older (70.6±14.6 vs 64.9±11.2 years; p=0.006) and more frequently man (13.3% vs 4.8%; p=0.043). Several comorbidities such as diabetes (23.8% vs 8.9%; p=0.008); pulmonary (45.2% vs 12.9%; p Conclusion Our results demonstrate that to classify TTS patients in primary or secondary form is clinically relevant. Secondary form generally is associated to higher rate of comorbidities and to atypical presentation. Owing to the worse in-hospital outcome of the secondary TTS patients a tailored and more intensive treatment should be adopted in this cohort. Funding Acknowledgement Type of funding source: None

Background Coronary artery ectasia (CAE) is a relatively frequent finding in patient with ST-elevation myocardial infarction (STEMI) who undergo emergent coronary angiography. However, the long-term outcome of STEMI patients with CAE as compared to Non-CAE has been poorly investigated. Purpose To compare the baseline features and outcome of patients with and without CAE in the clinical setting of STEMI. Methods All patients with STEMI who underwent emergent coronary angiography from January 2012 to December 2017 at our Institution were retrospectively enrolled. Baseline demographic, clinical, instrumental, angiographic and percutaneous coronary intervention (PCI) findings were collected for patients with and without CAE. The study outcome measures were recurrent myocardial infarction (MI) and all-cause death. The propensity score weighting (PSW) technique was used to take into account for potential selection bias in treatment assignment between CAE and Non-CAE groups. Results The study included 534 patients with STEMI (mean age 62.9±12.0 years), 154 were CAE and 380 Non-CAE. The two groups were significantly different in terms of sex (90.9% in CAE vs 72,6% in Non-CAE, p The survival free from recurrent MI was lower, although not statistically significant, in CAE vs. Non-CAE patients (3.1/100 person/years vs. 4.8/100 person/years; Log-Rank = 0.068). After PSW, an optimal balance was obtained as demonstrated by a standardized mean difference Conclusions Patient with STEMI and angiographic evidence of CAE have a different clinical profile compared to Non-CAE. In this analysis focused on STEMI patients, CAE was associated with a higher risk of recurrent MI at long-term follow-up. Funding Acknowledgement Type of funding source: None

Left ventricular pseudoaneurysm (LVPsA) is a rare complication of myocardial infarction, cardiac surgery, chest trauma, infection or transcatheter interventions. It may cause arrhythmias, mass effect, thromboembolism and life-threatening rupture. The transcatheter approach is nowadays considered a cost-effective alternative to surgery. In this setting, 3D printing could be an emerging, powerful tool to plan transcatheter closure and choose the best occluding device. This study reports on three cases of complex LVPsA successfully treated by transcatheter device implantation guided by printed 3D heart models.

An 86‐year‐old man affected by severe aortic stenosis (AS) was referred to our institution owing to decompensated heart failure. Three months before, the patient was scheduled for transcatheter aortic valve implantation (TAVI), which was postponed owing to the coronavirus disease 2019 (COVID‐19) outbreak. Owing to COVID‐19 suspicion, he underwent nasopharyngeal swab and was temporarily isolated. However, the rapid deterioration of clinical and haemodynamic conditions prompted us to perform balloon aortic valvuloplasty (BAV) as bridge to TAVI. The patient's haemodynamics improved; and the next day, the reverse transcriptase–polymerase chain reaction for COVID‐19 was negative. At Day 5, he underwent TAVI procedure. Subsequent clinical course was uneventful. During COVID‐19 pandemic, the deferral of TAVI procedure should be assessed on a case‐by‐case basis to avoid delay in patients at high risk for adverse events. BAV may be an option when TAVI is temporarily contraindicated such as in AS patients suspected for COVID‐19.

Background Takotsubo syndrome (TTS) is a transient left ventricular (LV) heart failure due to a reversible systolic dysfunction, usually recovering within days or weeks. Purpose To assess the dynamic changes of LV cardiac mechanics in a small cohort of TTS patients through the estimation of myocardial work, a newly developed non-invasive approach which allows correction of global longitudinal strain (GLS) for systolic blood pressure. Methods Twenty-four patients (mean age, 63.8 ± 8.4 yy; all female) with TTS diagnosis were retrospectively enrolled. Data from transthoracic two-dimensional and speckle-tracking echocardiography on admission and at 3 months follow-up were collected. Global myocardial work index (GWI, mmHg%) was calculated as the area of the LV pressure (LVP)-strain loop, where LVP was estimated noninvasively using a standard waveform fitted to valvular events and scaled to systolic blood pressure. From GWI we also assessed: global constructive work (GCW, mmHg%: work performed during shortening in systole + negative work during lenghtening in isovolumetric relaxation, IVR), global wasted work (GWW, mmHg%: negative workperformed by a segment during lengthening in systole + work performed during shortening in IVR) and global work efficiency (GWE, %: constructive work divided by the sum of constructive and wasted work). Baseline demographic and clinical features, including in-hospital adverse events as acute heart failure, cardiogenic shock and cardiac death, were also assessed. Results On overall population, a reduced ejection fraction (EF) and GLS were detected at hospital admission, with a substantial improvement at discharge and at follow-up (from 41.7 ± 8.3% to 54.5 ± 6.5% to 60.2 ± 4.6% for EF and from -11.7 ± 4.5% to -16.2 ± 4.2 to -21.3 ± 2.8% for GLS, respectively). Similarly, global MWI and MWE both showed a positive trend during the hospital course and at follow-up: MWI increased from 1048.8 ± 580.5 to 1522.4 ± 695.4 to 2021.1 ± 388.6 mmHg% and MWE from 78.7 ± 10.2 to 91.1 ± 4.6 to 94.5 ± 3.8 %. Increasing in MWE has been obtained through an improvement of GCW (from 1195.9 ± 537.2 to 1651.3 ± 700.3 to 2316.8 ± 490.6 mmHg%) and a contemporary decreasing in GWW (from 237.9 ± 137.2 to 106 ± 37.2 to 131.8 ± 150.8 mmHg%). In-hospital adverse events occurred in 8 (50%) patients. Of note, despite EF and GLS at admission showed no significant differences, patients experiencing in-hospital adverse events showed lower value of acute MWI (725.6 ± 289.6 vs 1371.9 ± 632.1 mmHg%; p= 0.02) and MWE (73.6 ± 3.4 vs 83.8 ± 12.4%; p= 0.04) compared to patients without in-hospital complications. Conclusion Non-invasive assessment of myocardial work through echocardiographic strain-based technique could be useful to demonstrate the peculiar dynamic changes of cardiac mechanics and for a better risk stratification in TTS patients. Abstract P322 Figure.

Background Available scientific evidence of transcatheter mitral valve repair with the MitraClip comes from randomized controlled trials, which showed controversial results that hardly translate into real-world practice, and from registries of relatively small sample size. Aim To collect real-world data in a multicenter, prospective, country-level registry. Methods and result The Italian Society of Interventional Cardiology (GIse) Registry Of Transcatheter Treatment of Mitral Valve RegurgitaTiOn (GIOTTO) is an ongoing single-arm, multicenter, prospective registry that started enrollment in February 2016. Clinical end points were defined according to the Mitral Valve Academic Research Consortium (MVARC) criteria. From February 2016 to December 2018, 1189 patients (mean age 76 ± 9.1 years) were enrolled. The main MR etiology was functional (64.9%). MVARC technical success was 96.6%. At 30-day follow-up ( n = 1131), MVARC device and procedural success were 92.5% and 87% respectively, and all-cause death was 3%. The majority of patients who died at 30-day had functional MR (69.7%). Mixed etiology (OR 0.94, 95% CI 0.02–0.61) and prolonged length of stay in ICU (OR 0.97, 95% CI 0.95–0.99) were found to be negative independent predictors of device success at 30-day. The EuroSCORE II (OR 0.96, 95% CI 0.93–0.99), LVEDV-I (OR 0.99, 95% CI 0.98–0.99) and prolonged length of stay in ICU (OR 0.98, 95% CI 0.97–0.99) were negative independent factors of MVARC procedural success at 30-day. Conclusions The GIOTTO registry is one of the largest prospective registries available on MitraClip and shows favorable acute and 30-day safety and efficacy.

Background The risk of death in patients affected by ST-elevation segment myocardial infarction (STEMI) is well known, but more data are required to define the in-hospital mortality in special subsets. We sought to assess the prognostic value of indicators in patients with large anterior STEMI as a first acute coronary event, undergoing percutaneous coronary intervention (PCI) and intra-aortic balloon pump (IABP). Methods and results We evaluated 48 consecutive large anterior STEMI patients admitted as first acute coronary event, undergoing in acute phase both PCI and IABP. Patient demographics, clinical, noninvasive and invasive findings, together with in-hospital complications, were collected. Moreover, findings obtained after a 24-month follow-up were reported. The primary endpoint was in-hospital mortality, whereas the secondary endpoints were out of hospital mortality, rehospitalization for heart failure or reinfarction, and New York Heart Association (NYHA) class at least 2 at follow-up visit. The univariate analysis showed a significant association with symptom to balloon, left anterior descending coronary artery, myocardial blush grade, and wall motion score index. Results of the multivariable analysis revealed the strongest predictive power for in-hospital mortality of proximal left anterior descending coronary artery (odds ratio: 6.9; 95% confidence interval: 1.1-67.7) and of myocardial blush grade 0-1 (odds ratio: 5.5; 95% confidence interval: 1.0-38.8). In-hospital death occurred in 13 patients (27% of total cases), whereas, at follow-up, the mean of survival was 66.7 ± 7.0%. Conclusion The patients with large anterior STEMI as a first acute coronary event, undergoing PCI and IABP, had a very high in-hospital mortality, whereas the mortality rate over the follow-up period was lower. The involvement of a large territory at risk and the ineffective treatment in terms of myocardial reperfusion were the main predictors of in-hospital mortality.

Background Although generally considered a benign disease, Takotsubo syndrome (TTS) has recently been associated to a substantially comparable long-term outcome than acute coronary syndrome (ACS). The use of beta-blockers (BB) has been advocated in these patients for secondary prevention after the index event, considering the presumed role of catecholamine in TTS pathophysiology. However, the effect of BB on long-term outcome remains controversial due to the paucity of data and the lack of evidence from randomized studies. Purpose To investigate the impact of BB therapy on long-term outcome in patients with TTS. Methods The study included all TTS patients enrolled in the Takotsubo Italian Network multicenter registry. Patients were divided in two study groups according to the BB therapy after discharge. The following major adverse cardiac events (MACE) were assessed at the longest available follow-up: cardiac death, TTS recurrence, rehospitalization for cardiac cause, acute or worsening heart failure (HF) and ACS. Also, the composite of cardiac death and rehospitalization as well as the overall MACE were analyzed Results The study population included 548 patients (mean age 68.7±11.4 years; 44 males, 8%). Among them, BB treatment was reported in 368 (BB group, 67.2%) and 180 (no-BB group, 32.8%) patients, respectively. The baseline clinical characteristics were substantially comparable among groups with the only exception of COPD, which was prevalent in the no-BB group (10.3% vs 21.7%, p=0.001). During follow-up (median 18 months 25–75% c.i. 6–29), TTS recurrence was reported in 26 patients (4.7%), ACS in 10 (1.8%), acute or worsening HF in 39 (7.1%), cardiac hospitalization in 71 (13.0%) and cardiac death in 18 (3.3%). The rate of TTS recurrence and ACS was comparable between groups. Conversely, no-BB patients experienced more frequently acute or worsening HF (5.4% vs 10.6%, p=0.034), cardiac rehospitalization (10.9% vs 17.2%, p=0.042) and cardiac death (1.9% vs 6.1, p=0.018) than BB patients. Therefore, the MACE composite endpoint was significantly prevalent in the no-BB group (12.0% vs 20.6%, p=0.010). Kaplan-Meier curves for the composite of cardiac death and rehospitalization showed a statistically lower survival in the no-BB patients compared to the BB group (p=0.006). Moreover, landmark analysis showed a wider survival benefit in the BB patients after 2 years. Conclusions Although in absence of a secondary preventive effect on TTS recurrence, BB may improve the long-term cardiac outcome in patients with TTS. Prospective randomized studies are advisable to confirm these findings.

To determine the prevalence, clinical characteristics, in-hospital course and determinants of major adverse events in a cohort of Caucasian patients with Takotsubo syndrome (TTS) and right ventricular involvement (RVi), regardless of left ventricular variant forms.The study population consisted of 424 patients (mean age 69.1±11.5years; female 92.2%) with a diagnosis of TTS divided into two groups according to the presence or absence of RVi. RVi patients (n=57; 13.4%) showed a higher prevalence of comorbidities, especially respiratory diseases (p=0.011), and a higher Charlson comorbidity index (CCI; p=0.006) than non-RVi patients. In-hospital major adverse events (acute heart failure, cardiogenic shock and death) occurred more frequently in RVi patients (p0.001). Heart rate and CCI, along with the echocardiographic parameters of wall motion score index, E/e' ratio, tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP) were associated with adverse in-hospital outcome. At multivariate analysis, CCI (HR: 1.871; 95% CI: 1.202-2.912; p=0.006), sPAP (HR: 1.059; 95% CI: 1.016-1.104; p=0.007) and TAPSE (HR: 0.728; 95% CI: 0.619-0.855; p0.001) were independent correlates of the composite outcome in patients with RVi.Patients with RVi are characterized by distinct clinical profile and should undergo closely clinical and echocardiographic monitoring. The presence of echocardiographic signs of right ventricular failure along with substantial comorbidities burden identify a cohort at higher risk of in-hospital major adverse cardiovascular events.

Background: B-type natriuretic peptide (BNP) is regarded as a reliable predictor of outcome in patients with acute decompensated heart failure (ADHF). However, according to some scholars, a single isolated measurement of serum BNP at the time of hospital admission would not be sufficient to provide reliable prognostic information. Methods: A retrospective study was carried out on patients hospitalized for ADHF, who had then undergone follow-up of at least 6 months, in order to see if there was any difference in midterm mortality among patients with rising BNP at discharge as compared to those with decreasing BNP at discharge. Medical records had to be carefully examined to divide the case records into two groups, the former characterized by an increase in BNP during hospitalization, and the latter showing a decrease in BNP from the time of admission to the time of discharge. Results: Ultimately, 177 patients were enrolled in a retrospective study. Among them, 53 patients (29.94%) had increased BNPs at the time of discharge relative to admission, whereas 124 (70.06%) exhibited decreases in serum BNP during their hospital stay. The group with patients who exhibited BNP increases at the time of discharge had higher degree of congestion evident in the higher frequency of persistent jugular venous distention (odds ratio: 3.72; P = 0.0001) and persistent orthopnea at discharge (odds ratio: 2.93; P = 0.0016). Moreover, patients with increased BNP at the time of discharge had a lower reduction in inferior vena cava maximum diameter (1.58 ± 2.2 mm vs. 6.32 ± 1.82 mm; P = 0.001 (one-way ANOVA)). In contrast, there was no significant difference in weight loss when patients with increased BNP at discharge were compared to those with no such increase. A total of 14 patients (7.9%) died during the 6-month follow-up period. Cox proportional hazard analysis revealed that BNP increase at the time of discharge was an independent predictor of 6-month all-cause mortality after adjustment for age, sodium at discharge, creatinine at discharge and New York Heart Association (NYHA) class at discharge (hazard ratio 34.49; 95% confidence intervals: 4.55 - 261.06; P = 0.001). Conclusions: Among patients with recent ADHF, increased BNP at the time of discharge from the hospital entailed a higher grade of congestion and higher 6-month mortality. J Clin Med Res. 2016;8(10):737-742 doi: http://dx.doi.org/10.14740/jocmr2691w

Background: In recent years, some observational studies suggested that pramipexole, a non-ergot dopamine agonist (DA) used for the treatment of Parkinson’s disease (PD), may increase the risk of heart failure (HF). However, the limitations inherent in observational studies made it difficult to determine whether the excess of incident HF was related to the drug or to other determinants. Thus, some concerns remained regarding the increased putative HF risk associated with non-ergot DAs as a class or individually. Methods: In our meta-analysis, primary endpoint was the risk of incident HF in patients with PD treated with non-ergot DAs compared to those treated with monotherapy with levodopa. Secondary outcome measures were all-cause mortality and cardiovascular events. For these purposes, only randomized controlled trials (RCTs) were considered, provided that they offered complete outcome data pertaining to the incident HF, all-cause mortality and risk of cardiovascular events. Systematic searches were performed in the databases of PubMed, Embase and ClinicalTrial.gov up to May 2015. The effect size was estimated using the pooled relative risk (RR) of non-ergot DAs versus placebo on incident HF as well as on all-cause mortality or cardiovascular events. Results: Six out of 27 RCTs reported at least one case of incident HF; therefore, we included them in the RR estimate, whereas 13 RCTs were included in the meta-analysis for mortality rates and 22 RCTs were included to evaluate cardiovascular events. Treatment with non-ergot DAs did not reveal an increase in the risk of incident HF as compared with the placebo group (pooled RR: 0.95; 95% CI: 0.30 - 2.90; P = 0.893). Similarly, patients treated with non-ergot DAs did not show any significant differences compared to controls with regard to all-cause mortality (pooled RR: 0.617; 95% CI: 0.330 - 1.153; P = 0.13) as well as with regard to cardiovascular events (pooled RR: 1.067; 95% CI: 0.663 - 1.717; P = 0.789). Conclusions: The use of non-ergot DAs in PD patients was not associated with an increased risk of incident HF, nor was it shown to increase the overall mortality or the risk of cardiovascular events compared to the PD patients taking monotherapy with levodopa alone. However, larger studies are warranted to confirm the cardiovascular safety of non-ergot DAs for PD management. J Clin Med Res. 2016;8(6):449-460 doi: http://dx.doi.org/10.14740/jocmr2541e

Knowledge of the right atrial pressure (RAP) values is critical to ascertain the existence of a state of hemodynamic congestion, irrespective of the possible presence of signs and symptoms of clinical congestion and cardiac overload that can be lacking in some conditions of concealed or clinically misleading cardiac decompensation. In addition, a more reliable estimate of RAP would make it possible to determine more accurately also the systolic pulmonary arterial pressure with the only echocardiographic methods. The authors briefly illustrate some of the criteria that have been implemented to obtain a non-invasive RAP estimate, some of which have been approved by current guidelines and others are still awaiting official endorsement from the Scientific Societies of Cardiology. There is a representation of the sometimes opposing views of researchers who have studied the problem, and the prospects for development of new diagnostic criteria are outlined, in particular those derived from the matched use of two- and three-dimensional echocardiographic parameters.

Background: The MacNew questionnaire is a neuro-behavioral tool which is easy and immediately usable. This self-reported questionnaire filled out by the patient allows the physician to achieve helpful information concerning the ways for optimizing the therapy and patient’s lifestyles. In this retrospective study, our aim was to assess whether relatively high scores found using the MacNew questionnaire in patients who had undergone percutaneous or surgical revascularization were associated with a decreased risk of unscheduled hospitalizations during the follow-up. Methods: A retrospective analysis concerning 210 patients was carried out. The clinical sheets of these patients were examined as regards the information provided in the specific questionnaires (MacNew Italian version) routinely administered during the hospitalization prescribed for recovering from recent interventions of coronary percutaneous or surgery revascularization. Every patient undergoing the psychological test with MacNew questionnaire was followed up for 3 years. Results: Using univariate analysis, a global score’s high value (i.e., above the median of the whole examined population) was shown to be associated with a significantly decreased risk of rehospitalization (HR (hazard ratio): 0.4312; 95% CI: 0.3463 - 0.5370; P < 0.0001). After adjustment for age, gender and myocardial infarction as initiating event, using a multivariate Cox proportional hazards regression model, the protection exerted by a high MacNew score against the risk of hospitalizations remained significant (HR: 0.0885; 95% CI: 0.0317 - 0.2472; P < 0.0001). Conclusions: A relatively elevated MacNew global score appears to be associated with a significantly decreased risk of unscheduled hospitalizations after coronary revascularization over a 3-year follow-up. J Clin Med Res. 2016;8(3):210-214 doi: http://dx.doi.org/10.14740/jocmr2447w

Stating a well-codified and widely accepted therapeutic conduct for patients with patent foramen ovale (PFO) and previous cryptogenic stroke is made difficult and somewhat controversial by several issues remained unresolved so far. In this short review, some aspects of the possible role played by the PFO in the pathogenesis of cryptogenic stroke are succinctly analyzed. First, some aspects of cardiovascular anatomy of the human fetus and the adult are outlined. Subsequently, the three randomized controlled trials (RCTs) that have been accomplished so far to compare the implant of a transeptal occluding device with a simple medical therapy in patients with PFO and history of cryptogenic stroke are briefly examined. These RCTs, when assessed using the "intention to treat" method, do not show a greater protective effect of therapy with transeptal device as regards the recurrences of stroke. Afterwards, there is a brief presentation of the findings of several meta-analyses that have been derived from the three above mentioned RCTs, whose results are strikingly discordant with each other. In fact, some of them come to the conclusion that the transcatheter closure of PFO does not offer significant advantages compared to antithrombotic therapy for the secondary prevention of cryptogenic stroke, while others based on subgroup analyses argue that the transcatheter closure of PFO with Amplatzer device, differently from the one performed using the STARFlex device, would be associated with significantly lower incidence of cerebrovascular events compared with medical therapy alone. Finally, the authors argue the need to adhere to the current scientific guidelines. They substantially deny an alleged superior efficacy of transcatheter PFO occlusion compared to medical therapy with antithrombotic agents (anticoagulants or antiplatelet agents), except for selected cases of patients with documented PFO and concomitant clinical-instrumental picture of deep venous thrombosis.

Background The prognostic predictors of outcome in patients with functional mitral regurgitation (FMR) undergoing MitraClip implantation (MCi) are still poorly known. The aim of our study is to identify the baseline predictors of outcome in FMR patients candidate to MCi. Methods All patients with symptomatic moderate-to-severe or severe FMR undergoing MCi at our institution were consecutively and prospectively enrolled. Baseline clinical and instrumental data were collected. Primary endpoint was the occurrence of cardiac death; secondary endpoints were all-cause death and the composite of cardiac death or rehospitalization for heart failure. Results 74 patients (mean 71.6 ± 8.3 years) were enrolled. During follow-up (median 416.0 days), the primary endpoint occurred in 15 (20.3%), all-cause death in 26 (35.1%) and the composite endpoint in 25 (33.8%). At multivariate analysis, the left atrial volume index (LAVi; HR:1.02; P = 0.048) and the low peak oxygen uptake (peak VO2; HR:0.73; P = 0.018) increased the risk of cardiac death at follow-up; atrial fibrillation (AF; HR:2.69; P = 0.027) was independently associated to all-cause death and the low level of peak VO2 was an independent predictor of overall mortality (HR:0.70; P The ROC analysis identified a peak VO2 cut-off of 10.0 mL/kg/min as the best predictor for the three study endpoints; the best LAVi cut-off for cardiac death was 67 mL/m2. Kaplan-Meier analysis for the individual and combined outcome predictors confirmed their significant stratification ability during follow-up. Conclusions Peak VO2, along with LAVi and AF, identify FMR patients with the worst prognosis after MCi.

BACKGROUND The aim of this study was to investigate long-term survival, clinical status, and echocardiographic findings of patients with severe functional mitral regurgitation (FMR) undergoing MitraClip (MC) treatment and to explore the role of baseline features on outcome. Methods and Results: Randomized and observational studies of FMR patients undergoing MC treatment were collected to evaluate the overall survival, New York Heart Association (NYHA) class and echocardiographic changes after MC treatment. Baseline parameters associated with mortality and echocardiographic changes were also investigated. Across 23 studies enrolling 3,253 patients, the inhospital death rate was 2.31%, whereas the mortality rate was 5.37% at 1 month, 11.87% at 6 months, 18.47% at 1 year and 31.08% at 2 years. Mitral regurgitation Grade

Myocardial injury after non cardiac surgery (MINS) is a rather new nosological entity and an unfortunately common perioperative complication. The diagnostic criteria for MINS, also indicated as isolated myocardi- al injury (IMI), are an elevated postoperative high sensitivity Troponin T (hsTnT level ranging between 20 and 65 ng/L with an absolute change of at least 5 ng/L or hsTnT level > 65 ng/L), in absence of symptoms and/or EKG findings suggestive of ischemia and without a non ischemic aetiology causing Troponin eleva- tion. MINS does not fulfill the universal definition of myocardial infarction even if it is related to ischemic causes and it is independently associated with 30-day postoperative mortality and complications. Neverthe- less, mortality at 30 days in MINS patients has been calculated up to 10% and it increases exponentially as a function of peak postoperative Troponin concentration. Physician and researchers should discriminate MINS from perioperative myocardial infarction and from not ischemic Troponin increases. In the postop- erative period, the possibility of missing the diagnosis of an acute coronary syndrome for the paucity of clinical symptoms or because physician failed to evaluate a postoperative EKG recording should always be considered. Physiopathology of MINS is not yet well defined: current hypotheses are surrogated from peri- operative myocardial infarction studies. Up to now there aren't specific treatments for MINS, even if an- tithrombotic therapy is under evaluation. Treatment decisions should be tailored to the individual case; po- tential benefits of Troponin screening include a cardiology consultation and consequently, improved pa- tients' information to promote lifestyle changes and enhanced therapy.

Spontaneous coronary artery rupture is a rare disorder that may develop early into a sudden death due to the abrupt evolution of the associated cardiac tamponade. In some cases the rupture is contained and a false aneurysm develops with slower evolution of clinical signs. The correct diagnosis of spontaneous coronary artery rupture deserves a high level of suspicion; frequently it may be missed because the time window of its evolution seems to be very short or signs of acute coronary syndrome sometimes can prevail, leading to delays in diagnosis or to misdiagnosis. We report the case of a patient presenting a giant pseudoaneurysm of the right coronary artery due to spontaneous coronary artery rupture without any underlying disease. Moreover we present a review of the few cases in the literature, offering a pathophysiological hypothesis linking the site of rupture and clinical presentation.

Introduction : Chronic atrial fibrillation (AF), coexisting with a history of recent coronary angioplasty with stent (PCI-S) represents an encoded indication for oral anticoagulation with warfarin (OAC) plus dual antiplatelet therapy (DAPT). Methods : Using a retrospective cohort study we determined the respective impacts on cardio- vascular outcomes of three different pharmacologic regimens, i.e., triple therapy (TT) with warfarin + clopidogrel and aspirin, dual therapy (DT) with warfarin +clopidogrel or aspirin, dual antiplatelet therapy (DAPT) with clopidogrel + aspirin. Outcomes of interest were all-cause mortality, ischemic cardiac events, ischemic cerebral events, bleeding events. The inclusion criterion was the coexistence of an indication for OAC (e.g., chronic AF) with an indication for dual antiplatelet therapy due to recent PCI-S. Results : Among the 98 patients enrolled, 48 (49%), 31 (31.6%), and 19(19.4%) patients were prescribed TT, DT, and DAPT, respectively. Throughout a mean follow-up of 378± 15.7days, there were no significant differences between the three regimens for all abovementioned outcomes. In particular, the total frequency of major bleeding was similar in the three groups: 5 cases (10.4%) in TT, one case (3.22%) in DT and no case in DAPT groups (p [chi-square test] = 0.1987). Conclusions : TT, DT and DAPT displayed similar efficacy and safety. Although the superiority of OAC vs. DAPT for stroke prevention in AF patients has been demonstrated by previous randomized trials, a smaller frequency of high thromboembolic risks' features in DAPT group of the present study may have prevented the observation of a higher incidence of ischemic stroke in this group.