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Coronary microvascular dysfunction (CMD) has been proposed as a key driver in the etiopathogenesis of Takotsubo syndrome (TTS), likely related to an “adrenergic storm” upon a susceptible microvascular circulation. The aim of our manuscript was to assess CMD in patients with TTS through the computation of the angiography-derived index of microcirculatory resistance (IMR) and its correlation with clinical presentation. Coronary angiograms of 41 consecutive TTS patients were retrospectively analyzed to derive angiography-based indices of CMD. Three indices (NH-IMRangio, AngioIMR and A-IMR) were calculated based on quantitative flow ratio. CMD was defined as an IMRangio value ≥ 25 units. The correlation between CMD and clinical presentation was then assessed. Median age was 76 years, 85.7% were women and mean left ventricular ejection fraction (LVEF) at first echocardiogram was 41.2%. Angiography-derived IMR was higher in left anterior descending artery (LAD) than circumflex and right coronary artery with either NH-IMRangio (53.9 ± 19.8 vs 35.8 ± 15.4 vs 40.8 ± 18.5, p-value

A 49-year-old man was referred to our cath-lab in 2015 after the detection of inducible ischaemia in the infero-lateral wall on single-photon emission CT performed due to a worsening stable angina. His cardiovascular risk factors accounted for family history of ischemic disease, high blood pressure and dyslipidaemia. The echocardiography highlighted a mildly reduced left ventricular function with infero-lateral wall hypokinesia. Coronary angiography revealed a chronic total occlusion (CTO) of the left circumflex artery (LCX) and a long diffuse severe disease of the right coronary artery (RCA). The left anterior descending artery (LAD) showed a diffuse atherosclerotic involvement without critical stenoses. Percutaneous coronary intervention (PCI) was performed after Heart Team discussion with implantation of two 3.5×28mm and 3.5×23mm Absorb bioresorbable vascular scaffold (BVS) on the RCA. Moreover, the LCX CTO was successfully treated by anterograde approach with implantation of a 3.0×28 mm Absorb BVS. Intravascular ultrasound confirmed the optimal result of both the interventions, while confirmed the long diffuse calcific involvement of the LAD with a thick cap calcific fibroatheroma at the virtual histology. The patient was discharged on dual antiplatelet therapy for twelve months. After five uneventful years, he was readmitted to our department for recurrence of worsening stable angina. At the coronary angiography a significant progression of the proximal LAD disease was noted. The lesion was judged hemodynamic relevant with pressure derived indices (instantaneous wave-free ratio 0.86; fractional flow reserve 0.70). The IVUS and optical coherence tomography (OCT) analysis confirmed the significant progression of the disease with a long, diffuse, sub-occlusive thick cap fibroatheroma stenosis (minimal lumen area 1.9 mm2; plaque burden 91%). The OCT analysis showed the complete resorption of the devices previously implanted to the RCA and the LCX, with optimal long-term results and positive remodelling in the LCX. Therefore, an OCT-guided PCI with marker-to-marker implantation of two 3.5×25 and 3×20 mm magnesium-based Magmaris BVS was performed. In 2022, the patient underwent an elective coronary angiography that demonstrated a complete resorption of both the Magmaris with an optimal OCT result. Conversely, the positive remodelled segment resulting from complete resorption of the poly-L-lactic-based BVS in the mid-LCX was shown to be progressed to a critical sub-occlusive fibroatheroma. A further OCT-guided PCI with deployment one 3.5×20mm Magmaris BVS was performed. Six months later, patient was asymptomatic with a good performance status. To the best of our knowledge, the present is the first case of multivessel repetitive imaging-based percutaneous revascularizations with the use of two different BVS technologies and a total of six devices implanted, with very long-term intracoronary imaging result. Through the paired intravascular imaging analysis, this case sought to provide insightful findings on vulnerable plaque atherosclerotic progression and on BVS biologic restoration therapy, a process that appears particularly appealing in young patients with advanced CAD, namely multivessel involvement and diffuse disease that still poses limitations to PCI.

Background the development of bioresorbable scaffolds (BRSs) has been conceived as revolution in interventional cardiology for the prospective improvements in the treatment of coronary artery disease. However, metallic drug eluting stent (DES) demonstrated greater safety and efficacy than bioresorbable vascular scaffold (BVS) Absorb in dedicated trials culminating in the commercial withdrawal of Absorb device in 2017. Nevertheless, the progressive absorption of the scaffold and the restoration of physiological coronary artery characteristics attracted attention, so currently research on BRSs is in progress. Case presentation a 58-year-old woman was admitted in our department after an episode of typical angina at rest without significant troponin elevation. The electrocardiogram showed T wave inversion in lateral leads. Hypokinesia of distal septum and anterior wall and mildly reduced left ventricular ejection fraction (LVEF 50%) were observed on echocardiography. Her cardiovascular risk factors included obesity, arterial hypertension, dyslipidaemia, family history of ischemic heart disease and former smoking. Her past medical history was remarkable for chronic kidney disease (CKD EPI eGFR 50 ml/min) and previous connective tissue disease. Coronary angiography highlighted a critical stenosis in the middle segment of left anterior descending artery (LAD). Optical coherence tomography (OCT) imaging showed recanalized and organized throumbus and calcific plaques. After adequate predilatation and stent sizing by OCT, a 3×25 mm Magnesium-based BVS (Magmaris, Biotronik AG, Buelach, Switzerland) was implanted. OCT confirmed good expansion and apposition of the stent after postdilatation. Patient was discharged on dual antiplatelet therapy (DAPT) for 12 months, anti-remodeling cardiac and lipid-lowering therapy. One year later, the patient underwent and elective coronary angiography and OCT control showing a complete reabsorption of the Magmaris BVS with positive remodelling and luminal enlargement of the vessel. The patient was asymptomatic throughout the year with a good performance status. Conclusion The present case illustrates an example of imaging-based revascularization with BVS Magmaris and optimal intracoronary imaging result at 1 year follow up in agreement with the last available evidence. The last European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommends the use of BVS only in the context of clinical controlled studies. However, encouraging results obtained and what expected from the current studies with Magmaris scaffolds, might change indications considering the potential benefit about the restoration of natural vasomotion, the reduced risk of neoatherosclerosis and the positive vascular remodelling following the scaffold absorption.

Background Arterial hypertension is a complex and in most cases multifactorial pathology. Despite the numerous pharmacological treatments available, it is estimated that in Europe only 25%-39% of hypertensive patients achieve adequate blood pressure (BP) control. Renal arteries denervation (RDN) is an additional therapeutic weapon, complementary to Optimal Medical Therapy (OMT) in patients with resistant or refractory primary (or essential) arterial hypertension. In order to improve patients management and select those who are eligible for renal denervation, our Center has established the Interdisciplinary Group for the Treatment of Resistant Arterial Hypertension (G.I.T.I.A.R.), including Cardiologists, Nephrologists, Internists and Geriatricians. Methods From January 2018 to July 2022 the G.I.T.I.A.R. held twelve meetings evaluating 62 patients with resistant or refractory forms of arterial hypertension, contraindications or intolerance to antihypertensive drugs, suspected secondary or pseudoresistant forms (i.e. linked to poor patient compliance, drugs and/or inadequate dosages, concomitant intake of substances with hypertensive effect, incorrect measurements). For each of them, medical therapy was optimized and the need for second level diagnostic tests, multi-specialist follow-up and RDN candidacy were assessed. After three, six, twelve months and then annually following RDN, the patients underwent clinical and multi-specialist evaluation (where deemed appropriate), blood tests monitoring and 24-hour ambulatory blood pressure monitoring (ABPM). Results Of the 62 patients evaluated by the G.I.T.I.A.R., 64.5% (n=40) were male. The mean age at the time of evaluation was 64 years (range 18-87). After the first collegial discussion, 46.8% (n=29) have been declared eligible for RDN, while 53.2% (n=33) of the patients was initially rejected: 39.4% of these (n=13) for suspected or ascertained secondary hypertension, 12.1% (n=4) for the possibility of further optimization of medical therapy, 48.5% (n=16) for the presence of inclusion or exclusion criteria of ongoing studies design. Among the excluded patients, six presented moderate renal artery stenosis on non-invasive imaging: in two patients (33.3%) the stenosis turned out to be hemodynamically significant on angiographic and functional evaluation (Pd/Pa measurement), so renal angioplasty was performed; RDN was performed in the remaining 66.7% (n=4), in which a hemodynamic significance of the stenosis was excluded. Of the subgroup who had optimized medical therapy, one patient (25%) was subsequently referred to RDN for failure of all pharmacological strategies, while 3 of 4 (75%) achieved adequate BP control. Conclusions Resistant arterial hypertension is associated with an increased risk of development and progression of cardiovascular and renal diseases, with a significant impact on mortality and morbidity. Renal denervation has proved to be an effective and safe therapeutic strategy, complementary to OMT, whose selection of the ideal patient actually represents one of the greatest challenges. The integrated multidisciplinary approach improves the management of the hypertensive patient, the individualization of therapy and allows the identification of subjects who may benefit from RDN.

Background Right Ventricle/Pulmonary Artery (RV/PA) coupling has recently emerged as a relevant prognostic factor in patients undergoing transcatheter valvular interventions. The aim of this study is to assess the interaction between RV/PA coupling ratio and the incidence of Acute Kidney Injury (AKI) following TAVI in patients with severe aortic stenosis. Furthermore we investigated the interaction between this novel ratio and adverse events at 24 months follow-up. Methods A population of 283 patients was selected from the Verona Valvular Registry (CESC n =1918). RV/PA coupling was estimated as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PAPs) obtained through transthoracic echocardiograms. AKI was defined as an increase in serum creatinine (sCr) of at least 0.3 mg/dL up to 48 hours following TAVI. Major adverse cardiovascular events (MACEs) were defined as the composite occurrence of cardiac death, re-hospitalization for congestive heart failure and stroke. Results Mean age was 83.4 ± 5.36 years and 41.3% of patients were female. The median value of TAPSE/PAPs ratio was 0.5667 mm/mmHg and was used as a cut-off. A TAPSE/PASP ratio Furthermore, risk for 24 months MACEs was higher in the population with lower TAPSE/PAPs ratio (HR 2.672; CI 95% [1.195–5.974]; p = 0.017). Conclusion RV/PA coupling, as characterized by TAPSE/PAPs ratio, is a promising independent predictor of AKI, also associated with higher risk of major adverse cardiac events at follow-up in subjects undergoing TAVI. These data suggest a possible role for this novel index in risk stratification, assessment of the prognosis, and decision-making in these patients.

(1) Background: In spite of the undeniable clinical value of the index of microvascular resistance (IMR) in assessing the status of coronary microcirculation, its use globally remains very low. The aim of this study was to validate the novel single-view, pressure-wire- and adenosine-free angiographic microvascular resistance (AMR) index, having the invasive wire-based IMR as a reference standard. (2) Methods: one hundred and sixty-three patients (257 vessels) were investigated with pressure wire-based IMR. Microvascular dysfunction (CMD) was defined by IMR ≥ 25. AMR was independently computed from the diagnostic coronary angiography in a blinded fashion. (3) Results: AMR demonstrated a good correlation (r = 0.83, p < 0.001) and diagnostic performance (AUC 0.94; 95% CI: 0.91 to 0.97) compared with wire-based IMR. The best cutoff value for AMR in determining IMR ≥ 25 was 2.5 mmHg*s/cm. The overall diagnostic accuracy of AMR was 87.2% (95% CI: 83.0% to 91.3%), with a sensitivity of 93.5% (95% CI: 87.0% to 97.3%), a specificity of 82.7% (95% CI: 75.6% to 88.4%), a positive predictive value of 79.4% (95% CI: 71.2% to 86.1%) and a negative predictive value of 94.7% (95% CI: 89.3% to 97.8%). No difference in terms of CMD rate was described among different clinical presentations. (4) Conclusions: AMR derived solely from a single angiographic view is a feasible computational alternative to pressure wire-based IMR, with good diagnostic accuracy in assessing CMD.

BACKGROUND Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) disagree in about 20% of intermediate coronary lesions. As the physiological pattern of coronary artery disease has a significant influence on FFR-iFR discordance, we sought to assess it may impact on the diagnostic accuracy of quantitative flow reserve (QFR). METHODS One hundred and ninety-four patients with 224 intermediate coronary lesions were investigated with iFR, FFR, and QFR. The physiological pattern of disease was assessed with iFR Scout pullback and QFR virtual pullback in all the cases. RESULTS A predominantly physiologically focal pattern was observed in 81 (36.2%) lesions, whereas a predominantly physiologically diffuse was observed in 143 (63.8%) cases. QFR demonstrated a significant correlation (r = 0.581, p

Aims Acute kidney injury (AKI) represents a common complication following TAVI, that correlates strictly with in-hospital, short, and long-term mortality. Extra-valvular cardiac damage (EVCD) showed to affect long-term outcomes in patients with severe aortic stenosis (AS). We sought to determine the differences in the incidence of AKI and acute kidney recovery (AKR) among patients undergoing TAVI and their impact on clinical outcomes according to EVCD. Methods and results 706 symptomatic severe AS patients were selected and retrospectively analysed. Based on echocardiography findings, patients were classified based on the degree of EVCD. AKI was defined as a relative increase at 24–72H in sCr concentration of at least 0.3 mg/dl, and was classified according to AKIN stages. AKR was defined either as an increase of GFR of 25% or a decrease in sCr of at least 0.3 mg/dl, both measured at 24–72H after the procedure. After dichotomized analysis, patients in EVCD stage 3–4 reported a significantly higher rate of AKI (27.4% vs. 11.3%; P Conclusions AKI demonstrated to negatively impact on 24-month all-cause mortality only when occurring in advanced stages of EVCD, but not in early stages. Conversely, early EVCD was associated with a higher incidence of AKR, which not significantly improved clinical outcomes but was associated with an improvement of renal function at 12-months. The application of this staging system may provide an additional tool for the decision-making process in patients with severe AS. 111 Figure

Aims Autosomal dominant polycystic kidney disease (ADPKD) is a monogenic disorder driven by mutation of one of two genes: PKD1, which codifies polycystin-1, and PKD2, which codifies polycystin-2. The mutated proteins determine the formation of multiple renal cysts with a consequent decline in kidney function eventually leading to end-stage renal disease (ESRD). In the last decades the cardiovascular complications of ADPKD are emerging as the leading cause of death, but coronary artery disease (CAD) remains to be an uncommon complication. Methods and results A 60-year-old male patient affected by ADPKD, in dialysis treatment for ESRD, was admitted in 2020 to our hospital for invasive coronary angiography (ICA), checking eligibility for kidney transplantation. He had a previous history of hypertension and chronic ischaemic cardiomyopathy. ICA performed in 2017 for unstable angina assessed ectasiant coronary arteries with diffuse atherosclerotic disease (Figure 1), determining significant stenosis of the proximal left anterior descending artery and proximal circumflex artery, treated with percutaneous coronary intervention (PCI). In 2020 was so repeated ICA, that evidenced a good result of the previous PCI, but pointed out a severe progression of ectasiant disease, which led to formation of giant aneurysm of the proximal tract of the right coronary artery, assessed at 3.8 cm × 2.5 cm (Figure 2), fistulizing to the right atrium and determining significant flow limitation in the following part of the right coronary artery. The absence of any symptoms and the lack of evidence of ongoing heart dysfunction, led our team to indicate conservative management and angiography follow-up. Conclusions Cardiovascular disease is a major cause of morbidity and death in ADPKD, underlying a tendency towards accelerated atherosclerosis, but wide data about coronary involvement are still lacking. ADPKD patients seem to have an increased risk of developing coronary aneurisms, but either due to the expression of mutated proteins in arterial smooth cells, to the accelerated atherosclerotic disease or to the combination of both, is still controversial. Consequently, it is difficult to differentiate the underlying pathophysiology of aneurysm formation in an individual patient and to speculate whether ADPKD patients have an increased risk of developing coronary aneurysms independent of their accelerated atherosclerotic process.

Aims Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) disagree in ∼20% of intermediate coronary lesions. The physiological pattern of disease has a significant influence on FFR-iFR discordance. However, if the pattern of disease (diffuse vs. focal) impacts on QFR accuracy and on its agreement with FFR and iFR remains unknown. Methods and results 194 unselected patients with 224 intermediate coronary lesions were investigated with iFR, FFR and QFR. The physiological pattern of disease was independently assessed with iFR Scout pullback in all the cases by two expert interventional cardiologists who were blinded to the clinical presentation, patient characteristics, coronary angiography and QFR results. A predominantly physiologically focal pattern was observed in 81 (36.2%) lesions, whereas a predominantly physiologically diffuse was observed in 143 (63.8%) cases. QFR demonstrated a significant correlation (r = 0.581, P Conclusions QFR has a good diagnostic accuracy in assessing myocardial ischemia independently of the pattern of coronary disease. However, the physiological pattern of disease has an influence on the QFR/IFR disagreement, which occurs in ∼20% of the cases. The QFR virtual pullback correctly defined the physiological pattern of disease in the majority of the cases using the iFR pullback as reference.

Aims Coronary microvascular dysfunction (CMD) has been proposed as a key driver in the etiopathogenesis of Takotsubo syndrome (TTS), likely related to an ‘adrenergic storm’ upon a susceptible microvascular circulation. The aim of our manuscript was to assess and quantify coronary microvascular disfunction in patients with TTS using the recently developed angiography-derived index of microcirculation (IMRangio) and evaluate its correlation with clinical and instrumental presentation. Methods and results 41 consecutive TTS patients were retrospectively analysed. Three different formulas for compute non-hyperemic IMRangio (NH-IMRangio) derived by 3D-Quantitative Coronary Angiography (3D-QCA) and Quantitative Flow Reserve (QFR) analysis were used according to each fluidodynamic mathematical expression as reported by respective authors. CMD was defined as an IMRangio ≥25. Moreover, correlation between NH-IMRangio and clinical presentation and a comparation between the three formulas were provided. Median age was 76 years, 85.7% were women and mean LVEF at first echocardiogram was 41.2%. All patients presented CMD with NH-IMRangio ≥25 in at least one territory. Mean NH-IMRangio was higher in Left Anterior Descending artery (LAD) than Circumflex artery (CX) and Right Coronary artery (RCA) with either Oxford-NH-IMRangio (52.7 ± 18.6 vs. 35.3 ± 13.6 vs. 41.4 ± 15.1, P-value < 0.001), Madrid-NH-IMRangio (47.2 ± 17.3 vs. 31.8 ± 12.2 vs. 37.3 ± 13.7, P-value Conclusions CMD, assessed with NH-IMRangio, is a common finding in TTS and it is associated with LVEF dysfunction and LVEF recovery. The validated formulas for NH-IMRangio computation have a superimposable diagnostic performance and accuracy.

An 80-year-old woman was electively hospitalized at our institution to undergo transcatheter aortic valve replacement (TAVR) for severe aortic valve stenosis symptomatic for exertional dyspnoea (NYHA III). At the admission she presented a normal electrocardiogram (EKG), a creatinine clearance (CrCl) of 36 ml/min, a normal size and hypertrophic left ventricle with a preserved ejection fraction (EF 70%). A pre-procedure coronary angiography was performed and showed absence of significant epicardic stenoses. A balloon-expandable valve (Edwards Sapien 26 mm) was successfully implanted via the trans-femoral access without intra-procedural complication and the patient was transferred to cardiology ward for monitoring; in the post-procedure, the patient complained of nausea and a feeling of vomiting, without other cardiologic symptoms; she had low blood pressure (BP 95/70 mmHg) with normal heart rate and oxygen saturation (Killip 1). An EKG was performed and showed a ST-elevation in antero-lateral leads, so a bed-side echocardiogram was performed showing a good function of TAVR but an ipo-akinesia of the left ventricle’s lateral wall. The patient was transferred to the Cath lab and at the emergent coronary angiography no clear epicardic stenoses were seen, with a diffuse narrowing of an early obtuse marginal (OM) branch and of the distal branches of circumflex artery, suggestive for a spasm, that was refractory to repeated nitroglycerine infusions. A clear mismatch between coronary angiogram findings and EKG was detected. Considering the hemodynamic compromise and symptoms persistence a percutaneous transluminal coronary angioplasty of OM was performed with a partial ST resolution. The patient was transferred to the Coronary Unit Care where an echocardiogram was repeated confirming the good function of TAVR but outlining the presence of a voluminous intramural haematoma (>30 mm of maximum diameter) with anterior, lateral and posterior wall akinesia and depressed left ventricle ejection fraction (EF 35%). A conservative management of the haematoma was chosen. The hospital stay was complicated by an acute pulmonary oedema, requiring non-invasive ventilation, a cardiogenic shock, requiring inotropic (dobutamine) support, and an acute renal failure (creatinine peak 2.9 mg/dl with CrCl of 15 ml/min) with anuria, requiring continuous renal replacement therapy for two days; she developed a left branch block with no complete atrioventricular block. The pre-discharged echocardiogram showed a partially organized moderate pericardial effusion (1.3 cm) and moderate mitral regurgitation. After six months, she was asymptomatic, with a significant improvement of functional status (NYHA II) and a stable renal function (CrCl > 30 ml/min); no more echocardiographic signs of pericardial effusion were shown but the persistence of akinesia of the postero-lateral- and anterior-wall with depressed left ventricle ejection fraction (EF 37%) and moderate-severe mitral regurgitation. The persistence of good result of TAVR (aortic mean gradient 9 mmHg, absence of peri-valvular leak) was confirmed. Intramural dissecting haematoma (IDH) is a rare complication of myocardial infarction, chest trauma and percutaneous interventions; it consists of a cavity filled with blood, with the integrity of both the outer wall (myocardium and pericardium) and the inner wall (myocardium and endocardium) and it can develop in the left ventricle free wall, the right ventricle and the interventricular septum. IDH’s formation may result from intra-myocardial vessels’ rupture in the interstitial space. Never understimate nausea as symptom: think about heart is challenging but mandatory!

A 75-years-old Caucasian man presented to the Emergency Department due to worsening dyspnoea and leg oedema in the previous days. His past medical history was significant for a minor surgical operation performed a few days earlier. A previous echocardiography described a hypertrophic left ventricular septum (IVSd 14 mm) in the absence of significant hypertension, with an intraventricular pressure gradient of 10 mmHg at rest and a prolapse of the anterior mitral leaflet. At the time of the admission, tachycardia and a 2/6 cardiac murmur were observed and blood tests showed elevated high-sensitivity Troponin T and N-terminal-pro-B-type natriuretic peptide. The EKG showed synus rhythm and sign of ventricular hypertrophy. Therefore ,the patient was transferred to the Cardiology department and therapy for a subacute coronary syndrome was initiated. A transthoracic echocardiogram revealed a hypertrophic left ventricle (IVSd 15 mm), with apical ballooning shape resulting in a moderately reduced ejection fraction. Moderate mitral regurgitation with systolic anterior movement of the anterior mitral leaflet (SAM), was observed, and an estimated left intraventricular gradient of 108 mmHg at rest was recorded. The patient underwent a coronary angiography: no critical obstructive coronary disease was observed. During ventriculography a typical apical ballooning was revealed and a Tako-Tsubo Syndrome was confirmed, besides this an intraventricular gradient of 34 mmHg was measured. A beta-blocker therapy was promptly initiated (metoprolol), since the patient was haemodynamically stable and QTc was only mildly prolonged. A cardiac magnetic resonance (CMR) performed at day 20, excluded both ischaemic pattern and signs of previous myocarditis. Furthermore, CMR showed an only mildly hypertrophic left ventricle (IVSd 12 mm) and no fibrosis, further supporting the idea that in our patient LVOTO was part of TTS physiopathology and not the sign of an underlying hypertrophic cardiomyopathy. One month later echocardiography showed a completely restored left ventricular systolic function; LVOTO was no more detectable and a complete normalization of left ventricular thickness was observed, in accordance with many papers describing a reversible hypertrophy induced by TTS. Early LVOTO, the one experienced by our patient, is a quite common complication of TTS. It is more often observed among the elderlies, in patient with redundant mitral valve leaflets and in those with septal hypertrophy. Besides this, late onset LVOTO is also described: it is only partially reversible and requiring a previous underlying cardiopathy. In both cases, LVOTO is an established bad prognostic factor. The existing evidence discourages the administration of inotropic agents and nitrates, supporting instead the use of beta-blockers aiming at reducing intraventricular gradient. In patients with haemodynamic instability and significant LVOTO, short acting beta blockers should be preferred, although concomitant hypotension may impose the use of mechanical support therapy. On the contrary, clinically stable patients often benefit from oral administration of beta blockers. In conclusion, LVOTO is a common complication of TTS that must be discerned from a probable underlying hypertrophic cardiomyopathy, that can be excluded only after observing a complete reversibility.

The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.

Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.

Improved and durable control of hypertension is a global priority for healthcare providers and policymakers. Despite all the efforts, hypertension is still misdiagnosed in half of hypertensive patients and poor drug adherence, reaching half of drug-treated patients, represents the major cause of uncontrolled hypertension. Initial studies on renal denervation (RDN) for the treatment of uncontrolled resistant hypertension produced conflicting results. A new generation of randomized clinical trials has shown promising results with new-generation devices in various hypertensive populations. From uncontrolled-resistant hypertension, the target population for RDN has moved to difficult-to-treat or resistant hypertensive patients. The selection process should take into account not only blood pressure values and the global cardiovascular risk profile, but also drug adherence and tolerability and patient preferences. The following is a state-of-the-art review of current studies and an analysis of the characteristics of hypertensive patients that could benefit from RDN.

In this study we sought to determine the differences in incidence of acute kidney injury (AKI) and acute kidney recovery (AKR) among patients undergoing transcatheter aortic valve implantation (TAVI), according to the degree of extravalvular cardiac damage (EVCD).From the Verona Valvular Heart Disease Registry, 674 symptomatic severe aortic stenosis (AS) patients were selected and retrospectively analysed. Using echocardiographic data, patients were classified based on the degree of EVCD.After dichotomized analysis, patients in EVCD stage 3 or 4 reported a significantly higher rate of AKI (29.5% vs 11.2%; P 0.001). Using a multivariate analysis model, higher EVCD stage, lower glomerular filtrate rate (GFR) at admission, and amount of contrast used were found to be independent predictors of AKI, whereas stage of cardiac damage and GFR were found to be independent predictors of AKR. For the overall population after multivariate analysis AKI was associated with a higher incidence of 12-month all-cause mortality (hazard ratio, 2.142; 95% confidence interval, 1.082-4.239; P = 0.029) with a significant impact in the advanced cardiac damage stages, but not in the early stages (P for interaction = 0.006). AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months.Increase in EVCD stage was associated with a higher rate of AKI after TAVI. AKI had a negative impact on long-term clinical outcomes but only in patients with advanced cardiac damage. AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months.

Cardiac allograft vasculopathy (CAV) is a unique form of accelerated atherosclerosis that represents the main late cause of morbidity and mortality, affecting almost half patients at ten years after heart transplantation (HTx). Unless the pathogenesis of CAV is still not completely understood, it seems to be the result of a complex interplay between immunological and non-immunological factors that induce endothelial injury. Histologically epicardial and intramural vessels present a concentric circumferential intimal thickening caused by smooth muscle cell proliferation, inflammatory cells, and lipid deposition. Coronary angiography is still considered the gold-standard diagnostic tool for CAV detection but has reduced sensibility due to its inability to visualize beyond the arterial lumen. Intravascular ultrasound (IVUS) allows detecting early intimal thickening with high sensitivity. Plaque composition and vulnerability, detectable with virtual histology (VH/IVUS), and optical coherence tomography (OCT) seem to relate to adverse clinical events. Treatment approaches continue to evolve, but prevention and early detection remain the focus. Mammalian target of rapamycin inhibitors can significantly delay the development and the progression of CAV, but their optimal use remains to be established. New encouraging results come from monoclonal autoantibodies. At present percutaneous revascularization procedures seem to have only a palliative meaning, with no clear evidence of survival advantage over medical therapy and should be considered in case of a focal disease. Drug-eluting stents have proven to reduce in-stent restenosis, with a potential role of imaging-guided intervention in this setting. Heart re-transplantation is the only resolutive therapy and is considered in the case of CAV associated with graft dysfunction.