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Introduction Patterns and prognostic impact of suboptimal adherence to statin therapy, after STEMI, remains understudied Purpose To identify predictors and to estimate the prognostic impact of low statin adherence after STEMI Method We evaluated real-world purchase of statins and typical cardiovascular drugs, after STEMI, in a large regional database that enrolled patients from 2012 to 2017; adherence was defined as the ratio of bought tablets divided by the number of expected tablets in the follow-up period. Cox regression was used for multivariate analysis; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of all-cause mortality at follow-up Results A total of 4062 patients were enrolled, of which 12.6% died after a median of 4.7 years of follow up (IQR 3.7–5.7). Statin adherence lower than 80%, identified as the best cutoff at Youden's analysis, was identified in 42% of the registry population; statin adherent patients were more likely younger, with known dyslipidemia at enrollment, discharged with ACE inhibitors and a potent P2Y12 inhibitor (ticagrelor or prasugrel), and with a statin diverse from atorvastatin. After multivariate adjustment for in-study outcome predictors, low statin adherence was independently associated with all cause mortality (HR 0.57; 95% CI 0.46–0.70; p Conclusions In the contemporary real-world setting, statin adherence following STEMI remains poor, especially in high risk patients, and is still a crucial independent predictor of all-cause mortality. Effective strategies to improve statint adherence remain an unmet clinical need. Funding Acknowledgement Type of funding sources: None.

Background During SARS-CoV-2 pandemic, various studies have shown a significant reduction of Emergency Department (ED) presentations for acute cardiac diseases requiring in-hospital management. The aim of our study was to quantify hospital admission and mortality, comparing pandemic period and pre-pandemic period in different countries. Methods We performed an updated meta-analysis of observational studies to quantify on a large basis the impact of the SARS-CoV-2 outbreak on patients admitted to the ED for STEMI and NSTEMI. The literature research was conducted on PubMed, EMBASE, Scopus, Science Direct, Web of Science and Cochrane database registry on 6 January 2022. We performed a random-effect model meta-analysis. Results A total of 61 studies were included: came from Italy, China, Germany, Israel, Turkey, France, Helvetic Confederation, India, Poland, Spain, US, UK, Albania, Austria, Egypt, Greece, Iran, Ireland, Japan, Pakistan, Portugal, Saudi Arabia and Canada. Hospital admissions for STEMI decreased in most country. The countries with the high levels of reduction were Italy (IRR = 0.68) and Germany (IRR = 0.69). Mortality rates for STEMI increased differently among countries analyzed: p = 0.003. The highest mortality rate was in Serbia (OR = 2.15), followed by Italy (OR = 1.97), Pakistan (OR = 1.69) and France (OR = 1.55). Among the High-Income countries, the highest mortality rate was in Italy (OR = 3.71), the highest among the Upper-Middle-Income was in Serbia (OR = 2.15) and the highest among Low- Middle-Income was in Pakistan (OR = 1.69). Regarding NSTEMI, hospital admissions showed that Italy had the lowest value for with IRR = 0.59. Among countries, the meta-regression subgroups analysis, showed statistical difference (p < 0.001). Conclusions Our meta-analysis may represent a robust snapshot that might help healthcare systems manage and assist an expected higher number of people coming to the hospitals for severe, post-acute cardiological issues in the future. Key messages • The study shows hospital admission and mortality, comparing pandemic period and pre-pandemic period in different countries. • Epidemiological data suggests that one-fourth to one-third of MI patients, in large areas of the globe, during the COVID-19 pandemic in 2020, remained at home and did not have access to ED.

Background The clinical value of high-risk coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non-flow-limiting lesion remains uncertain. Purpose We performed a systematic review and meta-analysis to study the prognostic impact of CPCs on patient-level and lesion-level major cardiovascular adverse events (MACE). Methods We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for studies evaluating the association of CPC with patient-level and lesion-level MACE. CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low attenuation plaque, spotty calcification, napkin ring sign, or positive remodelling. Results Thirty studies (21 retrospective, 9 prospective) with 30,369 patients were included. CPCs were evaluated by invasive intravascular techniques in 9 studies (optical coherence tomography=4, intravascular ultrasound imaging=3, near-infrared spectroscopy intravascular ultrasound imaging=2) and by coronary computed tomography angiography (CCTA) in 21 studies. CPCs significantly predicted patient-level and lesion-level MACE in both unadjusted and adjusted analyses. For each CPC, the risks were higher for lesion-level (HR range 3.2–16.8) as compared with patient-level MACE (HR range 1.8–4.1). Accuracy was modest to good for most CPCs at the patient-level (AUC for MACE ranging between 0.53 and 0.84) and moderate to good for most CPCs at the lesion-level (AUC for MACE ranging between 0.71 and 0.83). Plaques with more than one CPC had the highest accuracy for lesion-level MACE (AUC 0.87, 95% CI 0.84–0.90). The pooled sensitivities of CPCs for lesion-level MACE ranged between 40% and 63% and specificities between 73% and 98%. As the pooled prevalence of CPCs among plaques was low (3% to 28%), the estimated positive predictive values for lesion-level MACE were modest (range 1% to 26%). Conclusions CCTA and intravascular imaging characterization of CPCs identifies high-risk atherosclerotic plaques that place lesions and patients at risk for future MACE, albeit with modest sensitivity and positive predictive value (PROSPERO identifier: CRD42021251810). Funding Acknowledgement Type of funding sources: None.

Introduction Potential protective role of complete revascularization for development of Heart Failure (HF) after an Acute Coronary Syndrome (ACS) remains to be elucidated. Methods CORALYS is a multicenter, retrospective, observational registry enrolling consecutive patients admitted for ACS and treated with PCI. Patients with known history of HF or reduced left ventricular ejection fraction (LVEF) before index admission were excluded. The composite of first hospitalization for HF or cardiovascular (CV) death was the primary endpoint, while its single components along with all-cause death were the secondary ones. Complete vs. non complete revascularization (CR vs. non-CR) strategies were compared with Inverse Probability Treatment Weighting (IPTW) across all patients and for those admitted for STEMI and NSTEMI ACS and with Ejection Fraction (EF) at discharge above or below 50%. Results Out of 14699 patients, 5054 presented with multivessel disease. Of them, 1473 (29.2%) underwent CR. Over 5 years follow up, complete revascularization reduced the primary combined endpoint (9.2% vs. 16.2%, p Conclusions Complete revascularization after ACS reduces risk of CV death and of hospitalizations for HF, providing another explanation of the prognostic role of CR apart from prevention of recurrent infarctions and a clear therapeutic strategy. Funding Acknowledgement Type of funding sources: None.

Background Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR-CA) remains difficult in this subset. Methods Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR-CA based on clinical assessment underwent 99mTc-DPD cardiac scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR-CA in AS, was retrospectively calculated to rule-out ATTR-CA in the remaining patients. Patients were categorized as follow: “ATTR-CA+”: patients with confirmed ATTR-CA at 99mTc-DPD cardiac scintigraphy; “ATTR-CA−”: patients with negative 99mTc-DPD cardiac scintigraphy or a negative RAISE score; c) “ATTR-CA indeterminate”: patients not undergoing ATTR-CA assessment with a positive RAISE score. The characteristics of ATTR-CA+ and ATTR-CA− patients were compared. Results Of 107 included patients, ATTR-CA suspicion was posed in 13 patients and confirmed in 6. Patients were categorized as follow: 6 (5.6%) ATTR-CA+, 79 (73.8%) ATTR-CA−, 22 (20.6%) ATTR-CA indeterminate. Excluding ATTR-CA indeterminate patients, the prevalence of ATTR-CA was 7.1%. As compared to ATTR-CA− patients, ATTR-CA+ patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, bifascicular block was more common. No difference in procedural outcomes and 1-year mortality was observed between groups. Conclusions Among severe AS patients, ATTR-CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. A clinical approach based on routine search of amyloidosis features may effectively lead to selective 99mTc-DPD cardiac scintigraphy with a satisfactory positive predictive value. Funding Acknowledgement Type of funding sources: None.

Ellis grade III coronary artery perforations (G3-CAP) remain a life-threatening complication of percutaneous coronary intervention (PCI), with high morbidity and mortality and lack of consensus regarding optimal treatment strategies. We reviewed all PCIs performed in 10 European centers from 1993 to 2019 recording all G3-CAP along with management strategies, in-hospital and long-term outcome according to Device-related perforations (DP) and Guidewire-related perforations (WP). Among 106,592 PCI (including 7,773 chronic total occlusions), G3-CAP occurred in 311 patients (0.29%). DP occurred in 194 cases (62.4%), more commonly in proximal segments (73.2%) and frequently secondary to balloon dilatation (66.0%). WP arose in 117 patients (37.6%) with chronic total occlusions guidewires involved in 61.3% of cases. Overall sealing success rate was 90.7% and usually required multiple maneuvers (80.4%). The most commonly adopted strategies to obtain hemostasis were prolonged balloon inflation (73.2%) with covered stent implantation (64.4%) in the DP group, and prolonged balloon inflation (53.8%) with coil embolization (41%) in the WP group. Procedural or in-hospital events arose in 38.2% of cases: mortality was higher after DP (7.2% vs 2.6%, p = 0.05) and acute stent thrombosis 3-fold higher (3.1% vs 0.9%, p = 0.19). At clinical follow-up, median 2 years, a major cardiovascular event occurred in one-third of cases (all-cause mortality 8.2% and 7.1% respectively, without differences between groups). In conclusion, although rare and despite improved rates of adequate perforation sealing G3-CAP cause significant adverse events. DP and WP result in different patterns of G3-CAP and management strategies should be based on this classification.

Background Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR–CA) remains difficult in this subset. Methods Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR–CA based on clinical assessment underwent 99mTc–DPD cardiac scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR–CA in AS, was retrospectively calculated to rule–out ATTR–CA in the remaining patients. Patients were categorized as follow: “ATTR–CA +”: patients with confirmed ATTR–CA at 99mTc–DPD cardiac scintigraphy; “ATTR–CA –”: patients with negative 99mTc–DPD cardiac scintigraphy or a negative RAISE score; c) “ATTR–CA indeterminate”: patients not undergoing ATTR–CA assessment with a positive RAISE score. The characteristics and outcomes of ATTR–CA + and ATTR–CA – patients were compared. Results Of 107 included patients, ATTR–CA suspicion was posed in 13 patients and confirmed in 6. Patients were categorized as follow: 6 (5.6%) ATTR–CA +, 79 (73.8%) ATTR–CA –, 22 (20.6%) ATTR–CA indeterminate. Excluding ATTR–CA indeterminate patients, the prevalence of ATTR–CA was 7.1%. As compared to ATTR–CA – patients, ATTR–CA + patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, bifascicular block was more common. No difference in procedural outcomes and 1–year mortality was observed between groups. Conclusions Among severe AS patients, ATTR–CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. The procedural and mid–term outcomes following TAVR seems unaffected by ATTR–CA status.

Background Trans–ventricular off pump mitral valve (MV) repair with neochordae implantation (Neochord procedure) is a minimally invasive surgical technique for correction of degenerative mitral regurgitation (MR) due to prolapse or flail. The aim of this study was to evaluate mid–term results of patients undergoing this procedure and find new three–dimensional pre–operative echocardiographic parameters to predict MR recurrence at follow–up. Methods We performed a retrospective analysis of 72 consecutive patients with severe MR due to prolapse or flail who underwent Neochord procedure at our hospital from March 2015 to February 2021. MV pre–operative anatomical parameters were assessed using 2D TEE, 3D TEE and dedicated three–dimensional (3D) post–processing analysis with dedicated software (QLAB, Philips). TTE follow–up and clinical evaluation were performed at 3 months, 6 months, 1 year and then annually. Results Twenty–seven patients were female (37.5%), mean age was 77±9 years. The average preoperative EuroSCORE II was 2.2%±1.5%. Twenty–three patients (32%) had an history of paroxysmal or persistent atrial fibrillation. Procedural success at discharge was achieved in sixty–eight patients (94.5%). Mean follow–up was 30±16 months. Three years follow–up was completed by fifty patients. At three years thirteen patients (26%) presented with recurrence of severe MR or underwent new surgical operation. Prevalence of mild or trace MR at three years follow–up visit was 70%. End–systolic annulus area (12.5±2.5 cm2 vs 14.1±2.6 cm2; p = 0.038), end–systolic annulus diameter (13.2±1.2 cm vs 14±1.3 cm; p = 0.042) and indexed left atrial volume (59±17 ml/m2 vs 76±37 ml/m2; p = 0.041) were lower in patients with residual MR less than moderate (MR Conclusion In patients with degenerative MR treated with Neochord procedure, 3D analysis focused on annular measures and coaptation indexes, that included 3D annular dimensions, predicts better MR relapse than conventional 2D parameters.

Aims Stratifying prognosis following coronary bifurcation percutaneous coronary intervention (PCI) is an unmet need. Machine learning (ML) may identify patterns from multidimensional, non–linear relationships to make outcome predictions. We sought to develop a ML–based risk stratification model built on clinical, anatomical and procedural features to predict all–cause mortality following contemporary bifurcation PCI. Methods and Results Multiple ML models to predict all–cause mortality were tested on a cohort of 2,393 patients (training, n = 1,795; internal validation, n = 598) undergoing bifurcation PCI with contemporary stents from the real–world RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) registry. Among 38 commonly available features, 25 (13 patient–related, 12 lesion–related) were selected to train ML models. The best performing model (the RAIN–ML prediction model) was validated in an external validation cohort of 1,701 patients undergoing bifurcation PCI from the DUTCH PEERS (DUrable polymer–based sTent CHallenge of Promus ElemEnt versus ReSolute integrity: TWENTE II) trial and the BIO–RESORT trial cohorts. The area under the receiver operating characteristic curves for the prediction of 2–year mortality was 0.786 (0.74–0.83) in the overall population, 0.736 (0.72–0.847) at internal validation and 0.706 (0.6919–0.794) at external validation. Performance at risk ranking analysis, k–center cross validation, and with continual learning confirmed the generalizability of the models, available also as an online interface. Conclusions The RAIN–ML prediction model represents the first tool combining clinical, anatomical and procedural features to predict all–cause mortality among patients undergoing contemporary bifurcation PCI with a good discriminative performance.

Background The clinical value of coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non–flow–limiting lesion remains uncertain. We performed a systematic review and meta–analysis to study the prognostic impact of CPCs comprehensively assessed with invasive and non–invasive imaging technologies on patient–level and lesion–level major cardiovascular adverse events (MACE). Methods We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for studies evaluating the association of CPC with patient–level and lesion–level (MACE). CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low attenuation plaque, spotty calcification, napkin ring sign or positive remodelling. Results Thirty studies (21 retrospective, 9 prospective) with 30.369 patients were included. CPCs were evaluated by invasive intravascular techniques in 9 studies (optical coherence tomography=4, intravascular ultrasound imaging=3, near–infrared spectroscopy intravascular ultrasound imaging=2) and by coronary computed tomography angiography (CCTA) in 21 studies. CPCs were significantly predictive of patient–level and lesion–level MACE, also when only adjusted data where considered. For each CPC, the odds appeared higher for lesion–level (HR range 3.2–16.8) as compared to patient–level MACE (HR range 1.8–4.1). Accuracy was modest to moderate for most CPCs at the patient–level (AUC for MACE ranging between 0.53 and 0.84) and moderate to good for most CPCs at the lesion–level (AUC for MACE ranging between 0.71 and 0.83). Plaques with more than one CPC had the highest accuracy for lesion–level MACE (AUC 0.87, 95%CI 0.84–0.90). CPC pooled sensitivities for lesion–level MACE ranged between 40% and 63% and specificities between 73% and 98%. As the pooled prevalence of CPCs among plaques was low (3% to 28%), the estimated positive predictive values for lesion–level MACE were modest (range 33% to 45%). Conclusion CCTA and intravascular imaging characterization of CPCs provides independent prognostic value among atherosclerotic patients and lesions. However, the modest sensitivity and positive predictive value observed across all CPCs seem to suggest modest clinical value, especially to predict lesion–level events (PROSPERO identifier: CRD42021251810).

Background Data about long-term clinical outcomes of young patients experiencing an acute myocardial infarction (MI), along with the potential impact of gender on incidence and prognosis in such subset are scant and mostly including USA populations. Thus, there is a paucity of data about European patients suffering from a juvenile MI. Purpose The purpose of the current study was to investigate temporal trends, survival, MI recurrence and sex differences among subjects who experienced their first MI at young age in the Piedmont region (Italy) between 2007 and 2018. Methods Hospital Discharge Register records of Piedmont region (Italy) from 2007 to 2018 were interrogated to identify incident juvenile MI cases and MI recurrences (ICD-9-CM codes: “410”, “411” and their subcodes). Patients were considered young if the first MI occurred before or at 47 years of age. Incidence of first Juvenile MI event and subsequent overall survival among patients who survived to hospital discharge were defined as primary outcomes of interest. Subgroup analysis were performed according to sex category, comorbidities and clinical intervention (obtained from the HDRs records). Incidence of MI recurrence among patients who survived to hospital discharge was defined as secondary outcome of interest. Lastly, we evaluated whether experiencing a MI recurrence was associated with a lower overall survival at follow-up. Results Out of 114.816 hospitalizations due to MI, 4482 occurred in people aged ≤47, with median age 44 years old. At baseline, men had more hypertension (13% vs 9.4%, p Conclusions In young patients with a MI, women had more in-hospital mortality compared to men, but among patients who survived to hospital discharge, overall long-term prognosis did not differ. MI recurrences were more common in men and were associated with lower long-term survival rate. Funding Acknowledgement Type of funding sources: None.

Introduction Despite limited to short and mid-term outcomes, Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a less invasive alternative to redo surgery for high and intermediate-risk patients with good outcomes across different surgical risk profiles. Purpose The aim of the resent meta-analysis is to compare short and mid-term outcomes of VIV and surgical redo fo patients with a degenerative aortic bioprosthesis. Methods All studies comparing with multivariate adjustment between ViV TAVI and re-SAVR were screened. All-cause mortality at 30-day and at follow-up were the primary endpoints, while Valve Academy research Consortium (VARC) endpoints at 30 days including stroke, myocardial infarction (MI), major vascular complications, major bleeding, new onset atrial fibrillation (AF) and permanent pacemaker implantation (PPI) during the index hospitalization were the secondary endpoints. Subgroup analysis were performed according to the surgical risk. All the analyses were stratified according to the design of the study (observational vs propensity-matched study). Results We obtained data from 11 studies, encompassing 8570 patients, 4224 undergoing ViV TAVI and 4346 re-SAVR. Four studies included intermediate-risk patients and seven high-risk patients. Mean age was 76 and 71.5 years in the ViV and re-SAVR group respectively, with a 60.2% and 61.3% of male. For the ViV procedure, BE prostheses were used in the 49.6% of patients and SE prostheses in the 45.8%. The ViV group have higher prevalence of previous CAD (53.8% vs 41.1%) and CABG (35% vs 23.6%) and more history of HF (72.1% vs 65.6%), CKD (26.6% vs 14.8%) and COPD (25.4 vs 14.8%). 30-day all-cause and CV mortality were significantly lower in ViV (OR 0.43, 0.29–0.64 and OR 0.44, 0.26–0.73 respectively), while after a mean follow-up of 717 (180–1825) days, there were no difference between the two groups (OR 1.04, 0.87–1.25 and OR 1.05, 0.78–1.43 respectively). The result were consistent both in intermediate and high-risk classes. The risk of stroke (OR 1.03, 0.59–1.82), MI (OR 0.70, 0.34–1.44), major vascular complications (OR 0.92, 0.50–1.67) and permanent pacemaker implantation (OR 0.67, 0.36–1.25) at 30 days did not differ, while major bleedings and new onset atrial fibrillation were significantly lower in ViV patients (OR 0.41, 0.25–0.67 and OR 0.23, 0.12–0.42 respectively, all CI 95%). Conclusions In patients with a degenerated aortic bioprosthesis, ViV TAVI is associated with better short-term outcomes, including all-cause mortality, without any difference in all-cause and cardiovascular mortality at mid-term follow-up compared to surgical redo. Funding Acknowledgement Type of funding sources: None.

Objective The aim of the present analysis was to evaluate the incidence and predictors of in-hospital adverse outcomes in nonagenarian patients undergoing primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). Methods Consecutive nonagenarian patients undergoing pPCI for STEMI from 2009 to 2019 were retrospectively included in an international multicenter registry. In-hospital all-cause death was the primary outcome. Results A total of 308 patients were included (mean age 92.5±2.5 years, 65.6% female). Mean systolic blood pressure (SBP) at hospital admission was 130.7±33.5 mmHg, 46 (17%) patients presented with a Killip class III-IV, mean left ventricle ejection fraction (LVEF) was 40.0±11.5% and 147 (58%) patients were independent in everyday activities. In-hospital death occurred in 99 patients (32%). [Figure 1] After multivariate adjustment, lower LVEF (OR per unit reduction 1.08, 95% CI 1.03–1.11, p-value Conclusion Nonagenarian patients presenting with STEMI and undergoing pPCI have high in-hospital mortality. Independency in everyday life is a strong independent predictor of survival to hospital discharge. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Background Higher risk of bleeding with ticagrelor over clopidogrel in elderly patients with acute coronary syndrome (ACS) has been suggested. Purpose We assessed the incidence of major bleeding (MB), reinfarction (REAMI), and all-cause death in elderly patients to evaluate the safety and efficacy of ticagrelor versus clopidogrel in a population at high risk of bleeding and ischemia treated with percutaneous coronary intervention (PCI). Methods RENAMI and BleeMACS, real-world registries of patients with ACS who underwent PCI and received dual antiplatelet therapy, were merged. The pooled cohort was divided into two groups, clopidogrel versus ticagrelor and propensity score matching (PSM) analysis performed. Statistical analysis considered two age groups ( Endpoints were BARC 3–5 MB, REAMI and all-cause death at 1 year. Independent risk factors of MB were identified. Results The study included 16,653 patients (13,153 Conclusions Ticagrelor did not significantly increase MB compared with clopidogrel in elderly patients hospitalized for ACS and treated with PCI, significantly improving 1-year survival. Further studies on elderly patients are required. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Astra Zeneca

Background Heart failure (HF) is the pandemic of the third millennium with the highest mortality among general population, while lung cancer is the second most common cause of death. As cancer, HF can affect close organs, as lungs, or can reach peripheral organs (kidney, liver, brain), leading to multi-organ dysfunction, like cancer metastasis. Purpose We proposed a new staging system named HLM, analogous to TNM classification used in oncology, which refers to heart damage (H), lung involvement (L), and malfunction (M) of peripheral organs. The aim of this study is a comparison between HLM and NYHA, ACC/AHA and MAGGIC scores to assess the most accurate prognosis of HF patients in terms of rehospitalization for acute HF (AHF) or major adverse cardiac and cerebrovascular events (MACCE), and cardiac death. Methods We performed a single-center observational study of HF patients. All parameters for heart, lungs and peripheral organs function were examined. Each patient was classified according to HLM, NYHA, ACC/AHA and MAGGIC score at the entrance and at the discharge. Rehospitalization for MACCE or AHF and cardiac death were checked at 12 months follow up. Results We enrolled 2054 patients: 68.5% males, 31.3% females, mean age 70.18±7.48 years. Among them, overall survival curves regarding rehospitalization for MACCE, AHF and cardiac death at 12 months, show that HLM classification is as valid as the others (p Conclusion(s) According to our results, HLM classification has greater prognostic power compared to other nosologies in terms of rehospitalization for MACCE, AHF and cardiac death for HF patients, thanks to a more accurate evaluation of the systemic impact of heart failure. Such a multivariable, holistic approach should be used in HF patients, rather than a “cardiocentric” approach, in order to address the pathophysiological mechanisms underlining heart abnormalities, improving clinical management and costs. Funding Acknowledgement Type of funding source: None

Background About 40% of patients undergoing transcatheter aortic valve replacement (TAVR) have a history of atrial fibrillation (AF) and an additional 10% develop AF after TAVR. However, there is paucity of data regarding the optimal antithrombotic regimen following TAVR in patients with a clinical indication for oral anticoagulants (OAC). Purpose To compare the prognostic impact of OAC plus at least one antiplatelet agent (APT) versus OAC therapy alone in patients undergoing TAVR. Methods We systematically searched the literature for studies evaluating the comparative efficacy and safety of OAC + APT versus OAC alone in TAVR. Random-effect meta-analysis was performed comparing clinical outcomes between the two groups. All-cause mortality and cardiovascular mortality were the efficacy outcomes. Stroke and major bleeding, defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety outcome. Results Overall, 398 titles and abstracts were identified through database searching. Four observational studies were selected, for a total of 1929 patients. After a median follow-up of 18.5 months (IQR 11.3–29.3), OAC + APT increased major bleeding events compared to OAC alone (OR=1.79; 95% CI 1.21–2.66; P=0.004) with no difference in stroke (OR 01.02; 95% CI 0.52–2.01; P=0.95), all-cause mortality (OR=1.07; 95% CI 0.78–1.47; P=0.66) and cardiovascular mortality (OR=1.08; 95% CI 0.79–1.47; P=0.62). Conclusion A combination strategy of OAC + APT provides increased risk of bleeding compared to OAC therapy alone in patients undergoing TAVR with similar outcomes in terms of stroke, all-cause mortality and cardiovascular mortality; therefore, when feasible, it should be advised not to add APT on top of OAC therapy in patients without other clinical indications for APT treatment. Funding Acknowledgement Type of funding source: None

Background Surgical aortic valve replacement has been the treatment of choice for patients with aortic valve disease before the arrival of transcatheter aortic valve replacement (TAVI), although limited by degeneration of the bioprosthesis. “Redo” intervention itself is burdened by high risk of complications and valve-in-valve (ViV) TAVI could be a valid strategy of redo for patients with comorbidities. The aim of this meta-analysis is to give an overview of the state of the art of ViV TAVI in high-risk patients, analyzing efficacy, safety, intra-hospital outcomes and 1-year outcomes and assess predictors of survival at short and mid-term follow up. Methods Two independent reviewers screened all studies investigating patients undergoing ViV TAVI. PubMed database was searched for reports published in English according to the following highly sensitive strategy: (Transcatheter[All Fields] AND “aortic”[All Fields]) AND valve-in-valve[All Fields] AND “implantation”[All Fields] NOT (review[pt] OR editorial[pt] OR letter[pt])AND “humans”[MeSH Terms]). Mortality at 30 days and at 1 year were the primary end point, while procedural and short-term outcomes and echocardiographic parameters at hospital discharge were the secondary end points. Results Of 286 studies identified, 26 articles were included, with a total of 1448 patients. Median age was 78.8 years, 57.7% of the patients were male. Median STS-predicted risk of mortality was 9.4% while median Logistic EuroSCORE was 31.3%. Median age of bioprosthesis was 10 years with 84.6% of stented valves. Stenosis (45%), followed by regurgitation (31%) and mixed defects (21%) were the causes of prosthesis failure. Diameter of the degenerated valve was ≤21 mm in 25.4%, 22–25 mm in 55% and >25mm in 11.7% of the patients. Transfemoral approach was preferred (76%), with a prevalence of balloon expandable valve (73.3%). Mean post procedural gradient was 16.7±0.8 mmHg. Mean follow up was 376 days. Overall and cardiovascular mortality at 30 days was 6.5% and 5.5% respectively, while at 1 year it was 14.5% and 8.9% respectively. Regarding short-term outcomes, overall bleeding (10.4%), pacemaker implantation (9.4%) and vascular complications (8.3%) were the most common peri-procedural complications, while stroke (2.3%), myocardial infarction (2.7%) and coronary obstruction (2.8%) were less frequent. At meta-regression analysis study year (p Conclusions Percutaneous valve-in-valve aortic valve implantation offers a valid strategy to treat high risk patients with a degenerative bioprosthesis. Short and mid-term outcomes are substantially superimposable to those of TAVI, except for coronary obstruction which appears more frequent. Future studies are needed to find predictors of long- term survival and outcomes in lower risk patients. Outcome of VIV TAVI Funding Acknowledgement Type of funding source: None

Background Given the continuous increase in life expectancy, elderly patients with ST segment elevation myocardial infarction (STEMI) are becoming a growing proportion of those referred for primary percutaneous coronary intervention (pPCI). However, this population is usually excluded from randomized trials and limited data are available to guide clinical decisions. The aim of this study-level meta-analysis was to describe and analyze the determinants of outcomes in this population. Methods We searched the literature for studies reporting ischemic and hemorrhagic outcomes and/or mortality in nonagenarian patients undergoing pPCI. An analysis of the heterogeneity between studies in outcome reports was performed with I2 test. A univariate meta-regression analysis was conducted to explore the relationship between outcomes of interest and classic cardiovascular risk factors, gender, previous myocardial infarction (MI), MI location, PCI characteristics, hemodynamic instability, vascular access, intra-aortic balloon pump (IABP) and Glycoprotein IIb/IIIa inhibitor (GPI) use. Results Overall, 15 observational studies met our inclusion criteria, with a total of 6787 patients; mean age was 92.4 and 35% were male. The incidence of in-hospital death was 21.3%, 1.4% of our population suffered an in-hospital ischemic stroke and 11.1% faced acute renal failure; in-hospital major bleedings affected 1.7% of the population, but blood-transfusion was needed in 6.9%. Long-term mortality rate was 21.5%. Killip III-IV at admission was related with increased in-hospital mortality (β: 0.2%; p: 0.041), but lower incidence of ARF (β: −0.6%; p: 0.004). Angiographic success was associated with a lower incidence of long-term all-cause mortality (β: −1.7%; p: 0.017) and higher incidence of ARF (β: 1.7%, p Discussion Our meta-analysis, pooling the largest cohort of nonagenarians undergoing pPCI confirms the feasibility of urgent percutaneous coronary intervention also in this frail population. In particular, although angiographic success increased the incidence of in-hospital ARF, it was associated with a higher long-term survival underling the pivotal role of myocardial reperfusion. Funding Acknowledgement Type of funding source: None

Background Thinner stent struts of new DES (drug eluting stent) are associated with shorter time of reendothelialization, a reduction of shear stress and inflammation of coronary walls. Despite this great innovations their clinical safety and efficacy in challenging scenarios as non left main bifurcation coronary lesions has not been tested. Methods RAIN is a multicenter registry enrolling patients treated on bifurcated coronary lesions and left main with thin-strut DES. Baseline characteristics and procedural data were recorded. Target lesion revascularization (TLR) was the primary endpoint, whereas major adverse clinical events (MACE; composite of all-cause death, myocardial infarction (MI), target vessel revascularization (TVR), TLR and stent thrombosis (ST)) along with its single components were the secondary endpoints. A multivariate analysis to identify predictors of TLR and sub-analysis according to stenting strategy (provisional vs 2-stent technique), use of final kissing balloon (FKB) and IVUS/OCT optimization were performed. Results Data from 1803 patients (59% ACS, 61% stable CAD) treated on bifurcations were retrospectively evaluated. Follow up was available for 1685 (94%) patients for a median of 12 months (IQR 7–18). TLR occurred globally in 2.5% of cases (2.2% in provisional stenting, 3.5% in 2-stent technique). The rate of MACE was 9.4%, whereas all-cause death and MI, occurred in 4.1% and 3.2% of cases respectively. TVR and definite ST incidence were 3.7% and 1.1%. At multivariate analysis, chronic kidney disease (CKD) negatively influenced the main endpoint (HR 1.95, 95% CI 1.06–3.6, p=0.03), whereas post-dilatation (HR 0.56, 95% CI 0.3–0.93, p=0.04) and provisional stenting resulted being protective factors. FKB reduced TLR occurrence at FU only in 2-stent technique (p=0.03), whereas intracoronary imaging (performed in 29% of patients) were uninfluential. Conclusion Very thin-strut DES represents a highly effective solution in bifurcation lesions. The risk of TLR is reduced by post-dilatation and provisional stenting. FKB is recommended in 2-stent technique, whereas further studies are required to address the impact of intracoronary imaging in this setting.

Introduction Prognosis in pulmonary hypertension (PH) is strictly linked to right ventricle (RV) failure, which results from uncoupling between RV and the superimposed pressure load; in first phases, coupling between these two actors still be preserved, at the price of augmented right ventricle wall tension (RVWT). Purpose We sought to describe how to estimate RVWT with echocardiography, how it correlates with RV hemodynamics and if it may predict prognosis. Methods A total of 190 patients without overt RV failure, with suspected pulmonary hypertension (PH) to a previous echocardiography, underwent to right heart catheterization (RHC) and nearly-simultaneous echocardiography. We estimated RVWT according to Laplace law (RV length × tricuspid regurgitation peak gradient [TRPG]), in order to predict initial RV stress, and was correlated with RV hemodynamic profile; its potential prognostic impact was tested along with canonical RV function parameters. Results In patients enrolled in our study, RVWT correlated significantly with invasive estimation of right ventricle end diastolic pressure (R 0.343, p Correlation: RWVT and RV hemodynamic Hemodynamic variable R R2 p value Mean pulmonary artery pressure 0.742 0.550 Prognosis: different RV variables Discussion We identified a novel bedside echocardiographic predictor of altered RV hemodynamic, which results precociously altered in patients without overt RV failure, and able to predict all cause mortality at a long term follow up. Further studies are needed to confirm its role in PH patients.

Background The LEADERS FREE trial established the favourable clinical profile of a new polymer-free biolimus A9-eluting stent (PF-BES) in patients at high bleeding risk when used with a 1-month dual anti-platelet therapy (DAPT) strategy. Purpose This is the first study evaluating real-world reasons and outcomes for a 1-month versus longer DAPT strategies following PF-BES percutaneous coronary intervention (PCI). Methods FREEDOM is an all-comers registry including all patients who underwent PCI with at least one PF-BES at 10 sites, between January 2016 and July 2018. Patients were stratified according to DAPT strategy at discharge (1-month vs >1-month). Baseline features, reasons for PF-BES as reported by the treating physician, and outcomes were compared between groups. Primary outcomes were the 390-day estimates of a patient-oriented composite endpoint (POCE: death, myocardial infarction (MI) or target vessel revascularization) and of a device-oriented composite endpoint (DOCE: cardiac death, target vessel-MI or ischemia-driven target lesion revascularization). Incidence rates were adjusted for clinically relevant factors and outcome predictors. To avoid survival bias, landmark analyses starting from 1-month post-PCI were further carried. Results Following PF-BES PCI, 328 (40.3%) patients were discharged with 1-month DAPT and 485 (59.6%) patients with longer DAPT (median 12 months, IQR 6–12 months). Patients with hypertension or on oral anticoagulation (OAT) were more likely and patients with a previous or an index MI were less likely to be discharged on 1-month DAPT. Patients prescribed with 1-month DAPT were more likely to have had a PF-BES for a LEADERS FREE high bleeding risk criterium than those with longer DAPT (90.2% vs 69.9%, p=0.001). The same association was observed when the reason for PF-BES was a planned major surgery (13.1% vs 6.2%; p=0.001) or OAC to be continued after PCI (38.7% vs 16.5%, p1-month DAPT: POCE 11.9% vs 13.2%, p=0.747; adj-HR 1.29 [95% CI 0.78–2.10]; DOCE: 4.8% vs 8.1%, p=0.500; adj-HR 1.01 [95% CI 0.50–2.07]) and of bleedings (any: 11.3% vs 9.4%, p=0.472; adj-HR 0.87 [95% CI 0.51–1-50]; BARC 3–5: 4.2% vs 2.2%; p=0.108; adj-HR 1.50 [95% CI 0.58–3.87]) were observed. Landmark analyses showed similar results. Conclusions In a large contemporary all-comers registry, factors reflecting the operator-perceived patient high bleeding risk were the main drivers of a very-short DAPT strategy following PF-BES PCI. We found no interaction of DAPT duration with outcomes following PF-BES PCI, an observation warranting investigation in adequately powered randomised studies.

Introduction Even though left ventricular ejection fraction (LVEF) is a well-documented strong predictor of mortality after an acute coronary syndrome (ACS), its differential impact on the ischemic and bleeding risk of hemorrhage and ischemia is not well established. The aim of this study was to assess the impact of LVEF, measured by echocardiography, on the risk of acute myocardial infarction (AMI) and major bleeding (MB) after hospital discharge for ACS, during treatment with dual antiplatelet therapy (DAPT). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. From the initial merged data set, that contained 26,076 patients, we have excluded those without data about LVEF. So the final cohort was composed by 20,518 patients. The impact of LVEF in the ischemic and bleeding risk was assessed by a multivariable competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. All those variables with statistical (p Results During a mean follow-up of 12.2±5.2 months, 789 patients died (3.8%), 431 had an AMI (2.1%) and 537 had a MB (2.6%). The mean of LVEF was 53.2% ± 10.7%. Only 15.5% of patients had LVEF Conclusions After an ACS, as the LVEF decreases, there is an increase in ischemic risk, but not in bleeding risk. A LVEF

Introduction Peripheral artery disease (PAD) is associated with heightened ischemic and bleeding risk in patients with acute coronary syndrome (ACS). With this study from real-life patients, we try to analyze the balance between ischemic and bleeding risk during treatment with dual antiplatelet therapy (DAPT) after an ACS according to the presence or not of PAD. Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients with and without PAD. The impact of prior PAD in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction (AMI), whereas for bleeding risk we have considered major bleeding (MB) defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 1,600 have PAD (6.1%). Patients with PAD were older, and with more cardiovascular risk factors. DAPT with prasugrel/ticagrelor was less frequently prescribed in patients with PAD in comparison with the rest of the population (8.2% vs 22.8%, p Conclusions PAD was associated with higher ischemic and bleeding risk after hospital discharge for ACS treated with DAPT. However, the balance between ischemic and bleeding risk was positive for patients with PAD in comparison with patients without PAD. As summary, ACS patients with PAD had an ischemic risk greater than the bleeding risk.

Background The absence of a polymer-coat along with fast drug absorption represent the benchmark counterpart of the favourable clinical profile of a new polymer-free biolimus A9-eluting stent (PF-BES), also when used with a very short dual antiplatelet therapy (DAPT) strategy. Its current use in the real-world setting has not been thoroughly assessed. Purpose We evaluated contemporary patterns of indications, DAPT strategies and outcomes for the PF-BES. Methods FREEDOM is a multicenter registry including all patients who underwent percutaneous coronary intervention (PCI) with at least one PF-BES at 10 italian sites. Reasons for PF-BES PCI and planned antithrombotic regimen at discharge were collected. Primary outcomes were the 390-day Kaplan Meier estimates of a patient-oriented composite endpoint (POCE: death, any myocardial infarction [MI] or any target vessel revascularization [TVR]) and of a device-oriented composite endpoint (DOCE: cardiac death, target vessel-MI or ischemia-driven target lesion revascularization [ID-TLR]). The independent outcomes predictors were assessed through multivariate Cox proportional hazards analysis. Results Between January 2016 and July 2018, 858 patients (age: 74±10 years, 64.6% males, 58.7% acute coronary syndrome presentation) underwent PF-BES PCI. Main reasons for PF-BES physician's choice were advanced age (26.0%), oral anticoagulation (OAT) to be continued after PCI (25.3%), operator preference for PF-BES (9.9%), planned major surgery (8.6%), cancer (8.6%), anemia (7.9%) and recent bleeding (7.0%). Overall, the operator choice to implant a PF-BES reflected a perceived high bleeding risk in 77.7% of patients. At discharge, 99.2% of patients were on DAPT, 19.5% on triple therapy, and 0.8% on single antiplatelet therapy plus OAT. Planned DAPT duration was 1-month in 40.3% of patients, with 33.8% of these being on triple therapy. At 390-day follow-up (median 340 days, interquartile range: 187–390 days) the incident estimate of POCE was 13.1% (any MI 3.7%, any TVR 3.4%) and of DOCE was 7.1% (TV-MI 3.6%, ID-TLR 1.4%); while 390-day estimate of any bleeding event was 11.1% (BARC 3–5 bleeding 3.0%). Independent predictors of 390-day POCE were eGFR≤60 ml/min (HR 1.81; 95% CI 1.09–3.04, p=0.028), a history of cancer (HR 2.62; 95% CI 1.43–4.81, p=0.002) and severely calcified lesion/s (HR 2.05; 95% CI 1.09–3.85, p=0.025). Independent predictors of DOCE were a previous MI (HR 2.06; 95% CI 1.03–4.15, p=0.041), a history of cancer (HR 2.69; 95% CI 1.18–6.13, p=0.019) and bifurcation lesion/s (HR 2.66; 95% CI 1.38–5.13, p=0.004). Conclusions In a large, contemporary all-comers registry, the main reasons for PF-BES use reflected in most cases the operator-perceived high bleeding risk of the patient. Following PF-BES PCI, a very-short DAPT strategy was frequently implemented. The outcomes observed in this registry suggest a favorable safety and efficacy profile for the PF-BES in a real-world clinical setting.

Background The optimal antithrombotic therapy strategy in patients undergoing PCI who need OAC is currently debated. Purpose To determine the best regimen in terms of safety and efficacy. Methods We performed a meta-analysis of RCT and adjusted results reporting outcomes of patients who underwent PCI and were on TT or DAPT or DT. All-cause death was the primary end point, while MACE was the secondary outcome, along with its individual components, and major bleedings. Results 15 studies encompassing 27070 patients were included. After a follow up of 12 (11–14) months, TT reduced all-cause death compared to DAPT (OR 0.52, 0.35–0.78), mainly driven by a lower incidence of MI (OR 0.81, 0.69–0.85) and stroke (OR 0.76, 0.56–1.03) despite higher rates of major bleedings (OR 2.81, 1.54–5.12). Comparing TT vs. DT with warfarin, all-cause death was non-significantly different (OR 1.23, 0.60–2.53), nor MI (OR 0.77, 0.23–2.59) and stroke (OR 4.01, 0.80–20.07), while major bleeding was increased with TT (OR 2.40, 1.34–4.38). When compared to DT with NOACs, TT did not reduce risk of MI (OR 0.96, 0.67–1.36) or stroke (OR 0.82, 0.55–1.24), but increased major bleedings (OR 1.98, 1.43–2.73). The non-randomized comparison between DT with warfarin and DT with NOACs showed a neutral effect on death and major bleedings, with similar rates also of MI (OR 0.47, 0.20–1.11, all CI 95%). Conclusion Double therapy with warfarin or with NOAC plus a single antiplatelet agent reduces the risk of major bleeding compared to triple therapy, with a neutral impact of subsequent ischemic events.

Introduction Incidence and predictors of adverse events after dual antiplatelet therapy (DAPT) cessation in patients treated with ultrathin stents in unprotected left main (ULM) or coronary bifurcation remain undefined. Methods All consecutive patients presenting with a critical lesion of an ULM or a lesion involving a main coronary bifurcation and treated with very thin strut stents were included. MACE (a composite end point of cardiovascular death, myocardial infarction (MI), target lesion revascularization (TLR) and stent thrombosis (ST) was the primary endpoint, while target vessel revascularization (TVR) was the secondary endpoint. Moreover, type and occurrence of ST and occurrence of ST, CV death and MI during DAPT or after DAPT discontinuation were also evaluated. All analyses were performed according to length of DAPT dividing the patients in 3 groups: short DAPT (3-months), intermediate DAPT (3–12 months) and long DAPT (12-months). Results 117 patients were discharged with an indication for DAPT≤3 months (median 1:1–2.5), 200 for DAPT between 3 and 12 months (median 8:7–10) and 1958 with 12 months DAPT. After 12.8 months (8–20), MACE was significantly higher in the 3-month group compared to 3–12 and 12-month groups (9.4% vs. 4.0% vs. 7.2%, p≤0.001), mainly driven by MI (4.4% vs. 1.5% vs. 3%, p≤0.001) and overall ST (4.3% vs. 1.5% vs. 1.8%, p≤0.001). ST post DAPT cessation were comparable (1.7% vs. 0% vs. 0.7%, p=0.42) with a median time to ST post DAPT discontinuation of 1.67 months (0.48–4.7). At multivariate analysis, DAPT of 12-months compared to 3-months reduces the risk of overall ST (OR 0.103: 0.019–0.0563, 95% CI) while only a trend was noted for DAPT between 3 and 12 months (OR 0.61: 0.186–2.005, 95% CI). When analysed by stent strategy a 2-stent strategy predicted ST post DAPT cessation (OR 3.241: 1.048–10.026, 95% CI), which was reduced by use of FKB (OR 0.101:0.01–0.872, 95% CI). Conclusion Even stents with very thin strut when implanted in real-life ULM or coronary bifurcation patients discharged with short DAPT have a relevant risk of ST, which remains high although not significant after DAPT cessation. The correct identification before PCI of the more fragile patients who may receive a shorter DAPT regimen could help identify the safest PCI technique: provisional stenting and use of final kissing balloon (FKB) are the safest options.

Introduction In new generation drug eluting stents (DESs) era, the impact of stent geometry on freedom from recurrent events has been poorly explored. Impact of struts thickness, number of crowns and connectors on clinical outcomes was evaluated in the present study. Methods Randomized controlled trials comparing last generation DESs were selected. The primary endpoint was the rate of target lesion revascularization (TLR), while secondary was Definite Stent Thrombosis (ST). Results 53 studies with 52006 patients were included. A struts thickness ≤81 nm was associated with a lower incidence of TLR (2.9%: 2.4–3.4 vs. 3.6%: 3.0–4.3) and ST (0.8%: 0.6–1.1 vs. 1.3%: 0.9–1.8). A mean number of connectors >2.5 was also associated with a lower incidence of TLR (3.2%: 2.8–3.6 vs. 3.5%: 2.9–4.2) and ST (1.0%:0.8–1.3 vs. 1.3%: 0.9–1.7 vs for ST). On the other hand, stents with average number of crowns Conclusions The findings of the study support that lower struts thickness and higher numbers of connectors have a positive clinical outcome reducing stent thrombosis and target lesion revascularizations, while the average number of stent crowns plays a secondary role.

Background In the era of TAVI, also very high surgical risk patients can be treated and the importance of the Heart Team is to address the patient to the right therapy. In some cases due to comorbidities, lack of symptoms and patients' decision not always a final decision is achieved after the first clinical evaluation and the final strategy could be deferred for months. Purpose The study aims to analyze outcomes in patients with severe aortic stenosis differently treated according to the various approaches proposed by the Heart Team. Methods All the patients with a diagnosis of severe aortic stenosis considered at high and very high surgical risk were enrolled. Three international cardiology departments participated in this multicentre study. All the patients were divided into four groups according to the Heart Team decision of approach. Patients with indication to medical therapy only (DTO Drug therapy only), Patients first deferred from heart team decision, personal reasons or lack of symptoms and then addressed to medical therapy (D-DTO Deferred-Drug therapy only), Patients deferred and then addressed to TAVI within 3 months (D-TP Deferred TAVI Procedure), Patients with direct indication to TAVI (ITP Immediate TAVI procedure). Primary endpoint were overall survive at follow up comparing the differences between the four groups and the impact of the deferred strategy. Results 795 patients were enrolled (80 DTO, 451 ITP, 264 initially deferred and then 155 D-DTO and 109 D-TP). Median follow-up was 465 days. Overall survive of the four groups at 1 year was 74% DTO, 73% D-DTO, 77% D-TP and 78% ITP, at 2 years 62% DTO, 38% D-DTO, 62% D-TP and 68% ITP, at 3 years 39% DTO, 11% D-DTO, 25% D-TP and 56% ITP (p≤0,001 at log rank test). At the multivariate analysis, compared to the referral group DTO, D-DTO was associated with higher mortality (HR=1,90; IC [95%]: 1,05–3,58; p=0,03 at 2 years; HR 1,66; IC [95%]: 1,01–2,76; p Conclusions The Heart team decision on the approach of treatment strongly influence the survive of the patient. Compared to direct medical therapy, there is a higher risk of mortality for patients initially deferred and then treated with medical therapy and there is no survival benefit for patients initially deferred and then treated with TAVI. The choice of deferring the treatment of patients with severe aortic stenosis clearly decrease long term survive at follow up regardless the strategy of the approach.

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The degree of inflammation within the atherosclerotic plaque can be detected non-invasively by positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG). The incidence of aortic plaques with 18F-FDG increased uptake in octogenarians with aortic stenosis is unknown. Aim of this study was to evaluate the frequency of inflamed aortic atherosclerotic plaques in octogenarians with or without severe aortic stenosis and their correlations with calcifications.The study group comprised 27 patients older than 80 years who underwent a 18FDG PET/CT. Nine patients with severe symptomatic aortic stenosis, eligible to TAVI procedure (TAVI Group), and 18 patients age and sex matched, without clinical evidence of aortic stenosis (No TAVI Group), were selected and analysed.In the whole population 4/27 patients (9.3%) had a significant focal aortic vessel wall 18F-FDG increased uptake: 1 patient (11.1%) in TAVI group and 3 in non-TAVI Group (16.7%). Overall 81 aortic segments were analysed. 18F-FDG uptake rates were similar in the two groups (1/27, 3.7% in TAVI Group and 3/54, 5.5% in No TAVI Group, P=0.7). At CT scan calcifications were significantly more frequent in the TAVI Group compared to non-TAVI Group (23/27, 85.2% and 28/54, 51.8% P=0.005). None of the sites of arterial calcification had an increased focal 18F-FDG uptake.Irrespectively to the presence of aortic stenosis, a significant FDG plaque uptake in octogenarians is rare while calcifications are extremely frequent.