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The duration of the dual antiplatelet therapy (DAPT) is a widely debated topic within the scientific community. The latest guidelines on acute coronary syndromes have supported the possibility of different therapeutic approaches tailored to patient characteristics. However, the clinical cardiologist‘s decisions are not always based on certain principles. The following case report is a practical example. Discussion: A 31–years–old man came to our attention after a resuscitated cardiac arrest due to ventricular fibrillation during a motorcycle race. His history was characterized by a previous acute myocardial infarction at the age of thirteen due to a traumatic dissection of the proximal left anterior descending (LAD) coronary artery and ascending aorta treated conservatively, with residual transmural necrosis of the mid and subendocardial anterior wall on cardiac MRI. At the admission, ECG showed ST–segment elevation in the anterior leads. Coronary angiography revealed occlusion of the proximal LAD coronary artery, treated with drug–eluting stent (ONYX 5.0 mm), with evidence of dissection and aneurysmal wall of that segment. The patient started a DAPT with aspirin and prasugrel. At discharge, echocardiogram evidenced a moderate left ventricular dysfunction (ejection fraction 34%) with signs of anterior and apical necrosis. Later, the patient was admitted for a subcutaneous defibrillator implantation, due to persistent moderate ventricular dysfunction. One year after revascularization, a lifelong DAPT strategy with downgrading to clopidogrel was considered the best choice for the following considerations: the young age of the patient, the low bleeding risk (PRECISE DAPT score 8), a not elevated DAPT score (value 2), the revascularization in the aneurysmal segment without an appropriate stent apposition (due to absence of a right sizing) and the previous dissection with sign of partial thrombosis at coronary CT. Conclusions: The anatomical complexity of angioplasty procedures and the delicate balance between ischemic and thrombotic risks have led to continuously evolving therapeutic strategies. The clinical scores currently available cannot often account for complex coronary anatomy. Thus, it‘s essential to consider a personalized approach, individualized on clinical and imaging characteristics, that encompasses ischemic and bleeding risk and procedural data for the appropriate treatment for each patient.

A 66 year old woman with dilated cardiomyopathy, carrier of CRT–D device in secondary prevention since 2013 and a mitralic mechanical prosthesis, suffered of CIED infection, confirmed by PET imaging exam. She was scheduled in our Hospital Unit for transvenous lead extraction. The procedure was performed by the subclavian approach, and the transvenous lead extraction was staged using mechanical telescopic sheats. After the extraction of the atrial and ventricular leads, the advance of the sheats was hampered by tenacious adherences along the site of vascular subclavian access of the coronary sinus lead. Firstly the portion of the lead running inside the coronary sinus was retracted with a pigtail by femoral vein approach. The inability to pass over the tenacious adherences at the point of the subclavian vein access were overcome expanding the surgical field with the help of the Vascular Surgeon, finding out that the adherence was determined by the presence of an osteophyte embracing the lead to the clavicle. The osteophyte was then surgically removed and the lead was finally extracted by jugular vein access. In this case the CIED leads were implanted using a intrathoracic subclavian venous access, where the vein lies behind the medial region of the clavicle. This approach could rarely lead to a periosteal penetration during needle advance that can generate osteophytes between the lead and the bone. In those circumstances the transvenous lead extraction could become extremely complicated, whatever technique is used.

Dietary long-chain fatty acids (FA) may influence pathological processes involving endothelial activation, including inflammation and atherosclerosis. We have previously shown that the n-3 FA docosahexaenoate (DHA) inhibits endothelial activation in the range of nutritionally achievable plasma concentrations. The present study assessed structural determinants for this effect. Saturated, monounsaturated, and n-6 and n-3 polyunsaturated FA were incubated with cultured endothelial cells for 24-72 h alone, and then in the presence of interleukin-1, tumor necrosis factor, or bacterial lipopolysaccharide for an additional 24 h before assessing the expression of the vascular cell adhesion molecule-1 (VCAM-1) or other products of endothelial activation. No FA tested per se elicited endothelial activation. While saturated FA did not inhibit cytokine-induced expression of adhesion molecules, a progressively increasing inhibitory activity was observed, for the same chain length, with an increase in double bonds. Comparison of FA with the same length and number of unsaturation and only differing for the double bond position or for the cis/trans configuration indicated no difference in inhibitory potency, indicating no effect of the double bond position or configuration. As judged by Northern analysis, these latter FA also inhibited VCAM-1 messenger RNA steady state levels to the same extent, indicating a pre-translational site of action attributable to the single double bond. Thus the double bond is the minimum necessary and sufficient requirement for FA inhibition of endothelial activation. These properties are likely relevant to the anti-atherogenic and anti-inflammatory properties ascribed to n-3 FA, which are able to accommodate the highest number of double bonds in a fatty acid of given chain length.

We analyzed the cleavage properties and the transcription regulation of the newt (Triturus vulgaris meridionalis) self-cleaving RNA. In vitro self-cleavage of model oligoribonucleotides occurs within a double hammerhead structure. In addition, an entire ribozyme molecule, as well as its catalytic domain, "trans-cleaves" in vitro appropriate oligoribonucleotide substrates. Signals encoded within the ribozyme DNA sequences regulate the ribozyme transcription, which is RNA polymerase II dependent. Finally, the deduced secondary structure of the self-cleaving RNA appears to be conserved in evolutionarily distant newt species. These features suggest that the newt ribozyme could play some role in the cell, possibly related to its cleavage properties.