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While mitral stenosis of rheumatic origin has been effectively treated percutaneously for more than 20 years, transcatheter treatment of mitral (MR) and tricuspid (TR) regurgitation appears as a contemporary unmet clinical need. The advent of new transcatheter therapies offers several treatment options for elderly and frail patients at high surgical risk. MitraClip is now consolidated as a therapy for functional MR in selected patients. Transcatheter mitral valve replacement is a promising alternative to transcatheter repair, for both functional and degenerative forms. However, further developments and new evidence are needed. Transcatheter treatment of the tricuspid valve has arrived late compared to similar technologies that have been developed for the aortic and mitral valve, and is currently in its infancy. This is likely due, in part, to the previously underreported impact of TR on patient outcomes. Edge-to-edge repair is the most advanced transcatheter solution in development. Data on annuloplasty and tricuspid valve replacement are limited and more evidence is needed. The future looks promising for transcatheter mitral and tricuspid valve therapies, although their place in clinical practice has yet to be clearly defined.

Background: Left atrial (LA) function is crucial for assessing left ventricular filling in various cardiovascular conditions. Cardiac Amyloidosis (CA) is characterized by atrial myopathy and LA function impairment, with diastolic dysfunction up to restrictive filling pattern, leading to progressive heart failure and arrhythmias. This study evaluates LA function and deformation using speckle tracking echocardiography (STE) in patients with CA compared to a cohort of patients with sarcomeric Hypertrophic Cardiomyopathy (HCM) and a control group. Methods: We conducted a retrospective, observational study (from January 2019 to December 2022) including a total of 100 patients: 33 with ATTR-CA, 34 with HCMs, and 33 controls. Clinical evaluation, electrocardiograms, and transthoracic echocardiography were performed. Echocardiogram images were analyzed in post-processing using EchoPac software for LA strain quantification, including LA-reservoir, LA-conduit, and LA-contraction strain. Results: The CA group exhibited significantly impaired LA function compared to HCMs and control groups, with LA-reservoir median values of −9%, LA-conduit −6.7%, and LA-contraction −3%; this impairment was consistent even in the CA subgroup with preserved ejection fraction. LA strain parameters correlated with LV mass index, LA volume index, E/e’, and LV-global longitudinal strain and were found to be associated with atrial fibrillation and exertional dyspnea. Conclusions: LA function assessed by STE is significantly impaired in CA patients compared to HCMs patients and healthy controls. These findings highlight the potential supportive role of STE in the early detection and management of the disease.

The safety of concomitant percutaneous coronary intervention (PCI) during transcatheter aortic valve implantation (TAVI) setting is still highly debated. This study aimed to assess the safety and the effectiveness of TAVI and PCI performed in the same session compared with TAVI alone.Patients with severe aortic stenosis and coronary artery disease (CAD) (n=786) who underwent TAVI from June 2007 to April 2021 were divided into two groups: patients who underwent TAVI alone (n=633) and patients treated with TAVI and concomitant PCI (n=153). The propensity-score matching adjustment was used to account for baseline confounding variables.A total of 302 TAVI with CAD patients (151 matched pairs), undergoing either isolated TAVI or TAVI+PCI were compared. In-hospital death (6% vs 4%; p=0.427), stroke (2% vs 0.7%; p=0.314), myocardial infarction (MI) (0% vs 0.7%; p=0.317), major and life-threatening bleeding (14.6% vs 15.9%; p=0.749), and acute kidney injury (9.3% vs 10.6%; p=0.700) were similar for both groups. At 3 years, the rates of all-cause death (25.2% vs 19.2%; p=0.615), the composite endpoints of all-cause death and MI (27.2% vs 21.2%; p=0.699) and all-cause death, MI, and stroke (28.5% vs 22.5%; p=0.739) were also comparable between the two groups. Achieving complete coronary revascularization in the TAVI setting did not impact on long-term mortality (p=0.257).In patients with severe aortic stenosis and CAD, concomitant TAVI and PCI was as safe and effective as TAVI alone up to 3-year follow-up.

Objective To compare vascular complications in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) using ultrasound guidance (USG) versus fluoroscopy guidance (FSG) for femoral access. Background In patients undergoing PCI, using the arterial femoral access increases the risk of vascular complications compared using the radial access. USG reduces time to access, number of attempts, and vascular complications compared with FSG, but the efficacy of USG has never been tested in the setting of CTO-PCI. Methods A total of 197 patients undergoing CTO-PCI using at least a femoral vascular access from November 2015 to September 2020 were screened. The primary outcome was a composite of local hematoma, pseudoaneurysm , retroperitoneal hemorrhage , arteriovenous fistula or hemoglobin drop ≥3 g/dL during hospitalization. The independent association between USG and the primary outcome of interest was explored. Results The primary outcome occurred in 17.3% of patients. Patients in the USG group had a significantly lower incidence of vascular complications compared with patients in the FSG group (8.5% vs. 21.0%, p = 0.039), driven by a reduction of localized hematomas (3.4% vs 13.0%, p = 0.042). After adjustment for type of CTO approach and heparin dose, USG was significantly associated with a reduced relative risk of the composite primary outcome (adjusted odds ratio 0.16, 95% confidence interval 0.05 to 0.51; p = 0.002). Conclusion USG in CTO-PCI is associated with a decreased risk of vascular complications, primarily driven by a reduction in local hematomas, especially in complex CTO-PCI where the larger use of heparin increases the risk of vascular complications.

Background The coronavirus 2019 (COVID-19) pandemic upset healthcare systems and their logistics worldwide. We sought to assess safety and effectiveness of an optimized logistics for transcatheter aortic valve implantation (TAVI) pathway developed during the COVID-19 pandemic. Methods This is a retrospective analysis. An optimized TAVI logistics based on performing TAVI work-up and procedure during the same hospitalization was used during the COVID-19 pandemic. In-hospital and 30-day outcomes of patients treated during the pandemic were compared with an historical cohort of patients undergoing TAVI with staged work-up before the pandemic within an homogeneous timeframe. Results Of 536 patients, 227 (42.4%) underwent TAVI during the COVID-19 pandemic with a reduction of 26.5% compared to the pre-pandemic period (n = 309). The median age was 81 (77–85) years and STS score was 3.4 (2.2–5.6)%. Lower rates of in-hospital major vascular complications (2.2% vs. 8.7%; p, Graphical abstract Unlabelled Image

Achieving patient-specific commissural alignment of transcatheter aortic valves is particularly important to ensure coronary reaccess after transcatheter aortic valve implantation. Nevertheless, in case of uncommon origin of coronary arteries, commissural alignment could be counterproductive. This case shows how alignment techniques could serve to intentionally misalign the neocommissures in this subset of patients. (Level of Difficulty: Intermediate.), Central Illustration

Introduction: Antitachycardia pacing (ATP) is one of the therapies provided by an implantable cardioverter defibrillator (ICD) for the treatment of ventricular arrhythmias (VA). Successful ATP leads to avoidance of shock, that is related to an increase in mortality and morbidity. Methods and Results: A total of 63 documents have been obtained by using the key term “Antitachycardia pacing” in PubMed, focusing on optimal ATP and ICD programing to reduce inappropriate or avoidable therapies, predictive factors of ATP efficacy and latest technologies and devices still in experimentation. Conclusions: Antitachycardia pacing confirms to be a good therapeutic tool to interrupt ventricular arrhythmias. An optimal ICD programming could lead to the reduction of inappropriate or avoidable ATP therapies. Furthermore, a better knowledge in predictive factors of ATP efficacy not only could better orient physicians on the device to implant, but also could allow for a better arrhythmic risk stratification.

Background A number of clinical trials documented clinical benefits of glycoprotein IIb-IIIa inhibitors (GPIs) in the setting of acute coronary syndromes (ACS). The advantage of reducing thrombotic burden at the cost of a higher risk of bleeding has been evaluated in different studies. However, data regarding the use of GPIs as peri-interventional treatment is lacking. Indeed, in current European guidelines GPIs may only be considered in specific ‘bail-out’ situations including high intraprocedural thrombus burden, slow flow, or no-flow with closure of the stented coronary vessel. The REPLACE-2 (Randomised Evaluation in PCI Linking Angiomax to Reduced Clinical Events 2) trial showed that the outcome with bivalirudin and provisional glycoprotein (GP) IIb/IIIa blockade is similar to that of UFH plus planned GP IIb/IIIa inhibition during PCI. Moreover, the use of GPIs as bridge to elective percutaneous coronary intervention (PCI) planned after unsuccessful urgent PCI in patients with NSTE-ACS has never been evaluated. Clinical case A 67-year-old man with multiple risk factors (hypertension, smoking and dyslipidemia) and history of coronary artery disease (CAD) was referred for acute chest pain and 27179 ng/L high-sensitivity-cardiac troponine (HS-cTn) at laboratory testing. The echocardiogram showed inferior and lateral wall hypokinesis with an inspective left ventricular ejection fraction (LVEF) of 40%. Therefore, the patient was conducted in the cath-lab and a coronary angiography was performed showing a thrombotic occlusion of proximal right coronary artery (RCA) due to a large thrombus burden. Then, an urgent PCI was indicated. Different guidewires was unsuccessfully attempted to pass throughout the lesion on the proximal segment of the vessel. Eventually, the patient was monitored in intensive care unit and it was decided to administer a continuous infusion of tirofiban for 48 hours to reduce the thrombus burden. During these two days an improvement of the clinical status, a reduction of HS-cTn and an increase in terms of LVEF were observed. At the end the patient underwent to new invasive coronary angiography that demonstrated significant changes of the thrombus burden translating into plaque modification. A PCI was attempted again. The guidewire reached the distal part of the RCA and 1 DES 3.5/28 mm was implanted with consequent optimal angiographic result. Conclusion In the era of potent and faster acting P2Y12-inhibitors like prasugrel and ticagrelor, the benefit and, more importantly, the safety of GPI, remains discussed. In the current European guidelines on revascularization, GPIs infusion should be considered for bail out with evidence of no-reflow or thrombotic periprocedural complication (Class IIa, level of evidence C). This clinical case shows the potential benefit of administrating GPIs as bridge to PCI in selected patients. Patients with an occluded infarct-related artery and large thrombus burden could benefit from GPIs infusion facilitating PCI.

Introduction Patients with aortic stenosis often develop hypertrophy and fibrosis, regardless of symptoms. Cardiac magnetic resonance (CMR) represents the gold standard for the evaluation of fibrosis despite numerous limitations: cost, availability, atrial fibrillation, claustrophobia, kidney failure or inability to apnea. Aim The aim is to validate the role of echocardiographic parameters, such as Global Longitudinal Strain (GLS), as early marker of fibrosis. Clinical and laboratory data, particularly BNP, were also analyzed. Material and Methods In our study we recruited 33 patients with severe aortic stenosis, comparing echocardiographic values of GLS with those of Late Gadolinium Enhancement (LGE) and T1 mapping of CMR. Results 70% of patients with an alteration of GLS had LGE+. Univariate logistic regression shows that the factors associated with the presence of LGE on CMR are hypertension (p = 0.043), GLS (p = 0.032) and elevated Pro-BNP values (p = 0.021); for GLS, odds ratio (OR) is 5 so the chance of finding fibrosis on CMR increases 5 times in presence of an altered GLS. The multivariate analysis confirms the association with impaired GLS values (p = 0.033 =) and hypertension (p = 0.025), but not with elevated Pro-BNP values. Conclusions In patients with severe aortic stenosis, association between GLS and LGE can help identify earlier those with structural changes caused by the disease, who could benefit from early intervention. It remains to be established, through a longer follow-up, how the presence of these alterations can influence the outcome of patients suffering from aortic stenosis.

Introduction Left ventricular pseudoaneurysm is a rare and often fatal complication of myocardial infarction. It has an incidence of 0,2-0,4% of all the STEMI and a very high mortality, particularly in the first month. Symptoms can vary from shortness of breath on exertion, orthopnea, chest pain, fatigue. At least 10% of patients do not present any symptoms and the pseudoaneurysm is diagnosed incidentally during a follow-up appointment. Signs include persistent ST elevation on EKG and its diagnosis can easily be made with a transthoracic echocardiogram and more in depth with a CT scan and a cardiac MRI. Its treatment is surgical, but the choice is up to the anesthesiologist and cardiothoracic surgeon, depending on patient's comorbidity and surgery risk. Surgical treatment has a high rate of death, reaching even the 37%. Background We present the case of a 74 years old patient with an history of chronic hypertension and cerebral vasculopathy, who sustained a STEMI in 2017. Urgent coronarography study was performed, but unfortunately the angioplasty treatment was unsuccessful and the left anterior descending artery could not be recanalized. Therefore, the patient was transferred to the cardiothoracic department in order to undergo bypass surgery: surgery was performed five days after, using left internal mammary artery to the left anterior descending artery and great saphenous vein to the first diagonal. Surgery went well with no complications; the post-operative period passed by without any complications and, after 15 days, patient was discharged with no complains. Two months later, he was admitted to intensive care unit of a hospital of our town, because of dyspnea (NYHA 3), peripheral edema, moderate-severe mitral insufficiency, moderate pleural and pericardial effusion. He underwent a CT-scan that showed “9×6,4 cm cavity with blood that seemed to have a connection with the postero-lateral wall of the left ventricle”. He also underwent a cardiac MRI that displayed a pseudoaneurysm with an endoluminal thrombus. After an accurate evaluation of the case, the Heart Team decided to do not perform surgery because of the high risk of the patient. Thence, we have been followed him with close echocardiographic exams for more than four years. Methods From March 2018 to September 2022, we have been followed the patient with complete echocardiographic follow-ups, done every three-six month. Results and conclusions Patient with left ventricle pseudoaneurysm due to an extensive myocardial infarction has been followed in our echo lab for more than 4 years. He has been stable during these years, NYHA II, in a good clinical and hemodynamical state.

Introduction Woven coronary artery is a rare congenital vascular anomaly, namely a coronary segment divided into many independent thin channels, which intertwine around the coronary axis for several centimeters, and then re-anastomose distally in a single lumen. The etiology of woven coronary arteries is unknown; however, it is commonly considered a benign condition which only rarely results into myocardial ischemia and acute coronary events Clinical case A 47-year-old man, with history of hypertension and drug addiction, presented to the emergency department due to dyspnea (NYHA IV). The chest x-ray showed bilateral pneumonia with pleural effusion, and depressed left ventricular ejection fraction of 32% with antero-lateral ipokinesia and moderate mitral regurgitation was shown at echocardiography. The electrocardiogram showed right bundle branch block. Troponin levels were elevated, denoting myocardial injury and possibly an acute coronary syndrome; therefore the patient was referred to invasive coronary angiography. The coronary angiogram showed the aspect of“woven coronary artery” both in the right (more frequent) and in the circumflex coronary (Figure 1). As in this case, woven coronary is usually incidentally diagnosed during coronary angiography, in fact the anomaly could not explain this clinical scenario. Sometimes woven coronary can be confounded with dissections, recanalized thrombus and chronic total occlusion with bridging collaterals. In the current case the vessels presented a thrombolysis in myocardial infarction (TIMI) flow grade 3 and there was no coronary occlusion; moreover, the simultaneous multivessel presence of this suggestive angiographic aspect makes the hypothesis of a congenital anomaly more likely. Conclusion Woven coronary artery is a rare vascular anomaly, usually benign. Intravascular imaging, which was not performed in this case, may be helpful in equivocal circumstances to avoid unnecessary and potentially high-risk percutaneous coronary intervention.

Background Minimally invasive aortic valve replacement (MIAVR) is defined as a surgical aortic valve replacement which involves smaller chest incisions (mini-sternotomy and right anterior mini-thoracotomy approaches) and minimized degree of surgical intrusiveness. Compared with conventional surgery, it has been shown to reduce postoperative mortality, providing faster and shorter recovery, requires less rehabilitations resources and consequently cost reduction. Even though MIAVR has considered as a safe and acceptable surgical technique, higher learning curve and requirement for re-training should be endorsed as procedural limitations. Among procedural related complications, embolic events still remain the most serious. Clinical case A 70-year-old man, due to increasing dyspnea and chest pain came to emergency department. His medical history was notable for cigarettes smoke, dyslipidemia, non insuline dependent type 2 diabetes mellitus and hypertension. No abnormal electrocardiografic alterations. A transtoracic echocardiogram was performed showing, Left ventricular ejection fraction 50%, no wall motion abnormalities and thickened, ipomobil and calcified aortic valve cusps assessing a diagnosis of severe aortic stenosis. He was conducted to the cath-lab for a diagnostic coronary angiogram which showed a no-significant atherosclerotic disease. After Heart Team evaluation, MIAVR was the suitable and optimal management indicated for the patient. Four hours after ending surgical procedure, ST segment elevation suddenly appears on DII, DIII and aVF leads. Emergency coronary angiogram showed an acute occlusion of the proximal circumflex artery. After several unsuccessful attempts to cross the occlusion with different types of workhorse guidewires, we considered the cause of uncrossability was not a thrombus but a debris calcium embolus detached from valve apparatus. After failed attempts using FineCross, SuperCross 90° provided adequate support to gaining access and enhancing the penetrating power of guidewire; we put the guidewire distally through the Mo2 with partial flow regain. Then we proceeded to modify the plaque geometry with a NC balloon to help crossing guidewire through distal Cx. So we’ve passed over the lesion gaining Cx periphery with a Fielder XT guidewire and we’ve proceeded to prepare the lesion thorugh progressive NC balloon dilatations. At the end we’ve implanted a 3.5/15 mm DES on mid Cx. Conclusion As MIAVR has being more common in the last twenty years, it is useful knowing how to manage any possible related peri-operative complications. Calcific valve is a very uncommon source of coronary debirs embolization. Coronary embolism is associated to worse outcomes: early diagnosis and revascularization must be required. Knowledge of CTO techniques and materials (guidewires, microcatheters) for a “non-CTO” dedicated operators could be useful in several scenarios, such as that encountered in the present case.

Background TAVI-in-TAVI is a complex intervention, potentially associated with feared complications such as coronary artery obstruction or Sinus of Valsalva (SOV)sequestration. Coronary obstruction risk is high when the degenerated bioprosthesis has supra-annular leaflets, the sinus of Valsalva is effaced, and/or sino-tubular Junction (STJ) is narrow. Clinical Case A 91 years old man, underwent TAVI with Acurate NEO M in 2016 with good results: post procedural mean gradient was 8mmHg and PVL was mild. He was admitted in our Institute after six years from index procedure for an episode of acute heart failure with echocardiogram findings of prolapse of one of the prosthetic leaflet causing severe aortic regurgitation without signs of active endocarditis. He was a potential candidate for transfemoral TAVI in TAVI and he had an intermediate risk score. The most important phase of this procedure was a careful planning through the preprocedural CTA. The potential maximal neoskirt of the Acurate M is 30mm. In this case, on one hand, we had wide SOV of 33mm of diameter and wide STJ of 30mm of diameter, on the other hand we had a left main ostia height of 15.5mm, a right coronary artery ostia height of 14mm and a STJ height of 25mm from the basal plane of the transcatheter heart valve (THV), hence we excluded THV with higher frame as Evolut or Acurate to prevent the formation of a long-covered stent of at least 23-24mm and 29-30mm respectively. In the trasversal annular plane obtained by multiplanar CT reconstruction we implanted a “virtual” valve at the geometric center simplified as a cylinder with a diameter of 23 mm to measure the valve to coronary (VTC) and valve to sino-tubular junction (VTSTJ) distance obtaining safe values of 5mm and 8mm respectively, both above the high risk threshold of 4mm for VTC and 2,5-3,5mm for VTSTJ. We chose a SAPIEN ULTRA 23mm for its short frame with a potential maximal neoskirt of 18mm and for its open cell strut to facilitate coronaries reaccess at the cost of a higher degree of first THV leaflets overhang. We decided to perform a low implant with more percentage of overhang THV but a low risk of coronaries flow impairment. Results Excellent result with correct positioning, coronaries patency and absence of leak. The selective cannulation of both coronaries was performed easily and successfully. The patient was discharged the next day with stable haemoglobin and a mean gradient of 8mmHg with no intraprosthetic aortic regurgitation. Conclusion In case of leaflets degeneration with preserved mobility, the low implantation a short frame THV could preserve the formation of the neoskirt above the top of its frame and determining an overhang of first THV leaflets without precluding acute and short-term hemodynamics Discussion In consideration of the expansion of TAVI indication even in younger patients we will encounter an increase of TAVI in TAVI procedures, therefore it is essential to familiarize with CTA reconstructions to assess the risk of direct or indirect coronary occlusion and to do the best THV choice according to the cause of the dysfunction and the anatomical features.

Background In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), potent oral inhibitors of the adenosine diphosphate (ADP)–activated platelet P2Y12 receptor (i.e., prasugrel, ticagrelor) are recommended in addition to acetylsalicylic acid, given as a loading dose as soon as possible, and followed by a maintenance dose. However, the onset of action of oral P2Y12 inhibitors is relatively slower in STEMI patients. In comparison with oral P2Y12 inhibitors, cangrelor has several pharmacokinetic advantages due to its intravenous route of administration, including platelet inhibition within minutes. There is no randomized study so far comparing cangrelor with ticagrelor. The aim of this study was to investigate the comparative effectiveness of intravenous cangrelor and ticagrelor pre-treatment in STEMI patients undergoing primary PCI. Methods We looked for patients with STEMI undergoing primary PCI at a single high-volume center who were naïve from oral P2Y12 inhibitors at presentation and who received cangrelor (in-lab) or ticagrelor pretreatment. The primary endpoint of the study was a composite of all-cause death, myocardial infarction (MI), definite or probable stent thrombosis and unplanned repeat revascularization within hospital discharge. Secondary outcomes were represented by individual components of the primary composite endpoint, cardiovascular death, non-cardiovascular death, and major bleeding within 72 hours from PCI. Propensity score matching was used to account for potential confounders. Results A total of 396 patients with STEMI (October 2019-March 2022) met the eligibility criteria and entered the analysis; of them, 186 (47%) received intravenous cangrelor. The ticagrelor loading dose was administered before invasive coronary angiography in 210 patients (53%). In the unadjusted analysis, no statistically significant difference between cangrelor and ticagrelor was observed with respect to the primary composite outcome (odds ratio [OR], 1.49, 95% CI, 0.79 to 2.82; P=0.22) and all the other secondary outcomes. Consistently, after propensity-score matching of 133 matched pairs of patients receiving cangrelor or ticagrelor, no significant differences emerged with respect to the primary outcome (OR, 1.12, 95% CI, 0.44 to 2.85; P=0.81) and all the other secondary outcomes. Conclusion In patients with STEMI undergoing primary who were naïve from oral P2Y12 inhibitors at presentation cangrelor and ticagrelor yielded similar results. Thanks to its pharmacologic characteristics, cangrelor could be especially useful in the acute setting.

Background The VOYAGER PAD and COMPASS trials established the benefit of dual pathway inhibition (DPI) with aspirin and low dose rivaroxaban for eligible patients with peripheral artery disease (PAD) undergoing revascularisation and for those with PAD or chronic coronary syndromes (CCS), respectively. However, in-hospital implementation of DPI remains slow in clinical practice, also due to eligibility uncertainties. Purpose To assess the eligibility to DPI among contemporary patients hospitalised in cardiology and vascular surgery units, and to evaluate clinical outcomes of patients presenting with revascularised PAD according to their eligibility to the DPI strategy. Methods We analysed data from patients with revascularised PAD included in the prospective institutional RAPID (RivAroxaban for PerIpheral artery Disease) and applied the VOYAGER PAD criteria to identify patients eligible to DPI and the frequency and distribution of exclusion criteria. Clinical outcomes were compared between patients eligible and not eligible to DPI. The primary efficacy outcome was the composite of cardiovascular death, acute limb ischemia, or unplanned limb revascularization, while the primary safety outcome was major bleeding according to the Bleeding Academic Research Consortium definition (i.e., type 3 or 5). Secondary outcomes included the individual components of the primary efficacy outcome, all-cause death, clinically relevant bleeding and minor bleeding. Finally, to explore the residual potential for DPI applicability in clinical practice, COMPASS criteria were also applied to a contemporary CCS cohort from the institutional registry enrolling coronary artery disease patients undergoing invasive management, and the frequency and characteristics of DPI eligibility between PAD and CCS were compared. Results From May 2021 to August 2022, 122 patients (mean age 70.9±10.1 years, 74.6% male) were included in the RAPID registry. Based on VOYAGER PAD eligibility criteria, 62 patients (50.8%) were eligible to DPI. Main reasons for exclusion were oral anticoagulation (13.1%), prior stroke or transient ischemic attack (11.5%), high bleeding risk (46.7%), or concurrent indications for dual antiplatelet therapy (0.8%). In the CCS registry, 1,389 patients were enrolled in the same period (mean age 70.3±10.5 years, 75.6% male). CCS patients who were eligible to DPI were 276 (19.9%). Main reasons for exclusion were concurrent need for dual antiplatelet therapy (27.1%), high bleeding risk (44.8%), need for oral anticoagulation (21.4%), severe heart failure (9.9%), absence of CAD or PAD (35.3%), and end-stage renal disease (2.6%). To provide updated follow-up information, clinical outcomes will be made available for presentation on December 2022. Conclusions Approximately one patient out of two with revascularised PAD and only one fifth of patients with CCS undergoing invasive management were eligible to DPI. According to these results, unlike candidates to the VOYAGER PAD strategy, candidates to the COMPASS strategy are more likely to be identified in an outpatient than hospital setting.

We exhibit the case of a 75 years-old man who undertook cardio-oncological assessment for Non-Hodgkin Lymphoma: baseline echo revealed typical features of lipomatous hypertrophy of the interatrial septum (LHIS) and an apical hypoechoic left ventricle (LV) lesion. Five years before, the patient performed MRI (Magnetic Resonance Imaging), which confirmed LHIS, but superabundant epicardial fat extended to the right ventricle and the apical junction between the two ventricles, both characterized by normal ejection fraction, and surrounded the origin of the pulmonary trunk. LV lateral and inferior walls presented lipomatous metaplasia foci and no history or ECG sign of previous myocardial injury could be pointed out. A slight band of late gadolinium enhancement at the basal infero-lateral wall of LV was highlighted. The patient referred episodes of fainting: the Holter-ECG showed pronounced bradycardia which couldn't be explained by other secondary causes. So a bicameral pace-maker was implanted. During our ambulatory evaluation, we decided to repeat MRI, which showed no difference in comparison with the previous one, so excluding malignant degeneration of the fatty mass surrounding the heart. Despite older age and the lack of sudden cardiac death family history we searched for pathognomonic arrhythmogenic cardiomyopathy (ACM) mutations. In consideration of the new evidence of the metabolic risk associated with abundant epicardial fat (EF) we asked for updated laboratory dosage of plasma glucose, LDL cholesterol and triglycerides and we recommended stricter control of blood pressure. From 4% to 52% of cardiac mass is made up of fat but only EF interacts with myocardium and coronary arteries. Anomalous growth of fat in the heart can present itself as LHIS, excessive lipomatous infiltration or cardiac lipomas (real capsulated tumors) but also ACM is histologically characterized by fibrofatty replacement of cardiomyocites. Overabundant and inflammed EF is now considered a surrogate of metabolic risk and is associated with multivessel coronary disease, the finding of chronic total occlusions (CTO) and microvascular angina. Identifying fatty heart lesions and defining their clinical and prognostic role remains an intriguing challenge. We suggest a general binary way to follow: the “mechanic one” for lipomas or lipomatous infiltration, that is paying attention to compression phenomena or the generation of arrhythmias, and the “metabolic one”, in other words optimizing cardiovascular prevention when EF is too much. A careful research of imaging features of ACM can't be omitted.

We present the case of a 56-years old man, with a history of smoking and chronic hypertension. From September 2021, he began experiencing shortness of breath, with marked limitation of ordinary physical activity. He underwent a cardiologic evaluation: an echocardiogram was performed, finding no alterations in the wall motions, but founding an increased atrioventricular gradient in the right heart and an augmented systolic pulmonary arterial pressure. Also, the acceleration time in the pulmonary artery was increased. Patient's physician prescribed him laboratory exams that resulted within normal ranges, with no increased levels of D-dimer and Chest X-ray in which it resulted to be a nodule, in the lower lobe of the left lung, that was biopsied in our center. We evaluated the patient with CT scan, CT angiography, PET-scan and cardiac MRI and discovered that the increased pressure in the pulmonary artery was due to a non-better specified tumor, which was then completely resected. After one month, the final diagnosis came back: poorly differentiated pleomorphic sarcoma, with high mitotic index and large areas of necrosis, characterized mainly by spindle cells and cells with epithelioid morphology; furthermore, there was a formation of vascular spaces surrounded by pleomorphic cells and areas of lower density cells with myxoid stroma and hemangiopericytoma-like aspects. Considering several factors such as anamnesis, localization of the tumor, growth from the tunica intima of the pulmonary artery and immunophenotypic expression, the tumor was diagnosed as a pulmonary arterial intimal sarcoma.

Introduction Post-TAVI infective endocarditis is a rare event. The incidence is 3,25%, and it is associate with severe complications and high risk of mortality. Aim The aim of the study is to focus on the possibility of alternative therapy except surgery in treatment of a complicated endocarditis, choice taken also thanks to TEE, through it is possible analyze the integrity of the prosthesis, evidence/absence of rupture or ulceration and monitoring the evolution during therapy. Material and Methods A 76-year-old female patient who went to TAVI, reported fever, increased phlogosis indices and abdominal pain few days after the procedure. Diagnostic imaging resulted in infection of the aortic prosthesis and in thromboembolisms affecting splenic artery and celiac trunk. At TEE an isoechogenic vegetation (14×8 mm) was described in correspondence of aortic prothesis and high gradient was detected. Thromboembolic events have occurred and thrombo-endoarteriectomia of right femoral artery was performed. Staphylococcus Lugdunensis was found in blood cultures and intravenous antibiotic and anticoagulant therapy was undertaken. Results After one month of medical therapy, at TEE significant vegetation reduction was found. Patient was discharged at home, asymptomatic. After 1 month at TTE no sign of endocarditis was detected, blood sample was fine and patient was asymptomatic. Conclusions This case is an example of an early infective process involving biological valve post-TAVI, followed by systemic embolization, in which the only medical therapy was successful. Echocardiography has played a fundamental role to choose the strategy of therapy and to monitor its result.

Background Selective cannulation must be ensured especially in patient with coronary artery disease (CAD). Commissural alignment in self-expanding transcatheter heart valve (THV) is fundamental to facilitate subsequent coronary reaccess. Clinical Scenario A man of 84 years old, suffering from hypertension, dyslipidemia, diabetes mellitus, third stage of chronic kidney disease and obesity was admitted in our hospital for treatment. He had angina and dyspnea with a third NYHA class. The echocardiogram showed severer aortic stenosis with mean gradient of 48 mmHg and aortic valve area of 0.6cmq with preserved ejection fraction. He was eligible for transfemoral transcatheter aortic valve implantation (TAVI) and he had intermediate risk score. The preprocedural coronary angiogram revealed subocclusive and severe calcified lesion on mid circumflex artery. Methods The Acurate NEO 2 size L THV was chosen and was planned to implant the bioprosthesis with commissural orientation correlated to the native commeasures, selecting at the CT scan the projection of cusp overlap (right and left coronary cusp on the right of the screen). The delivery catheter was inserted into the introducer sheath with its flush port facing the six o’clock position and the after crossing the aortic arch and native annulus, the handle of the delivery catheter was torqued clockwise until 1 of the Acurate NEO 2 commissural posts faced the commissural of the aortic root. The final angiogram showed optimal position and orientation of the THV without paravalvular leak. The patient was discharged the next day with a mean gradient of 9mmHg. One month after TAVI, elective PCI was performed. We’ve prepared the lesion with rotational atherectomy, due to severe calcification. Three forward advancements of rotating abrasive burr was performed and subsequently one DES was implanted. The angiogram check showed excellent result with TIMI 3 flow. Conclusion The Acurate Neo 2 supra-annular valve platform provides a successful coronary cannulation. Coronary rotational atherectomy for severe calcified lesions after TAVI with Acurate Neo 2 is a feasible strategy

In May 2020, a 45-years-old woman was admitted to the Emergency Department due to transient ischemic attack. The thrombophilia screening showed hemizygous prothrombin gene mutation (Factor II) and homozygous MTHFR mutation. The transthoracic echocardiography was normal, with a left ventricular ejection fraction of 60% and no morphological or functional valve disease. The 24-h Holter ECG and the past medical history did not show any specific cause of the neurologic manifestations. In the absence of a specific and plausible cause of the transient ischemic attack, a diagnosis of cryptogenic stroke was made. The patient then underwent transcranial Doppler, which showed a high-grade shunt (curtain effect), and transesophageal echocardiography with bubble test, which showed the presence of a massive right-to-left shunt through a patent foramen ovale (PFO) during the Valsalva maneuver. A therapy with warfarin (achieving a target INR between 2 and 3) was therefore started, and the indication for a percutaneous PFO closure was given. In January 2021 the patient underwent successful percutaneous PFO closure with the Gore Cardioform Septal Occluder 25/25 mm (W.L. Gore and Associates, Inc.) through intracardiac echocardiographic guidance with no complication and without any residual shunt. The patient was discharged on dual antiplatelet therapy with aspirin 100 mg daily plus clopidogrel 75 mg daily for six months, and pantoprazole 20 mg daily, followed by aspirin 100 mg daily chronically. After 6 months the patient underwent transcranial Doppler, which was negative for shunt. 12 months after the implantation the patient stopped aspirin by her own initiative. In August 2022, due to the diagnosis of an ovarian cyst, the gynecologist prescribed estro-progestogen pill: in that occasion, the patient did not mention her thrombophilia. After 10 days, sudden onset of weakness of the right upper limb and aphasia. The patient was then admitted to the Emergency Department, were the computer tomography showed two acute lesions on the left cerebral hemisphere. Therefore, the patient underwent intravenous thrombolysis, with complete regression of the neurological symptoms: a diagnosis of stroke was then formulated. To understand the origin of such stroke, the neurologist gave indication to cardiological evaluation. The patient did not have any palpitation in the previous months and the electrocardiogram showed normal sinus rhythm. However, the transthoracic echocardiographic evaluation showed a dubious image of a mass attached to the interatrial septum, for which the patient underwent transesophageal echocardiography, which showed a 10×9 mm fluctuating thrombus attached to the left side of the previously implanted PFO closure device. Therefore, an oral anticoagulation therapy with warfarin plus a subcutaneous therapy with enoxaparin 6000 UI twice daily (as bridge to obtain the desired INR between 2 and 3) was started. After ten days, the patient underwent a new transesophageal echocardiography, which showed a substantial reduction in the dimensions of the thrombus (4×3 mm). The patient was then discharged in warfarin therapy with no residual neurological symptoms.

Background Latest iterations of devices for transcatheter aortic valve implantation (TAVI) have brought refinements to further improve patients outcomes, but comparisons of balloon-expandable Sapien 3 ULTRA (ULTRA) and self-expanding Acurate Neo 2 (NEO2) valves are lacking. Objectives To compare hemodynamic and clinical outcomes of patients undergoing TAVI with ULTRA or NEO 2 devices. Methods Patients undergoing TAVI with ULTRA and NEO 2 and enrolled in the REPLACE Registry from June 2019 to July 2022 (n=174) were analyzed. The primary efficacy and safety outcomes were VARC-3 device success and early safety, respectively. Secondary outcomes included technical success, 30-day clinical outcomes and echocardiographic device performance. Results A total of 119 patients receiving ULTRA (68.4%) and 55 receiving NEO 2 (31.6%) were compared. The primary efficacy (90.8% vs. 87.3%, for ULTRA and NEO2 respectively, p=0.483) and safety (87.4% vs. 85.5%, for ULTRA and NEO2 respectively, p=0.725) outcomes did not differ between patients receiving ULTRA or NEO 2 transcatheter aortic valves. On post-TAVI echocardiography, no cases of severe PVR were detected. The rate of mild-to-moderate paravalvular regurgitation (PVR) was lower in the ULTRA group (0.9% vs. 6.1%, p=0.002), with similar mean transvalvular gradients between the study groups (median 10 vs. 8.5 mmHg, for ULTRA and NEO2 respectively, p=0.11). Conclusions In this comparison, device success rates were high with both new-generation devices, with overall low rates of adverse events at 30 days after TAVI. Very low PPI rates were reported with both devices. PVR rates were low, but higher in patients receiving NEO 2.

Background Antiplatelet therapy is required in patients with atherosclerotic coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Current European and American guidelines recommend 6 months of DAPT in CCS and 12 months after ACS. However, a shorter duration of DAPT may be considered in high bleeding risk (HBR) patients, and a longer duration in those at higher thrombotic risk (HTR). To minimize the risk of thrombotic and bleeding events of an individual patient and therefore improve the overall outcomes of PCI, risk stratification is essential. In particular, bleeding and thrombotic characteristics must be weighed on a case-by-case basis to tailor antiplatelet therapy strategies and decisions over a patient's individual risk profile. We describe an illustrative case of complex PCI in patient with ACS in which defining the appropriate duration of DAPT is a clinical challenge. Clinical case A 68-year-old man with ACS-NSTEMI and anemia was hospitalized in intensive care unit. His medical history was notable for hypertension, dyslipidemia, diabetes mellitus, diabetic retinopathy, chronic kidney disease (CKD) and paroxysmal atrial fibrillation. A transthoracic echocardiogram showed left ventricular ejection fraction of 30% with diffuse hypokinesia, without relevant valvular disease. He was conducted to the cath-lab for a diagnostic coronary angiogram which showed a three-vessel critical CAD. After Heart Team evaluation coronary artery bypass surgery (CABG) was indicated. However, during the hospitalization in intensive care unit there was a worsening of clinical conditions with cognitive impairment due to mesencephalic stroke leading to a new Heart Team assessment that indicated PCI after stabilization of clinical scenario. After two weeks patient was conducted to the cath-lab to undergoing an IVUS guided PCI. PCI of the right coronary artery was performed with implantation of 1 DES (3.0/30 mm) on the middle segment and 1 DES (4.0/15 mm) on the ostial segment. PCI of the left main bifurcation was performed with implantation of 2 DES (4.0/28 mm) with culotte technique. Patients have both HBR and HTR, therefore, after procedure, the new trade off model score introduced by the Academic Research Consoritum (ARC) was applied. Based on his risk factor, the predicted 1-y risk of BARC type 3 to 5 bleeding (51.41%) was greater than the predicted 1-y risk of myocardial infarction or stroke (25.00%). Based on this result we decided to prescribe Triple antithrombotic therapy for 1 week, dual antithrombotic therapy for 12 months and after only oral anticoagulation. Conclusion In the context of patient with several risk factor undergoing complex PCI the stratification of bleeding and thrombotic individual risk is mandatory to define the appropriate duration of DAPT. The new trade-off model score is an important useful tool to identify patients who might benefit from individualized DAPT durations depending on the balance between HBR and HTR characteristics.

A 72-years-old woman was admitted to the Emergency Department due to acute stroke in April 2022. Some days later the patient developed acute respiratory failure with oxygen arterial desaturation (SpO2

Background Dual antiplatelet therapy (DAPT) reduces the risk of stent thrombosis after percutaneous intervention (PCI), but it is estimated that approximately 5 to 10% of PCI patients undergo major noncardiac surgeries within 12 months from the procedure, which requires DAPT interruption. The interruption of DAPT reduces the risk of perioperative bleeding, but increases the risk of stent thrombosis. Peri-operative “bridge” therapy with cangrelor, a reversible and competitive intravenous P2Y12 receptor inhibitor with rapid on/offset of action, may offer a solution for high-risk patients undergoing major noncardiac surgery who require DAPT interruption. However, the use of cangrelor for this indication is currently off-label. Clinical Scenario A 58-year-old man was admitted to ER with increasing dyspnea and oppressive chest pain on exertion. A diagnosis of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was made and PCI of the left main-left anterior descendent artery segment and the right coronary artery was performed with implantation of four drug-eluting stents. DAPT was prescribed for 12 months with acetylsalicylic acid 100 mg daily and ticagrelor 90 mg twice daily. The day after the procedure, due to gross hematuria with clots formation; the hemoglobin level fell to 8 g/dL and a transfusion was required. Subsequent abdominal echocardiography revealed two bladder neoformations that required further endoscopic evaluation and transurethral resection of bladder tumor (TURBT). In preparation for such invasive procedure, DAPT required interruption despite the high risk of catastrophic consequences. Methods After ticagrelor interruption, cangrelor was started intravenously at a rate of 0.6 mcg/Kg/min for 5 days and stopped 2 hours before the TURBT procedure, which was performed with minimal blood loss and no ischemic complications. Cangrelor infusion was re-started 2 hours after surgery at the same initial rate and planned for 12 hours if no sudden bleeding occurred. The day after the TURBT procedure cangrelor was stopped and DAPT was re-initiated with aspirin 100 mg daily and clopidogrel 75 mg daily (after a 600 mg loading dose). The patient was discharged 2 days later without any new bleeding or ischemic event. Conclusions Premature discontinuation of DAPT is a strong predictor of stent thrombosis in patients undergoing PCI who require major noncardiac surgery. Cangrelor represents a viable option for managing high-risk individuals who require prolonged P2Y12 receptor blockade with rapid onset and offset of action despite discontinuation of oral therapy. This use is currently off-label due to lack of well powered randomized clinical trials of bridge therapy.