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Background Left atrial appendage (LAA) closure is an alternative to chronic oral anticoagulation for stroke prevention in patients with atrial fibrillation (AF) at high bleeding risk. Patients with a previous percutaneous closure of a patent foramen ovale (PFO) present an increased risk for developing AF during their life, and the presence of an atrial septal device renders future percutaneous left atrial access more challenging. Very few cases of LAA occlusion in patients with a preexisting PFO closure device have been previously reported. Case summary A 74-years old woman was admitted to our hospital for symptomatic severe anaemia during direct oral anticoagulant treatment. Her past medical history reported an ischaemic stroke at the age of 55, at that time a PFO was diagnosed and a STARFlex™ PFO occluder (NMT Medical, Boston, MA, USA) was implanted. During the current hospitalization, the patient underwent a colonoscopy that showed colonic angiodysplasias unsuitable for endoscopic treatment and LAA closure was indicated for stroke prevention. After a multimodality pre-procedural planning that included a transoesophageal echocardiogram, a cardiac computed tomography scan and a three-dimensional cardiac model printing, the procedure was planned and the LAA successfully occluded. Discussion LAA closure can be performed safely and effectively in patients carrying a previously implanted PFO occlusion device. In complex settings, a pre-procedural multimodality imaging is critical for improving the procedural safety and success rate. We describe the first case of percutaneous LAA closure in a patient with a prior PFO occlusion with the implantation of a STARflex™ septal occlusion device.

Background Elderly patients represent a rapidly growing part of the population more susceptible to acute coronary syndromes and their complications. However, literature evidence is lacking in this clinical setting. Aim To describe the clinical features, in-hospital management and outcomes of "elderly" patients with myocardial infarction treated with antiplatelet and/or anticoagulation therapy. Methods This study was a retrospective analysis of all consecutive patients older than 80 years admitted to the Division of Cardiology of St. Andrea Hospital of Vercelli from January 2018 to December 2018 due to ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI). Clinical and laboratory data were collected for each patient, as well as the prevalence of previous or in-hospital atrial fibrillation (AF). In-hospital management, consisting of an invasive or conservative strategy, and the anti-thrombotic therapy used are described. Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint. Results Of the 105 patients enrolled (mean age 83.9 ± 3.6 years, 52.3% males), 68 (64.8%) were admitted due to NSTEMI and 37 (35.2%) due to STEMI. Among the STEMI patients, 34 (91.9%) underwent coronary angiography and all of them were treated with percutaneous coronary intervention (PCI); among the NSTEMI patients, 42 (61.8%) were assigned to an invasive strategy and 16 (38.1%) of them underwent a PCI. No significant difference between the groups was found concerning the prevalence of previous or in-hospital de-novo AF. 10.5% of the whole population received triple antithrombotic therapy and 9.5% single antiplatelet therapy plus oral anticoagulation (OAC), with no significant difference between the subgroups, although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients. A low rate of in-hospital death (5.7%) and 1-year cardiovascular death (3.3%) was registered. Seven (7.8%) patients experienced major adverse cardiovascular events, while the rate of minor and major bleeding at 1-year follow-up was 10% and 2.2%, respectively, with no difference between NSTEMI and STEMI patients. Conclusion In this real-world study, a tailored evaluation of an invasive strategy and antithrombotic therapy resulted in a low rate of adverse events in elderly patients hospitalized with acute myocardial infarction.

The present study explores how age and individual visuo-spatial factors influence the processes underlying spatial mental representations derived by learning from a map. Forty young adults (24–35 years old) and 40 older adults (65–75 years old) were assessed on visuo-spatial abilities and self-assessed spatial preferences. Then they studied a map of a botanical garden and were asked to place a list of landmarks on a sketch. When missed locations were considered in calculating accuracy, older adults were less accurate than young adults, and accuracy was predicted by age and a preference for exploring new environments. When only the landmarks placed in the sketch were considered, however, older adults were as accurate as young adults, and accuracy was predicted only by visuo-spatial working memory. These findings show that spatial representations have features differently predicted by age and visuo-spatial factors, and are discussed in the light of aging and spatial neurocognitive models.

Background : Cardiac resynchronization therapy with ICD (CRT-D) or pacemaker (CRT-P) is useful to reverse the deleterious effects of ventricular dyssynchronia in heart failure (HF) patients. To determinate the responders patients, hemodynamic parameters are difficult to evaluate during follow-up, due to the invasivity of the procedures. We compare hemodynamic response to CRT with cardiac output, not invasively detected (CO2 rebreathing method, Innocor system), with conventional clinical, functional and echocardiographic parameters. Methods : We enrolled 29 patients affected by end-stage dilated cardiomyopathy treated with CRT-P/CRT-D according to the latest guidelines (NYHA class II-IV, left ventricular ejection fraction [LVEF] ≤ 35%, QRS ≥ 120 ms, sinus rhythm, optimal medical therapy). Patients were evaluated before and after CRT (3 months), considering: NYHA class, Quality of Life score (Minnesota Living with Heart Failure questionnaire), QRS width, echocardiographic parameters (diastolic and systolic left ventricular volumes and related LVEF), six minutes walking test (6MWT) and cardiac output (detected with Innocor system). Results : Our data showed a significant improvement in Innocor cardiac output 3 months after CRT implant compared to baseline (4.01±0.72 vs 4.48±0.59 l/min, p=0.001). The percentage improvement in cardiac output correlates with the percentage increase in LVEF (25±6% vs 30±7%; r=0.541). The correlation is not statistically significant with NYHA class (from 2.52±0.73 to 1.78±0.60; r=0.098), QoL (from 22.57±15.37 to 9.91±9.14 score; r=0.231) and exercise tolerance (from 390±50 to 437±54 meters; r=0.144). Conclusions : The Innocor system is a promising non-invasive method to assess the cardiac output at baseline and during follow up in HF patients treated with CRT.

Background: It has been reported that contractility, as assessed using dobutamine infusion, is independently associated with reverse remodeling after CRT. Controversy, however, exists about the capacity of this approach to predict a long-term clinical response. This study's purpose was to assess whether long-term CRT clinical effects can be predicted according to acute inotropic response induced by biventricular stimulation (CRT on), as compared with AAI–VVI right stimulation pacing mode (CRT off), quantified at the time of implantation. Methods: In 98 patients (ejection fraction 29 ± 10%), acute changes in left ventricular (LV) elastance (Ees), arterial elastance (Ea), and Ees/Ea, as assessed from slope changes of the force–frequency relation obtained when the heart rate increased, and also assessed while measuring triplane LV volumes and continuous noninvasive blood pressure, were related to death or rehospitalization during a 3-year follow-up. Other covariances tested were age, gender, disease etiology, QRS duration, amount of mitral regurgitation, LV diastolic volume, ejection fraction, and the degree of asynchrony and longitudinal strain at baseline. Results: There was a marked increment in the Ees slope with CRT (interaction P = 0.004), no Ea change, and modest Ees/Ea increase (interaction P

Coronary artery diseases continue to be the most common causes of mortality and morbidity in the industrialized world, especially in the setting of acute myocardial infarction. Anticoagulation during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) has traditionally been supported by anticoagulant unfractionated heparin (UFH). Recently, alternative anticoagulants such as low molecular weight heparin (LMWH) were included in the management of STEMI. The aim of the present review is to compare efficacy and safety outcomes among patients receiving low molecular weight heparins (LMWH) or unfractionated heparin (UFH) while undergoing PCI for STEMI.

Abnormal glucose metabolism is a major determinant of coronary artery disease (CAD) and mortality in developed countries. Glycosylated hemoglobin (HbA1c) is a more stable, accurate parameter of glucose homeostasis than fasting glycemia, thus providing prognostic information in diabetics. However, its role and relationship with CAD remains unclear in non-diabetics.To evaluate the relationship between HbA1c and CAD in a consecutive cohort of patients without diabetes mellitus.Non-diabetic patients undergoing coronary angiography between April 2007 and October 2012 were included. Additionally carotid intima-media thickness (C-IMT) was evaluated during hospitalization in a consecutive cohort of patients.1,703 consecutive patients were included and divided according to HbA1c tertiles (5.5%, 5.5%-5.79%, ≥5.8%). HbA1c was associated with aging (p0.001); hypercholesterolemia (p=0.01); renal failure (p=0.006); hypertension (p=0.002); previous myocardial infarction (p=0.004); previous percutaneous coronary intervention (p=0.01); indication to angiography (p=0.01); use of angiotensin receptor blockers (p=0.01); beta-blockers (p=0.03); nitrates (p=0.02); statins (p=0.008); calcium antagonists (p=0.01); diuretics (p0.001); acetylsalicylic acid (p0.001); baseline glycemia (p0.001); triglycerides (p=0.02); and uric acid (p=0.04). HbA1c, but not fasting glycemia, was significantly associated with the prevalence of CAD (adjusted OR=1.51, 95% CI=1.15, 1.97, p=0.002), with 5.8% identified by the receiver operating characteristic (ROC) curve as the best cut-off value for CAD prediction. HbA1c was significantly associated with C-IMT and carotid plaques prevalence.Among non-diabetic patients, higher HbA1c even within the normal range is significantly associated with the risk of CAD. Future large studies are needed to evaluate whether more aggressive cardiovascular prevention can reduce the risk of CAD among patients with HbA1c ≥ 5.8%.