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The "Cutis Laxa" is a rare pathology of the connective tissue characterized by redundant skin and diffuse manifestations are identified by other organs (mainly heart and lungs). The low elasticity of the tissue is believed to be attributable to an anomalous elastin formation. Cutis Laxa is usually a genetic disease, but acquired forms have also been described. The case we describe is that of a 34 –year –old young woman with a diagnosis of Cutis Laxa acquired from the age of 15, complicated by a serious impairment at the pulmonary level in the form of marked emphysema and severe asthmatic framework. It came to our observation following the PEA type cardiovascular arrest episode during tracheostomy procedure, promptly resolved by resuscitation maneuvers according to the Als protocol. The echocardiogram was performed by the only belowocostal window by which a 4 –chamber apical projection was viewed, highlighting an anomalous position of the cardiac Hague (lower and media). The left ventricle appeared to be normal endocavity dimensions and parietal thicknesses with preserved indexes of systo–diastolic functionality in the presence of SIV discline; The right ventricle was instead slightly dilated, hypertrophic, with reduced Chinese of the free wall (nappese 18 mm), the tricuspid regurgitation was moderate with indirect signs of increased lung pressures. The echocardiographic appearance was therefore compatible with a chronic pulmonary heart frame, secondary to progressive pulmonary enfisema, and described in literature as the most fearful complication of Cuis Laxa syndrome, associated with an inauspicious prognosis and premature death.

Introduction PCSK9 inhibitors (PCSK9i) significantly decrease LDL cholesterol (LDL-C), either as monotherapy or in addition to the maximally tolerated dose of statin and/or ezetimibe. Yet, few data are available on efficacy and background lipid-lowering therapy (LLT) adjustment in patients treated with PCSK9i in real-world observations. Purpose AT-TARGET-IT is an Italian multicenter registry involving 9 Italian centers, designed to assess efficacy, adherence, and persistence of PCSK9i, as well as prescribing doctors' behavior in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH). The aim of the present analysis was to assess efficacy and changes in background LLT therapy in patients on PCSK9i in a real-world single country observation. Methods From June through November 2021, we enrolled patients with PCSK9i first prescription from 6 months before inclusion through starting of PCSK9i use. Clinical and demographic characteristics, concomitant therapies, blood chemistry, were recorded at the time of first prescription and at the latest observation preceding inclusion in the study. Background therapy was assessed at baseline and during follow-up, evaluating treatment withdrawal, reduction of doses, or changes from statin-ezetimibe association to single drug therapy. Results We enrolled 798 patients (27% with FH) receiving either alirocumab or evolocumab and followed for a median time of 19.3 months. At the time of PCSK9i first prescription LDL-C was 147.6 mg/dl and reached 51.5 mg/dl at the time of latest observation (64% reduction), and 129 patients (16%) were not receiving any LLT, 669 patients received background LLT, of them 246 (31%) were taking ezetimibe alone and 423 (53%) were taking statins with or without ezetimibe. At the end of the observation period, 785 patients (98%) were still receiving PCSK9i and 550 (69%) did not change background LLT. Of 248 patients changing background LLT, 116 (47%) withdrew therapy, 132 (53%) changed dose or type of LLT. After stratification by achievement of LDL-C target according CV risk class, 483 patients achieved the target (60%). Target was achieved at the end of the observation period in 63% of patients taking triple therapy, 65% patients receiving PCSK9i plus statins, 62% of patients receiving PCSK9i plus ezetimibe and 55% receiving PCSK9i alone (Figure 1). No significant differences in terms of percentage of patients changing background LLT during PCSK9i treatment were found between patients at target for LDL-C and those not at target. Conclusion AT-TARGET-IT study shows that PCSK9i therapy is effective in reaching LDL-C target in the majority of patients, yet a sizable number of them (40%) remains undertreated. LLT background therapy is either reduced or withdrawn in 31% of patients, being responsible for not reaching target. Reasons for inappropriate LLT changes in patients receiving PCSK9i should be identified and removed to optimize lipid control. Funding Acknowledgement Type of funding sources: None.

Woman, 38 aa, without cardiovascular risk factors with the exception of the tobagic habit; In anamnesis recent Caesarean cut about six months ago for a placenta with the central, complicated by hemorrhagic shock and consequent virgonecontomy. It came to our observation sent by the emergency room, where it had gone by on the onset of about 20 days of heart disease, nightlife dyspnea and fattening dyspnea, associated with the recent appearance of marked edemas declining in the lower limbs bilaterally. At the entrance to the ward, the patient presented himself vigilant, apipperic and tachipnoic. The feedback of turgor of the jugular and of extended edemas extended up to the upper third of the leg bilaterally was also reported. The ECG evidenced a sinus tachycardia and signs of left ventricular overload. The hematochimic tests, including myocardionecrosi markers, were in the norm, with the exception of the pro–bnp which was increased with a value of 5263 pg/ml (cutoff

Infective endocarditis (IE) refers to the colonization of cardiac valve endocardium by virulent microorganisms. It is the fourth leading cause of life–threatening infectious disease syndrome, if not efficiently diagnosed and treated. The three most common causes of IE on native valves (from the most to the least frequent) are Staphylococci, Streptococci and Enterococci. Enterococcus related IE are often associated to endoscopic procedures involving the digestive tract. The most remarkable structural complications associated with IE are: cusp or leaflet rupture, perforation, aneurysm/pseudoaneurysm, fistula, abscess, embolization. The usual final consequences of these lesions are severe valve regurgitation and heart failure.A 74 years old male patient with no history of heart disease, presented to the hospital with orthopnoea and periferal edema, consistent with acute heart failure.Few months before he underwent a routine colonscopy. Transthoracic echocardiography revealed a mildly reduced ejection fraction and the presence of a little, mobile mass on the aortic valve, suggestive of vegetation, associated with a severe aortic regurgitation. The diagnosis was confirmed thanks to a transesophageal echocardiogram that represents the technique of choice for the diagnosis of endocarditis and for detecting eventual perivalvular extention; it documented the presence of an endocarditic vegetation protruting in the LVOT, complicated by a pseudoaneurysm, identified as a pulsatile perivalvular echo free–space with colour doppler flow inside. Successively, a specific antibiotic therapy was started because of the positivity of blood cultures for Enterococcus Faecalis. After performing a thoracic computed tomography that showed the presence of “plus image" at the level of aortic valvular plane, particularly between the right coronary and non–coronary cusp, consistent firstly with a pseudoaneurysm, the patient underwent urgent cardiac surgery with the removal of the vegetations and the implantion of an aortic valve bioprosthesis after the apposition of bovine pericardial patches for repairing aortic wall’s lacerations. A post–operative transesophageal echocardiogram revealed a good result with a mild paravalvular leak. Pseudoaneurysm and severe valvular regurgitation are among the major causes of acute heart failure in the setting of infective endocarditis. In such cases, surgery should be considered to decrease mortality.

Pulmonary embolism is the third most frequent cardiovascular pathology, with an incidence of 100–200 cases for 100.000 inhabitants and is one of the main causes of mortality, morbidity and hospitalizations. Systematic thrombolysis represents the treatment of first choice in high–risk/high–intermediate–risk patients who experience hemodynamic instability, however there are absolute and relative contraindications that do not allow its use in all patients: in these cases, percutaneous catheter treatment can be attempted. A hypertensive and obese 84–year–old woman arrives at the emergency room with the onset of chest pain associated with dyspnea. In the emergency room, high levels of D–Dimer and highly sensitive Troponin T are found, therefore cardiological advice is requested. The echocardiogram shows severe dilatation of the right ventricle with McConnel sign, D–Shape and multiple thrombotic formations in the right atrium. On the advice of the consultant cardiologist, a pulmonary CT angiography is performed with evidence of thromboembolism of the main arterial trunks, massive at the level of the distal juxta–hilar portions. Therefore, high–intermediate–high risk pulmonary embolism is diagnosed and the patient is transferred to the ICU for proper treatment. Despite the infusion therapy with sodium heparin, there is a sudden worsening of the clinical and hemodynamic picture: thus, in the light of the impossibility of performing a rescue thrombolysis due to the recent patient’s femoral fracture, it is decided to perform a percutaneous treatment by thrombectomy, using an “INARI” thrombus–aspirator catheter positioned to the right femoral route. Pulmonary angiography reveals thrombotic sub–occlusion of booth main branches. Five aspiration cycles are performed, two of which in the right pulmonary artery and the remaining three in the left pulmonary artery. Control angiography shows reperfusion of the left lower lobe and partial reperfusion of the left upper lobe, while partial reperfusion of the right upper lobe is found on the right. Abundant thrombotic and partly fibrous material is found during aspiration. After the 5th cycle, cardio–circulatory arrest occurs and despite the resuscitation maneuvers, the patient dies. At present, percutaneous treatment in acute pulmonary embolism is still scarcely used in daily clinical practice, but it will certainly play an important role in the near future as a valid therapeutic alternative .

Arrhythmic storm is an emergency characterized by cardiac electrical instability leading to multiple episodes of sustained ventricular arrhythmias in a short period of time. Patients have multiple comorbidities that require multidisciplinary interventions to achieve clinical stability. The genesis of arrhythmic storm involves a complex interaction between a predisposing arrhythmogenic substrate, triggering factors, autonomic nervous system, and patient comorbidities. Antiarrhythmic drug therapy plays a key role and has been shown to be associated with a significant reduction in VT recurrence. Transcatheter ablation in patients refractory to drug therapy has been shown to reduce arrhythmic recurrences, ICD shocks, and improve patients‘ cumulative survival over time. Rare cases of arrhythmic storm refractoriness treated by plastic ventricle for the purpose of excluding scar are reported in the literature. We present the case of a 62–year–old man, Caucasian race, suffering from chronic ischemic heart disease with hypokinetic–dilated evolution carrying CRT–D, diabetic, obese, dyslipidemic, undergoing multiple percutaneous revascularizations. Sent to our hospital from a peripheral hospital for arrhythmic storm refractory to maximal antiarrhythmic therapy treated with multiple internal and external DC shocks. During hospitalization, the patient underwent SEF and attempted ATC which was ineffective in the following days due to recurrence of numerous episodes of TVS. In view of the clinical picture and refractoriness to therapy, it was decided to perform coronary examination which found subocclusion of the 1st diagonal branch treated by implantation of medicated stent. On ventriculography, the presence of severe pseudoaneurysmal formation supplied at the level of the anterior wall of the left ventricle was confirmed. It was decided to transfer the patient to cardiac surgery to perform ventriculoplasty surgery. In the following days, the patient underwent surgery through exclusion of the aneurysm by patching in pericardium in CEC. Procedure was free of complications. On follow–up echocardiogram dilated left ventricle with severe left ventricular dysfunction with findings of cardiac aneurysm exclusion. In the following days, the patient presented no further arrhythmic episodes.

Sarcomeric hypertrophic cardiomyopathy is among the most common genetic cardiovascular diseases.Clinical,electrocardiographic and echocardiographic evaluation plays a crucial role in the diagnosis and initial framing of the hypertrophic phenotype. A 51–year–old Caucasian man with multiple myeloma,previous autologous transplant,undergoing chemotherapy for disease recurrence,without cardiovascular risk factors or family history of MCV or MCI came to our outpatient clinic for a follow–up visit.At another center,cardiac amyloidosis was diagnosed due to the echocardiogram finding of concentric left ventricular hypertrophy. Patient asymptomatic for angor,NYHAI dyspnea,heart palpitation,syncope,presented with rhythmic cardiac action,2/6 systolic murmur at centrum and tip,no central or peripheral stasis.On ecg sinus bradycardia at fc57 bpm,PR202 msec,high QRS V4–V6 voltages with negative T waves in infero–lateral site,suggestive for left ventricular hypertrophy. On echocardiogram:concentric left ventricular hypertrophy with posterolateral papillary hypertrophy,preserved contractile function,FE 62%,grade I diastolic dysfunction,no signs of elevated filling pressures,left atrium and right ventricle in normal range;tripartite aortic valve in absence of gradients,prolapse of the LAM(A1–A2)with mild grade insufficiency,mild tricuspid insufficiency. At cardiac MRI:non–dilated left ventricle with concentric hypertrophy,maximum thickness 16mm at basal SIV level,apical inferior wall,15mm anterior wall,anterolateral media,apex systolic obliteration 14mm,FE 64%.Right ventricle and atria in normal.T2–STIR sequences tenuous hyperintensity at infero–lateral media wall,inferior apical wall and lateral,increased T2 mapping in relation to myocardial edema. Subendocardial LGE of middle infero–lateral,apical lateral and postero–medial papillary wall,slight increase in native T1 mapping,ECV 27%,picture of sarcomeric hypertrophic heart disease.Holter ecg showed no arrhythmias;at HCM score low risk,no indication for ICD implantation. The patient was undergoing genetic screening test for HCM.The presence of left ventricular hypertrophy may mimic different forms of hypertrophic cardiomyopathy,leading to misdiagnosis or delayed diagnosis.Differential diagnosis,ecg and specific use of imaging tests are of paramount importance.

A 64–year–old patient,hypertensive,ex–smoker,no family history of CAD or MCI,with electrocardiographic abnormalities during checkups for sports activity at age 40,came to our observation for reported brief episodes of heart palpitation.On ecg sinus rhythm,PR 200 msec,elevated QRS voltages,negative T waves from V3–V6 and infero–laterally,isolated BEV. Echocardiogram showed asymmetric left ventricular hypertrophy with involvement of septum and mid–apical segments,absence of obstruction,grade II diastolic dysfunction,enlarged left atrium,ectasia of aortic bulb,ascending aorta and arch with mild valvular insufficiency. Cardiac MRI showed asymmetric hypertrophy with prevalent involvement of the SIV and apex,normal systolic function.Right ventricle within limits.LAM elongated,biatrial dilatation.Areas of enhancement with intramural extension to the inferior SIV and extensive subendocardial area to the infero–lateral wall,picture suggestive of Fabry disease. Holter ecg was performed:RS at mean fc 61 bpm,numerous isolated BEVs and pairs,1 run of TVNS of 11 beats,for which dual–chamber ICD implantation was performed in primary prevention.Genetic examination showed absence of alpha galactosidase enzyme activity and mutation in exon 5 of GLA gene(p.N215S). The patient had no other systemic symptoms typical of Fabry‘s disease such as CRI,acroparesthesias,angiokeratomas,cornea verticillata,gastrointestinal disturbances nor central neurological involvement.In addition,he was starting enzyme replacement therapy with alpha galactosidase on a home regimen.Hypertrophic cardiomyopathy is a frequent finding in clinical practice.In MF, the age of cardiac involvement is usually later than in other forms of cardiomyopathy. Cardiac MRI is the most appropriate technique to place a correct differential diagnosis;numerous studies have demonstrated preferential localization of areas of "delayed enhancement" at the infero–lateral and posterolateral basal wall,present even in the absence of frank ventricular hypertrophy. Systemic involvement, may help in the differential diagnosis because of the presence of characteristic symptoms.In the reported clinical case,however,the diagnosis is even more insidious since in late forms or cardiac variants of MF,as with the p.N215S gene variant,cardiomyopathy may be the only significant clinical manifestation.

A 90–year–old woman is brought to the closest emergency room after being found in a confusional state of mind, with lateral–sided sight deviation with normal cardiovascular findings. Her past medical history is characterized by the presence of systemic hypertension, moderate–to–severe chronic disease. The 12–lead electrocardiogram showed sinus rhythm and aspecific anomalies of the left ventricular repolarization. Lab tests showed normal white blood cells count with increased creatinine levels and quite normal flogosis indices. An initial transthoracic echocardiogram (TTE) showed mild left ventricular concentric hypertrophy with preserved systolic function, but also revealed the presence of a moving posterior mitral leaflet mass, determining mild mitral regurgitation. A head CT scan was performed, showing a right temporo–insular ischemic ipodensity. Considering the echocardiographic and neuronal findings, a transesophageal echocardiogram (TEE) was indicated to look for and better describe the suspicious mass, after beginning an antibiotic therapy in an empiric regimen. TEE revelead a multi–lobular mass characterized by inhomogeneous echogenicity, leaning on the annulus and the atrial side of the posterior mitral leaflet that was fissurated, leading to mild mitral regurgitation. The left appendage showed normal emptying velocity and absence of thrombi. It was not easy to describe this mass morphology and dimensions, but in some projections, it reminded us of a reindeer with various antlers. This case could resemble a classic mitral valve endocarditis, evolved into valve fissuration and arterial embolization leading to ischemic stroke, but the unusual fact is that the laboratory tests showed no white blood cells alteration during the whole hospitalization, with a really minimal CRP change and always negative procalcitonin. That is why we came into the idea that such a mass could also not represent a classical endocarditis. Considering that the echocardiographic characteristics of a thrombus were not encountered, the mass may be a tumor. The most frequent tumors involving the heart valves are papillary fibroelastomas. Considering the absence of clinic endocarditis, some hints led to consider this differential diagnosis: fibroelastomas mostly occur during older ages, they frequently have a mitral or aortic location and they can embolize, differently from vegetations, they are located mostly on the annulus and the basal posterior mitral leaflet.

We present a case of a 65 years old patient with hypertension.He comes to our cath lab with an inferior STEMI treated with primary PCI of right coronary artery and we found a sub–occlusive and severly calcified lesion on proximal left anterior descending artery (LAD) and a diffused disease of its middle and distal portion (Fig 2). After collegial discussion on Heart Team we decided to proceed with a staged percutaneous revascularization on LAD. After an accurate planning we decided to proceed with a single femoral access a 14f femoral sheat was positioned on femorl artery, so we put the ventricular assistance catheter and then on the same sheat we put our 7 f guiding catheter to use only a single access for IMPELLA and for the guiding catheter (Fig. 1).The IVUS catheter doesn’t be able to cross the calcified lesion on LAD so we go on with a debulking using the orbital atherectomy of Diamond Back, with several passages antegrade and retrograde.At this point we are able to perform an IVUS Co–registration that demostrated also a critical lesion on ostial LAD.After multiple pre–dilatation to prepare the lesion we put three big drug eluting stent till 5 mm of diameter.The IVUS shows us a little malapposition so we proceed with a big non compliant balloon of 6mm with optimal result (Fig 3).In conclusion we go on with a reduction of ventricular assistance and final removal of IMPELLA catheter and closure of 14f vascular access with a single Pro–glide previously implanted.This procedure has some discussion points, first of all the possibility to treat a sub–occlusive lesion of an important non culprit artery after a few days of an acute coronary syndrome in safe mode with a ventricular assistance, that allowed us to work peacefully, being able to carry out all the maneuvers we considered appropriate (multiple balloon dilatations, IVUS evaluations, orbital atherectomy).An other point of discussion is the use of this new orbital atherectomy easy to use because with a single device,6f guiding catheter compatible, we are able to treat artery from 2.5 till 4mm only setting the rotational speed and removing not only the intraluminal calcium but also the deeper one and this allows a better stent expansion.The procedure is IVUS guided associated with angiographic images on Co–registration that allow us to obtain even more informations.The last comment is for the new stent Megatron, the only stent that are able to treat coronary artery till 6 mm.

Acute lymphoblastic leukemia (ALL) is the most common cancer in children and accounts for 75% of all leukemias. In ALL, very immature leukemia cells build up in the bone marrow, destroying and replacing normal cells. Thrombotic events are a complication of acute leukemia induction therapy, particularly acute lymphoblastic leukemia (ALL) treated with L – asparaginase. We present the case of a 23–year–old girl suffering from acute lymphoblastic leukemia from pediatric age, undergoing chemotherapy treatment. In August 2021 she was admitted to ICU for acute myocarditis in shock which resolved after specific therapy. In September 2021 he came to our observation again for chest pain, fever, pulmonary thickening, but with normal echocardiography and echocardiography. The next day, the patient presented a worsening of symptoms, with the appearance of an elevated ST in the anterior to the ecg trace and apical, SIV and anterior wall akinesia with severely reduced FE on the echocardiogram. After collegial discussion also with fellow haematologists for the presence of thrombocytopenia, antithrombotic therapy was administered and an urgent coronary examination was carried out. The examination showed acute thrombotic occlusion of the middle–distal VAT. In the same session we proceeded to thrombus aspiration and implantation of medicated stents, procedure concluded in the absence of complications. The following morning the patient complained of paresthesia and weakness in the right side. On the echocardiogram, the presence of a thrombus in the apical area of about 2 cm. Skull CT was performed in urgency which showed cortical–subcortical hypodensity area in the left frontal–parietal site, referring to a recent ischemic lesion. In agreement with colleagues from Stroke Unite and hematology, heparin was infused intravenously in an attempt to dissolve the thrombus, but three episodes of VF were treated with effective DC shock during the hospital stay. On the same day, the girl was transferred intubated to resuscitation for respiratory arrest; in the following hours we witnessed the exitus. Our patient presented acute thrombosis both in the heart and in the brain, although she was being treated with antiplatelet and antithrombotic drugs and in the presence of thrombocytopenia. This case highlights the strong procoagulative role of haematological disease and of the chemotherapy indicated for it.

Cardiac amyloidosis is a group of diseases characterized by the accumulation in the interstitial space of amorphous material consisting of amyloid fibrils and, until recently, considered rare, with poor therapeutic prospects and burdened by a poor prognosis. However, both for amyloidosis from immunoglobulin light chains (AL) and for transthyretin amyloidosis in its wild type and mutated forms, there has been a significant increase in diagnostic capabilities. The aim of this work is to show the characteristics found in our population affected by cardiac amyloidosis. Materials and Methods We enrolled 18 patients observed over 12 months. The mean age was 63 ± 5, 14 patients were male. 8 patients in NYHA Class I – II, 10 patients in NYHA Class II – III. On the ECG in 88% of cases low QRS voltages in the peripheral leads. Among the conduction disturbances: 1st degree AV block in 45%, EAS in 33%, BBSn in 17%, occurrence of isolated BEV and BESV in 90%; 1 patient presented with AF. Defibrillator was implanted in 3 patients for detection of TVS and TNnS. In the whole population, the echocardiogram showed concentric parietal hypertrophy with a granular sparkling appearance; the mean FE was 55 ± 3%, the diastolic filling pattern was altered in type I in 42%, type II in 33% and type III in 25% of patients, respectively. In 92% of cases the left atrium was dilated. In 87% of cases there was an involvement of the valves in particular in 64% of cases we found calcifications of the aortic valve and in 66% mitral insufficiency. In 42% of patients there was an increase in the thickness of the atrial septum as well as the free wall of the right ventricle. Finally, signs of non–buffering pericardial effusion were found in 33% of patients. Results In our study population, 15 patients had multiple myeloma and presented with cardiac AL–type amyloidosis; among these 3 also presented renal involvement. In 3 patients, on the other hand, after positive bone scan and genetic screening, we diagnosed cardiac amyloidosis due to transthyretin mutation for which therapy with Tafamidis was undertaken. 3 patients died. Conclusions Our population presented echographic and echocardiographic characteristics comparable to those reported in the literature.

Cardiac tumors are rare neoplastic processes that can arise from any tissue in the heart. They are divided into primitive (benign or malignant) and metastatic (always malignant). The prevalence of cardiac tumors ranges from 0.002% to 0.28%, of which most are benign. Papillary fibroelastoma is the third most common heart cancer and the most frequent heart valve cancer. We describe the case of a 50–year–old ex–smoker patient with a recent history of recurrent right popliteal – tibial femoral thrombectomy and subsequent percutaneous angioplasty. He arrived in the emergency room for ischemic ulcers and fistulization of the right lower limb, for which he was admitted to the Vascular Surgery Department. The patient came to our observation for appearance during the hospitalization of episodes of chest pain at rest with irradiation to the left upper limb and spontaneous regression. The physical examination, blood pressure, blood chemistry tests, chest X–ray and ECG were normal. Transthoracic and transesophageal echocardiography showed a left ventricle with good contractile function, a tricuspid aortic valve with cusp movement preserved with an oval mass, hypoechoic, with well–defined margins, adhering to the ventricular surface of the right coronary cusp, conditioning insufficiency of mild degree. This image was suggestive for papillary fibroelastoma. In addition, in anticipation of cardiac surgery, a coronary CT was performed which confirmed the presence of an oval, hypodense mass and the absence of significant coronary lesions. The absence of fever, increased inflammation and leukocytosis indices made it possible to exclude an endocarditic origin of the lesion, just as the echocardiographic and radiological characteristics eliminated the suspicion of thrombosis. The patient underwent cardiac surgery via longitudinal median sternotomy, in normothermic extracorporeal circulation (CEC). The mass was then excised, preserving the native aortic valve. Postoperative follow–up with transesophageal echocardiography showed no signs of aortic insufficiency. The postoperative course was uneventful. The histological examination of the lesion confirmed the diagnosis of papillary fibroelastoma. At the follow–up after about 3 years the patient was asymptomatic and without echocardiographic signs of local recurrence.

We share the case of a 71–year old man, affected by hypertension, presented in Emergency Room (ER) with chest pain. No clinical evidence of heart failure. EKG showed fast atrial fibrillation with QS complex and ST elevation in precordial leads. Echocardiogram confirmed sept and apex akinesia. Troponin I peak was 72pg/ml. In ER electrical cardioversion was efficacy performed. He was referred for invasive coronary angiography, that showed a left anterior descending (LAD) chronic total occlusion (CTO), with Rentrop grade 2 collaterals providing retrograde flow from the right coronary artery (RCA), a severe stenosis of ramus intermedius (RI) and a moderate stenosis of circumflex. A stress–echocardiogram demonstrated vitality of medio–basal anterior wall. Subsequent, recanalization procedure of LAD CTO was planned. J–CTO score was 1 (tapered calcific, lesion

We share the case of a 50–year old man, with no cardiovascular risk factor, presented in ER with ongoing angina and positive exercise stress testing. No clinical evidence of heart failure. EKG and echocardiogram was negative. He was referred for invasive coronary angiography, that showed severe stenosis of mid–LAD and moderate ostial LAD stenosis. Subsequent Optical Coherence Tomography–Angio Co–Registration (OCT–ACR) of Left Anterior Descending was performed. An EBU3.5 guiding catheter was engaged in the left coronary artery, and 8000 units of heparin administered. After a pre–dilatation with a semi–compliant balloon of mid LAD, a plaque rupture with thrombus was documented at mid–LAD and a fibro–lipidic plaque with a severe flow limitation (MLA

Cardiac contractility modulation therapy consists in the delivery, by a device implanted in the patient at the level of the subclavicular region and connected to the heart through leads that send high intensity electrical impulses within the absolute refractory period of the potential of myocardial action. These pulses are delivered in cycles of 1 hour 7 times a day, each interspersed with pauses of 2–3 hours. CCM has been shown to be able to improve myocardial contractility through better management of intracellular calcium by the cardiomyocyte, exerting short and long–term effects, even managing to induce a positive remodulation of the gene expression of cardiac cells. The recent ESC 2021 guidelines indicate that cardiac contractility modulation therapy (CCM) was evaluated in patients with heart failure, FE 25%–45% and normal QRS duration ( The purpose of this work is to show our little experience on the use of CCM in patients suffering from heart failure. Materials and methods 4 male patients, aged 38–75 years, with heart failure, on optimal medical therapy, NYHA class III – IV, QRS Results In the 3 and 6 month follow–up, patients reported an improvement in symptoms, better exercise capacity and consequently a transition to a lower NYHA class (II – III). BNP values were lower than baseline. Upon checking the defibrillator, the trend of fluid accumulation using the optivol algorithm did not show significant levels of accumulation. No further hospitalizations for heart failure exacerbation. Conclusion The data limited to our little experience show how CCM produces similar results to those demonstrated in previous studies in subjects with 25% ≤LVEF≤45% and QRS

The Botallo arterial duct connects the pulmonary artery and the aorta during fetal life; after birth there is a progressive fall in pulmonary resistance mediated by the increase in oxygen concentration and the decrease in prostaglandins with a vasodilating action. In these physiological conditions, spontaneous closure of the duct is observed within the first 48–72 hours of life. In the preterm infant the patency of the Botallo duct is very frequent due to the peculiar anatomical and physiological characteristics of the preterm infant. The incidence of PDA is higher the lower the birth weight and gestational age are. We report a case of Manuel, a baby born at 32 weeks of gestational age from elective CT due to transverse presentation with difficulty in extraction and anhydrosis. 37–year–old mother hospitalized for reduction of amniotic fluid (AFI 85 index) with no apparent rupture of the membranes, for which she began a cycle of glucocorticoids 12mg twice a day. At birth, the weight of the child was 1,780 g, length 42 cm, skull circumference 28 cm, absence of valid respiratory activity, bradycardia (78 bpm) APGAR index of 4. At 5 ‘of life he was intubated with a 3 Fi rush tube fixed to 8 cm from the buccal rim with neopuff with PIP 20 cmH2O, PEEP 5 cmH2O, FiO2 0.40, transferred to the NICU, placed in the incubator, connected to the ventilator and ventilated with A/C mode with PIP 23 cmH2O, PEEP 5 cmH2O, FiO2 0, 40 –> 0.60, given surfactant alfa 200 mg/kg. Anemic, plasma and red blood cells were administered multiple times; infectious disease tests (aerobic–anaerobic haemocolutre, umbilical culture, culture of OT tubes, BAL, ear and throat swabs) were negative. After 3 days, systolic heart murmur appeared 2–3/6 radiated to the axilla. The echocardium showed the persistence of the Duct of Botallo, with a mosaic jet in the pulmonary artery and a “growing” ductal flow pattern. He started treatment with indomethacin 0.2 mg/kg every 12 hours x 3 doses, but on echocardiographic control the picture remained unchanged. At 16 days of age, the newborn was transferred to the Bambin Gesù in Rome and underwent cardiac surgery via the left posterolateral thoracotomy to close the arterial duct with a Weck clip. The post–operative course was regular. Manuel was discharged 2.5 months after birth in good general conditions, good growth–weight, with a weight of 2460 g.

Acute heart failure refers to rapid or gradual onset of symptoms and/or signs of chronic heart failure due to precipitating factors. Many patients with heart failure progress into a phase of advanced heart failure, characterized by persistent symptoms despite maximal therapy. Prognosis remains poor, with high 1–year mortality. Prognostic stratification is important to identify the ideal time for referral to an appropriate center capable of providing advanced therapies. We present the case of a 36–year–old black homeless man was admitted to Cardiological intensive care unit for acute heart failure complicated by intermediate–high risk bilateral subsegmentary pulmonary embolism, left endoventricular thrombosis, severe biventricular systolic dysfunction and secondary severe mitral insufficiency. After infusional diuretic and anticoagulant therapy, coronary angiography was performed documenting non–obstructive epicardial coronary arteries. Thereafter the therapy with sacubitril/Valsartan was falled, due to marked hypotension. Due to the high risk of sudden cardiac death, a single–chamber ICD was implanted in primary prevention. He was not eligible for long–term mechanical assistance (VAD) implantation and/or heart transplantation from referral centers, because of the patient‘s precarious psychosocial background. Furthermore, in the fullness of his faculties, the patient refused this possibility for religious reasons. Discharged in fair compensation, after resolution of pulmonary embolism and intracavitary thrombosis, he was again hospitalized for an exacerbation of chronic heart failure. Once labile hemodynamic compensation was reached, a cardiac contractility modulation device (CCM) was positioned, with the aim of improving symptoms. After optimization of therapy, with persistence of severe symptoms despite optimal medical and device therapy, options for intervention on the mitral valve were evaluated before further deterioration of the clinical conditions. Since this is a highly symptomatic patient at high risk for surgery, we opted for a coronary sinus mitral annuloplasty repair with Carillon, performed in the absence of complications. At the follow–up there was a mitral regurgitant volume reduction, improvement symptoms, in the absence of further hospitalizations.

Mitral Regurgitation (MR) is both the most common and the most underdiagnosed valvulopathy in Western countries. When MR’s entity is moderate to severe it is highly burdened by incident heart failure causing an important impact on prognosis, in terms of mortality and re–hospitalization. Unfortunately a lot of symptomatic patients are not elegible to reparative or replacement surgery also due to the high procedural risks. Hence, the need for a less invasive treatment has grown, so endovascular repair techniques have been developed such as the CARILLON Mitral Contour System, a percutaneous procedure for reshape the mitral annulus reducing its dilation and mitral regurgitation. This technique is indicated for patients with secondary mitral regurgitation. The CARILLON is a simple and fast procedure with a right jugular approach that requires neither general anesthesia nor anticoagulant/antiplatelet therapy. Four patients including 3 men, aged 37–64 years, suffering from heart failure and moderate to severe secondary mitral regurgitation who were symptomatic in optimal medical therapy, NYHA II – III class, were admitted to our Cardiological Intensive Care Unit from April to September 2021. All patients underwent coronary angiography and three patients had no obstructive coronary artery disease (CAD). All patients underwent transthoracic and transesophageal echocardiography showing severely dilated left ventricles (DTD 70 ± 10mm, DTS 46 ± 21mm, VTD 264 ± 6ml, VTS 204 ± 6ml), severe reduction in ejection fraction (mean EF 24 ± 5%), severely dilated left atrium, mean volume values 47 ± 13ml/m2, moderate to severe mitral regurgitation (vena contracta 6 ± 2mm, EROA 34 ± 9mm2, regurgitation volume 37 ± 12 ml, regurgitation fraction mean 54 ± 4%). After implantation of the Carillon no complications were observed. In the 3–month follow–up, patients reported improvement in symptoms, exercise capacity and NYHA class. At the echocardiographic evaluation we saw improvement in contractile function and left ventricular size, reduction in the degree of mitral regurgitation to mild–moderate. There were no further hospitalizations for heart failure during the follow–up. The data, albeit limited to our little experience, show how the Carillon reduces mitral regurgitation and improves clinical outcomes in terms of exercise tolerance, quality of life and reduction of hospital admissions, which have social and economic relevance.

We describe the case of a 39–year–old woman with a history of recent natural birth, who came to our observation for an episode of oppressive chest pain while breastfeeding her baby at night. At the entrance, the electrocardiographic and echocardiographic findings and myocardiocitonecrosis enzymes were normal; after three hours the second enzymatic determination was clearly increased, so the patient was admitted to our ICU with a diagnosis of SCA / NSTEMI. She was therefore subjected to coronary angiography with a small hematoma in the distal tract of the marginal branch without flow limitation; it was therefore decided, in accordance with the AHA and ESC guidelines, for a conservative medical therapy. On the third day of hospitalization, the patient presented recurrence of chest pain with electrocardiographic evidence of ST segment elevation in the anterolateral site. A new angiographic evaluation was therefore performed urgently, showing a complete retrograde dissection from the marginal branch to the circumflex branch and to the anterior descending branch with TIMI 0–1 flow. During the procedure the patient underwent a prolonged hypotensive episode associated with frequent polymorphic ventricular ectopic beats, with rapid evolution towards a picture of overt cardiogenic shock. Therefore we proceeded quickly to perform PTCA with placement of medicated stents on all branches involved in the dissection, with rapid improvement of the haemodynamic picture. Spontaneous coronary dissections represent for a hemodynamist a condition of great technical difficulty where the margins of error are very high. Thanks to the technological evolution of materials, an experienced hemodynamist is able, more and more easily, to be successful in the revascularization procedure and to resolve extremely serious clinical pictures. This case report describes a spontaneous coronary dissection that most often occurs in young women in good health and without risk factors for coronary heart disease, particularly in the peripartum period. The presentation was similar to an acute coronary syndrome. According to AHA and ESC guidelines, therapy was conservative if dissection / hematoma is not a flow restriction with coronary angiography after a few days to demonstrate vessel restoration.

Summary. Background: Thromboembolism is a relatively common complication of chronic heart failure (HF) and the place of antiplatelet therapy is uncertain. Objectives: We characterized the rate of thromboxane and prostacyclin biosynthesis in chronic HF of ischemic origin, with the aim of separating the influence of HF on platelet activation from that of the underlying ischemic heart disease (IHD). Patients and Methods: We compared urinary 11-dehydro-thromboxane (TX)B2, 2,3 dinor 6-keto-PGF1α, 8-iso-prostaglandin (PG)F2α, and plasma N-terminal pro-brain natriuretic peptide (NT-pro-BNP), asymmetric dimethylarginine (ADMA), and soluble CD40 ligand (sCD40L), in 84 patients with HF secondary to IHD, 61 patients with IHD without HF and 42 healthy subjects. Results: HF patients not on aspirin had significantly higher urinary 11-dehydro-TXB2 as compared with healthy subjects (P

Objective— We recently demonstrated that inducible cyclooxygenase/PGE synthase-1 (COX-2/mPGES-1) are overexpressed in symptomatic plaques in association with PGE 2 -dependent metalloproteinase (matrix metalloproteinase [MMP]) biosynthesis and plaque rupture. However, it is not known which of the 4 PGE 2 receptors (EP1–4) mediates macrophage metalloproteinase generation. The aim of this study was to characterize EP1–4 expression in plaques from symptomatic and asymptomatic patients undergoing carotid endarterectomy and correlate it with the extent of inflammatory infiltration, COX-2/mPGES-1 and MMP expression and clinical features of patients’ presentation. Methods and Results— Plaques were analyzed for COX-2, mPGES-1, EP1–4, MMP-2, and MMP-9 by immunohistochemistry, reverse-transcription polymerase chain reaction and Western blot; zymography was used to detect MMP activity. We observed strong EP4 immunoreactivity, only very weak staining for EP2, and no expression of EP1 and EP3 in atherosclerotic plaques. EP4 was more abundant in MMP-rich symptomatic lesions, whereas EP2 was no different between symptomatic and asymptomatic plaques. Finally, MMP induction by PGE 2 in vitro was inhibited by the EP4 antagonist L-161 982, but not by its inactive analog L-161 983 or by the EP2 antagonist AH6809. Conclusions— This study shows that EP4 overexpression is associated with enhanced inflammatory reaction in atherosclerotic plaques. This effect might contribute to plaque destabilization by inducing culprit metalloproteinase expression.

Abstract —Inflammation plays a pathogenic role in the development of restenosis after percutaneous transluminal coronary angioplasty (PTCA). Monocyte chemoattractant protein-1 (MCP-1) is a potent chemoattractant of monocytes; however, its role in the pathophysiology of restenosis is still unclear. We set out to investigate the role of MCP-1 in restenosis after PTCA. In addition, we tested the hypothesis that MCP-1 exerts its effect, at least in part, by inducing O 2 − generation in circulating monocytes. Plasma levels of MCP-1 were measured before and 1, 5, 15, and 180 days after PTCA in 50 patients (30 males and 20 females, aged 62±5 years) who underwent PTCA and who had repeated angiograms at 6-month follow-up. Restenosis occurred in 14 (28%) patients. The MCP-1 level was no different at baseline between patients with or without restenosis. However, after the procedure, restenotic patients, compared with nonrestenotic patients, had statistically significant ( P 2 − generation. Finally, multivariate regression analysis showed that the MCP-1 plasma level measured 15 days after PTCA was the only statistically significant independent predictor of restenosis (β=0.688, P 2 − release in monocytes. Further understanding of the mechanism(s) by which MCP-1 is produced and acts after arterial injury may provide insight into therapies to limit the progression of atherosclerosis and restenosis after balloon angioplasty.

The hypothesis that persistence of undivided branches is a common finding after myocardial revascularization using the left internal mammary artery was explored.Three hundred seven consecutive postoperative angiographies of the left internal mammary artery were considered. Seven were excluded because of occlusion or malfunction of the conduit or the anastomosis. Of the remaining 300, 150 were harvested through a left anterior small thoracotomy (group A) and 150 through a median sternotomy (group B). The persistence of undivided branches was recorded for each group.Common origin with other branches of the subclavian artery was present in 55 patients in group A and 54 in group B (p = not significant); the persistence of lateral costal branch was also equally distributed in both groups (15 and 17; p = not significant). The first intercostal artery was present in 5 patients in group A and in none in group B (p = not significant). Branches of 1 mm or more were more frequent in group A (34 versus 4, p0.001), as well as branches of less than 1 mm (140 versus 67; p0.001). Only 2 patients in group A had no branches versus 48 patients in group B (p0.001).Common origin with other branches of the subclavian artery and persistence of the lateral costal branch are common aspects in the angiographic anatomy of the grafted left internal mammary artery. Moreover, new branches, sometimes wider than 1 mm, develop with time. These findings are independent from the harvesting technique, the left anterior small thoracotomy, or the median sternotomy. If flow competition between the coronary and noncoronary territories was a reality, coronary artery grafting with the left internal mammary artery would be unsuccessful since the beginning.

Background . The minimal access surgical technique of a left anterior small thoracotomy (LAST) for coronary artery bypass grafting is now well established. This procedure however, does not allow multivessel revascularization. We present our early experience of an integrated approach using LAST and percutaneous transluminal coronary angioplasty (PTCA), either staged or simultaneous. Methods . Eighteen patients (14 men and 4 women), mean age 63 (range 35–87 years) were treated. Four patients underwent simultaneous LAST and PTCA revascularization. The remaining 14 patients were first treated with the LAST procedure, followed 1–3 days later by angioplasty. Angiographic assessment was carried out before PTCA and at 6 months after. Results . The 14 patients who underwent the staged procedure all had patent left internal mammary artery/ left anterior descending coronary artery grafts. Angioplasty was performed on 21 vessels (10 stented) with good early angiographic results. All patients were extubated early, mean intensive care stay was 14.7 + 9.4 hours, mean hospital stay was 5 + 1.5 days. All patients were symptom free at 18 months follow-up. Conclusions . Staged LAST and angioplasty is a safe and effective approach suitable for patients in whom there are contraindications to the use of extracorporeal circulation. The simultaneous approach is limited by the risk of bleeding associated with the use of anticoagulation when coronary stenting is required.

Lack of angiographic results and technical difficulty in grafting the vessels in the lateral and posterior walls have reduced interest in myocardial revascularization without cardiopulmonary bypass (CPB). We describe our experience to demonstrate the feasibility of coronary surgical intervention without CPB in multivessel disease.From May 21, 1997, through February 1998, 227 patients underwent revascularization with two or more arterial conduits as the first operation: 122 without CPB (group A) and 105 with CPB (group B). Group A included a greater number of high-risk patients.Mean +/- SD anastomoses per patient were 2.5 +/- 0.6 in group A and 2.8 +/- 0.8 in group B (p = NS). No patient died in group A, whereas 1 patient (0.9%) died in group B. The postoperative complication rate was low in both groups, but intensive care unit and in-hospital stays were shorter in group A than in group B (14.1 +/- 7.1 versus 27.3 +/- 36 hours, p0.001, and 4.1 +/- 1.6 versus 5.4 +/- 2.4 days, p0.001, respectively [group A versus group B]). Sixty-seven patients in Group A (54.9%) underwent postoperative angiography 33 +/- 35 days after operation. The patency rate was 98.9% (98.2% for the marginal branches).Arterial revascularization of the coronary arteries without CPB is feasible, with results similar to those obtained with CPB. The two techniques, in our opinion, are complementary, not antagonistic.

Background: Our experience with a left internal thoracic artery graft to the left anterior descending artery via a left anterior small thoracotomy is reviewed to evaluate midterm results. Methods: From November 1994 to April 1997, four hundred sixty patients were scheduled to undergo a left internal thoracic artery graft to the left anterior descending coronary artery via a left anterior small thoracotomy; 26 of these patients (5.7%) were converted and 434 of them had the operation. Two hundred fourteen patients (49.3%) had isolated disease of the left anterior descending artery, and 220 patients(50.7%) had multiple vessel disease. A sufficient length of the left internal thoracic artery was harvested to reach the left anterior descending artery. Results: Three hundred nine patients (71.2%) underwent extubation by hour 2. Mean intensive care unit stay was 4.2 ± 4.5 hours; mean postoperative hospital stay was 66 ± 29 hours; the 30-day mortality rate was 1.1%; the late mortality rate was 1.4%. Eighteen patients underwent reoperation early (≤30 days), and eight patients underwent reoperation late (>30 days) because of conduit/anastomotic malfunction. Four patients underwent reoperation with patent anastomosis for progression of disease ( n = 3) or pericarditis ( n = 1). Three patients had a percutaneous transluminal coronary angioplasty. Cumulating angiographic and stress Doppler flow assessment results, a patent anastomosis was obtained in 417 patients and a nonrestrictive anastomosis in 404 patients. Twenty-nine months after surgery, survival was 97.1% ± 0.7% (95% confidence interval 90.5% to 100%) and event-free survival 89.4% ± 1.2% (95% confidence interval 78.2% to 100%). In the last 190 patients, with our increased experience and better instruments, we obtained a patent anastomosis in 188 patients (98.9%) and a nonrestrictive anastomosis in 185 (97.4%). Conclusions: Left anterior small thoracotomy gives acceptable midterm results. Incidence of patent and nonrestrictive anastomoses was satisfactory, especially in the most recent part of our experience, when the learning curve ended.(J Thorac Cardiovasc Surg 1998;115:763-71)

Objective: Sometimes the left internal mammary artery (LIMA) is not long enough to reach a too lateral LAD when a left anterior small thoracotomy (LAST operation) is the surgical approach to graft the LAD. LIMA elongation with an inferior epigastric artery (IEA) can be an useful surgical option. Methods: From November 1994 to June 30, 1996, out of 289 patients who underwent LAST operation; 28 patients had a LIMA elongation with an IEA, 20 patients had single vessel disease, 4 had two vessel disease, and 4 three vessel disease. Mean age was 62 ± 22 (48-84) and mean EF was 57 ± 86. The IEA was used only when the LAD was totally or nearly occluded with no transmural myocardial infarction (high expected run off). Results: All patients had an uneventful recovery. After 315 ± 104 days from surgery all were asymptomatic. A late doppler flow assessment, performed in 28 patients, showed a high velocity diastolic flow in 27. One patient was reoperated on because of graft occlusion 84 days after surgery. An angiography was performed after 87.5 ± 23.3 days in 22 patients. All conduit and anastomoses were patent but one, (patency rate 21/22, 95.4%); another showed mild anastomotical stenosis at the LIMA-IEA junction without clinical signs (perfect patency rate 20/22, 90.9%). Conclusions: IEA elongation of LIMA is an alternative strategy to reach a lateral LAD in selected cases; a satisfying patency rate can be expected, when correct surgical indications are used.

Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery.Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 microg) was injected and the average peak velocities before and after injection were calculated.The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 +/- 7 and 26 +/- 5 cm/sec, respectively, in group A versus 27 +/- 5 and 25 +/- 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 +/- 0.3 in group A versus 0.69 +/- 0.3 cm/s in group B; p = NS), but not distally (1.72 +/- 0.1 in group A versus 0.97 +/- 0.3 in group B; p0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 +/- 0.6 and 2.5 +/- 0.3 cm/s, respectively, in group A versus 2.6 +/- 0.5 and 2.6 +/- 0.3 cm/s, respectively, in group B; p = NS).The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.

Item does not contain fulltext BACKGROUND: The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. METHODS: In this double-blind, randomized trial, in a primary analysis involving 7243 patients under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus 75 mg of clopidogrel. RESULTS: At a median follow-up of 17 months, the primary end point of death from cardiovascular causes, myocardial infarction, or stroke among patients under the age of 75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel group (hazard ratio in the prasugrel group, 0.91; 95% confidence interval [CI], 0.79 to 1.05; P=0.21). Similar results were observed in the overall population. The prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P=0.04). Rates of severe and intracranial bleeding were similar in the two groups in all age groups. There was no significant between-group difference in the frequency of nonhemorrhagic serious adverse events, except for a higher frequency of heart failure in the clopidogrel group. CONCLUSIONS: Among patients with unstable angina or myocardial infarction without ST-segment elevation, prasugrel did not significantly reduce the frequency of the primary end point, as compared with clopidogrel, and similar risks of bleeding were observed. (Funded by Eli Lilly and Daiichi Sankyo; TRILOGY ACS ClinicalTrials.gov number, NCT00699998.).

In the paper we estimate an energy conservation supply curve form the investment in energy savings works in the Italian residential sector. First the average ldquotyperdquo of building, in terms of heating dispersion, is calculated for each age of construction and climatic zone. Then several possible strategies are considered, that range from substituting old heaters with new ones to installing thermal collectors and refurbishing the buildings, reducing the heating dispersion according to the new transmittance limits that will be compulsory in Italy (for new buildings) from the year 2010. The cost of implementing specific energy-saving works is calculated; a step-wise supply curve is obtained that measures the potential Mtep saved ad the merit order of the various instruments considered.

The aim of this study was to assess the safety of direct coronary stenting, its influence on costs, duration of the procedure, radiation exposure, clinical outcome and the incidence of periprocedural myocardial damage as assessed by enzyme release determination.We randomized 103 patients (109 lesions) to direct stent implant or stent implant following balloon predilatation. Patients with heavily calcified lesions, bifurcations, total occlusions, left main lesions and very tortuous vessels were excluded. Three samples of blood were drawn; before, 12 and 24 h after the procedure and total CK, CK MB mass and troponin I determination was carried out in a single centralized laboratory.Direct stenting was successful in 62/62 lesions (100%). No single loss or embolization of the stent occurred. All stents in the group with predilatation were effectively deployed. The immediate post procedure angiographic results were similar with both techniques. Contrast media consumption and procedural time were significantly lower in direct stenting (150+/-82 cc and 30+/-13 min) than in pre-dilated stenting (184+/-85 cc and 36+/-14 min) (P=0.04 and P=0.036 respectively) while fluoroscopy time was similar (9.1+/-12 vs 9.19+/-15 min, P=0.97). The incidence of enzyme release was similar in the groups with only three non Q MI all in the pre-dilated group (P=0.149). Any elevation of CK MB and troponin I occurred in 7% of direct stent vs 12% of pre-dilated group (P=0.66), isolated troponin I elevation in 21% of both groups. Major adverse cardiac events during hospitalization were 0 in direct and 3 in pre-dilated stenting (P=0.66), but there were no significant differences at follow-up at 1, 6 and 12 months between the 2 groups (target lesion revascularization at 12 months 11 vs 14% in the 2 groups respectively).Direct stenting is as safe as pre-dilated stenting in selected coronary lesions. Acute results and myocardial damage as assessed by enzyme release determination are similar, but procedural costs (as measured by resource consumption) and duration of the procedure are lower in direct stenting. Overall success rate and mid-term clinical outcome are similar with both techniques.

Objective: To investigate whether enhanced oxidant stress in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) is associated with a higher concentration of non-high density lipoprotein (HDL) cholesterol at baseline, and whether this contributes to the inflammatory reaction and luminal renarrowing after PTCA. Design: An ex vivo and in vitro study of 46 patients who underwent PTCA and who had repeat angiograms after six months. Blood samples were collected immediately before PTCA, and at 24 hours, 48 hours, and 15 days after. Setting: Tertiary referral centre. Subjects: 46 patients (30 male, 16 female; mean (SD) age, 62 (5) years) with stable or unstable angina who underwent elective PTCA. Main outcome measures: Continuous variable luminal loss as defined by change in minimum lumen diameter during follow up, normalised for vessel size; lag phase of low density lipoprotein to in vitro oxidation; plasma fluorescent products of lipid peroxidation (FPLP); plasma vitamin C and E; interleukin (IL) 1β secretion from unstimulated monocytes; plasma C reactive protein (CRP). Results: Restenosis occurred in 12 patients (26%). Oxidant stress after PTCA was greater (p < 0.0001 at 15 days) in the patients with restenosis and showed a significant correlation with the preprocedural concentration of non-HDL cholesterol (p < 0.001). Inflammatory reaction (as reflected by IL-1β production and CRP) and late lumen loss were linearly correlated (p < 0.001) with lag phase and FPLP throughout the study, and inversely (p < 0.05) with vitamin C and E measured at two and 15 days after PTCA. Conclusions: This study provides evidence for the critical role of cholesterol dependent oxidant stress in the pathophysiology of restenosis after PTCA. The findings raise the possibility that drugs capable of modulating oxidant status might provide a novel form of adjuvant treatment in patients with hypercholesterolaemia undergoing PTCA.

Background We explored the possibility of anastomosing the left internal mammary artery (LIMA) to the left anterior descending artery in a beating heart via a left anterior small thoracotomy. Methods This procedure was performed in 155 of 162 scheduled patients; in 7 (4.3%) the left anterior descending artery was not suitable or was too small. The chest was opened in the fourth intercostal space (mean wound length, 10.5 cm) and the LIMA was harvested for about 4 cm. The left anterior descending artery was occluded by means of two 4/0 Prolene (Ethicon, Somerville, NJ) sutures, and the proximal suture was snared. The anastomosis was performed with two 8/0 Prolene sutures while the heart was beating. Early postoperatively all patients underwent repeat angiography or a Doppler flow assessment of the LIMA or both. Results The LIMA was connected directly to the left anterior descending artery in 144 patients and with interposition of an inferior epigastric artery in 11. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. One patient (0.6%) died 38 days after the operation due to multiorgan failure. Nine patients (5.8%) had failure requiring a redo operation: 7 (4.5%) early and 2 (1.3%) late. One additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean 5.6 months of follow-up, 143 patients (92.2%) were alive, asymptomatic with or without medical treatment, and without cardiac events. Conclusions Left internal mammary artery-to-left anterior descending artery anastomosis performed on a beating heart via a left anterior small thoracotomy is a safe procedure. In selected patients the operation has good early and midterm results.

This report reviews 218 patients who underwent internal mammary artery (IMA) grafting alone or with vein graft between 1986-1989. Our experience with IMA started with a single attached graft for proximal left anterior descending lesions in young patients affected from stable angina. After that our indications became more extensive. One IMA was utilized in 209 cases, both two IMAs in the remaining 9. Sequential IMA graft was performed in 16 patients and free IMA graft in 8. There were 242 IMA anastomosis and 295 associated vein by-passes. The overall operative mortality was 2.3%. Perioperative complications include myocardial infarction in 3 (1.4%), reoperation for bleeding in 4 (1.8%) and sternal wound complication in 4 (1.8%). These results are comparable to those of patients having only saphenous vein by-pass during the same period. At the follow-up actuarial survival rate at 42 months was 94 1.8% and 90% of these patients were completely asymptomatic. We include that IMA grafting shows low operative risk and provide excellent short term results. Our findings and the high long term patency rate of this conduit encourage us to extend the indication to IMA and to perform those surgical techniques that make possible multiple mammary coronary anastomosis.

The problem of infectious endocarditis (IE) is approached through a review of personal experience. The series examined consists of patients, 17 with active and 21 dormant infection. Furthermore 12 in the first group, 18 in the second had natural heart valves, while 5 in group I, 3 in group II had been given artificial ones. After an analysis of the aetiopathogenic, clinical and diagnostic aspects of the condition with emphasis on the fact that Staphylococcus aureus is currently more responsible for infections in natural valves and the epidermidis for acute prosthesis infections which have a higher early and late mortality rate (40% in hospital, 33.3% long-term), the paper discusses the criteria for surgical intervention. In line with opinions expressed in the literature, it is pointed out that, while the patient's haemodynamic status is certainly the main criterion for any decision, other factors such as embolism, impaired conduction, kidney failure and expansion of the infection to contiguous tissues, should not be under-estimated.

Sixty patients (pts) with very disabling symptoms during supraventricular tachycardia (SVT) underwent electrophysiological study to determinate the mechanism of arrhythmia. 20 pts had, during normal sinus rythm (NSR), ECG pattern of ventricular pre-excitation (V-P); 40 pts, instead, had ECG pattern within normal limits (WNL). In V-P pts, circus movement tachycardia by overt accessory pathway (AP) was initiated. Among ECG-WNL pts group: 10 pts showed ectopic atrial rythm; 22 pts had SVT due to A-V nodal reciprocation; and 8 pts revealed the participation of concealed AP in the reentrant circuit of tachycardia. Among these latter, atrial stimulation at various sites and drugs-administration discovered extranodal by-pass liable for concealed V-P in 2 pts; in the remaining 4 pts it was possible to demonstrate concealed atrial preexcitation by ventricular stimulation, during NSR and SVT, and by atrial mapping during ventricular stimulation and SVT. Our report confirms the significative incidence of concealed AP at the basis of numerous cases of SVT (26%) and outlines the distinction between the latent W.P.W. syndrome and the atrial preexcitation, due to anomalous by-pass with anterograde block.

To define the risk of side branch occlusion during percutaneous transluminal coronary angioplasty (PTCA), 99 consecutive procedures, performed on 92 patients, were examined. In 77 of them side branches existed, originating from the stenosed segment; analysis was performed on 65 successful procedures (success rate = 84.4%). The 121 side branches were divided as follows: 53 (43.8%) originating from the stenosis itself (group A), of which 32 small in size (less than 1 mm) and 21 "moderate" (greater than or equal to 1 mm); 68 (56.2%) originating in the immediate vicinity of the stenosis (group B) of which 23 small and 45 moderate. After PTCA 3 side branches were occluded (2.5%): a small 1 of group A and 2 (1 small and 1 moderate) of group B. Three side branches (2.5%) all of group B, 1 small and 2 moderate, became stenotic in their take-off. In one only patient who had a side branch occlusion a slight CK-MB elevation (25 mU/ml) occurred together with a Q wave appearance in the aVL lead. In conclusion, side branches at risk are frequently present (in our population they account for 83.7% of the patients) but the real incidence of damage of these branches after PTCA is quite low, without any considerable difference between groups A and B, and significant clinical consequences are usually rare.

In nine patients (pts.) with recurrent SVT, we have performed a combined electrophysiological and hemodynamic study. Five pts. showed reciprocating nodal tachycardia and 4 pts. reentry tachycardia associated with WPW syndrome (2 with Kent bypass tract and 2 with James bypass tract). Hemodynamic parameters were recorded during sinus rhythm (SR), atrial (AP) and ventricular pacing (VP) and following the initiation of SVT. The arrhythmia was induced by rapid atrial pacing or with atrial or ventricular premature stimuli. Hemodynamic data were then compared. Our results point out a greater hemodynamic deterioration during SVT than during AP or sinus tachycardia at similar rates. We have often observed in SVT, and constantly in A-V nodal reentrant (AVN) cases, the appearance of giant waves in the right and left atrium. This finding confirms hypothesis of the primary role of the changes in atrioventricular contraction sequence during SVT, especially in AVN tachycardias, with subsequent reduction in stroke volume and cardiac output.

The authors study retrospectively some preoperative echocardiographic findings and their importance as predictors of reversible myocardial dysfunction. The functional status of 57 survivors after isolated aortic valve replacement was evaluated with exercise testing and on this ground the patients, were divided into three groups: A (28 pts) greater than 60%; C (10 pts) less than 40%; B (19 pts) from 40% to 60%. The authors conclude that the postoperative improvement in functional status is strictly correlated with some preoperative echocardiographic indexes (end-diastolic dimension, end-systolic dimension, shortening fraction, mean end-systolic radius/thickness ratio, end-systolic wall stress, myocardial mass, ejection fraction) with are also predictive of operative mortality. The authors consider the principal values of beginning left ventricular impairment: a) end-systolic dimension greater than or equal to 5.5 cm; b) shortening fraction less than 27%; c) mean end-systolic radius/thickness ratio greater than 2.5; d) end-systolic wall stress greater than 240 mmHg.