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True coronary bifurcation lesions (CBL) represent a challenging scenario for percutaneous coronary interventions (PCI), and are associated with a higher risk of target lesion failure (TLF), particularly when two stents are implanted. A hybrid strategy combining a drug-eluting stent (DES) in the main branch, and a drug-coated balloon in the side branch may improve outcomes by reducing the total stent length while maintaining an effective anti-prolipherative action. In this sub-study of the HYPER trial, 50 patients with true CBL were treated with a hybrid strategy: procedural success was 96%, one case of peri-procedural myocardial infarction and one case of TLF (in a DES-treated segment) at 1 year were reported. This study suggests that such a hybrid strategy may be a safe and effective option for true CBL PCI, and warrants additional investigations to compare outcomes with standard of care strategies.

Antiplatelet therapy is recommended among patients with established atherosclerosis. We compared monotherapy with a P2Y12inhibitor versus aspirin for secondary prevention.

ObjectiveRisk stratification is crucial to optimise treatment strategies in patients with COVID-19. We aimed to evaluate the impact on mortality of an early assessment of cardiac biomarkers in patients with COVID-19.MethodsHumanitas Clinical and Research Hospital (Rozzano-Milan, Lombardy, Italy) is a tertiary centre that has been converted to the management of COVID-19. Patients with confirmed COVID-19 were entered in a dedicated database for cohort observational analyses. Outcomes were stratified according to elevated levels (ie, above the upper level of normal) of high-sensitivity cardiac troponin I (hs-TnI), B-type natriuretic peptide (BNP) or both measured within 24 hours after hospital admission. The primary outcome was all-cause mortality.ResultsA total of 397 consecutive patients with COVID-19 were included up to 1 April 2020. At the time of hospital admission, 208 patients (52.4%) had normal values for cardiac biomarkers, 90 (22.7%) had elevated both hs-TnI and BNP, 59 (14.9%) had elevated only BNP and 40 (10.1%) had elevated only hs-TnI. The rate of mortality was higher in patients with elevated hs-TnI (22.5%, OR 4.35, 95% CI 1.72 to 11.04), BNP (33.9%, OR 7.37, 95% CI 3.53 to 16.75) or both (55.6%, OR 18.75, 95% CI 9.32 to 37.71) as compared with those without elevated cardiac biomarkers (6.25%). A multivariate analysis identified concomitant elevation of both hs-TnI and BNP as a strong independent predictor of all-cause mortality (OR 3.24, 95% CI 1.06 to 9.93).ConclusionsAn early detection of elevated hs-TnI and BNP predicts mortality in patients with COVID-19. Cardiac biomarkers should be systematically assessed in patients with COVID-19 at the time of hospital admission in order to optimise risk stratification.

The incidental finding of a severe occlusive disease of the aorta (coral reef aorta) during the assessment for transcatheter aortic valve replacement in a 75-year-old woman with severe aortic stenosis complicated the process for the Heart Team and led to the consideration of a different access route to find the safest and most appropriate strategy of intervention. A successful transapical transcatheter aortic valve replacement was eventually performed. Coral reef aorta, although rare, is associated with great morbidity and mortality, and it needs to be recognized when planning for intravascular procedures, both for a safer selection of treatment approach and for the prevention of intraprocedural and postprocedural morbidities.

ABSTRACTBackground:Although systematically underestimated in the past, the importance of tricuspid regurgitation (TR) is being progressively recognized. We aimed to evaluate the clinical significance of severe TR from a cohort of patients at a tertiary center.Methods:A retrospective analysis was performed on 6309 consecutive patients undergoing echocardiography between October 2014 and September 2015 in a single center in Milan, Italy. The study endpoints included cardiovascular mortality, major adverse cardiac and cerebrovascular events (MACCE) and net adverse clinical events (NACE).Results:A total of 2336 (37%) patients were found to have TR of any severity, 272 (4.3%) had severe TR, 415 (6.6%) moderate TR, and 1649 (26.1%) mild TR. In the severe TR group, 40 (14.7%) patients suffered cardiovascular death, while 53 (19.5%) and 141 (51.8%) developed MACCE and NACE, respectively. In addition, there were 88 (32.4%) patients with severe TR who were re-hospitalized for cardiovascular-related events. Patients with severe TR were more likely to be in New York Heart Association functional class III–IV (p= 0.022) and on higher doses of loop diuretic (p= 0.022) than those with only moderate TR. Multivariable analysis revealed that blood urea nitrogen (BUN, p= 0.031) and abnormal liver function blood tests (p= 0.010) were independent predictors of mid-term cardiovascular mortality, while BUN and tricuspid annular plane systolic excursion were found to be independent predictors of mid-term NACE.Conclusions:The prevalence of any TR was high in patients undergoing echocardiography at a tertiary referral center, and severe TR was not uncommon and associated with high mid-term morbidity and mortality.

Bioresorbable vascular scaffolds (BVSs) have recently been introduced into clinical practice; they have many potential advantages, 1 of which includes restoring physiological vasomotion. It has been shown that the degree of vasomotion is correlated with bioresorption. We present a case of intrascaffold spasm masquerading as restenosis 3 years after implantation, despite the ongoing process of bioresorption: intra-BVS vasospasm should therefore be considered and confirmed by intracoronary nitrate administration.

The risk of severe perioperative bradyarrhythmias in patients with chronic left bundle branch, or bifascicular block, and an additional first-degree atrioventricular block undergoing carotid endarterectomy (CEA) has never been specifically addressed. In this study, we aimed to investigate whether these conduction abnormalities entail an increased risk of hemodynamic compromise during CEA and the role of temporary transvenous pacemaker (TTVPM) implantation as a prophylactic measure in this subgroup of patients.

Individuals with advanced chronic kidney disease (CKD) and coronary artery disease are often denied percutaneous coronary intervention (PCI) because of an aversion to the risk of contrast-induced nephropathy. We present the case of a 76-year-old man with stage 4 CKD requiring coronary revascularization. Zero-contrast PCI was successfully performed using dextran-based optical coherence tomography (OCT) guidance. Our report suggests the feasibility of dextran-based, OCT-guided, zero-contrast PCI in patients with advanced CKD. Further studies should evaluate the safety and efficacy of this novel approach.

Although the rate of procedural complications during transcatheter aortic valve implantation has decreased because of technological advancement and increased operator experience, device embolization remains a rare but potentially fatal complication, even with new generation devices. We report, to our knowledge, the first case of Portico valve (St Jude Medical, Minneapolis, MN) migration despite apparent optimal initial implantation depth, which was retrieved using a novel strategy after failure of a traditional retrieval technique. We also describe a mechanism of left coronary artery systolic perfusion with diastolic backflow, which led to myocardial ischemia.

Un uomo di 39 anni giungeva in Pronto Soccorso per dolore toracico oppressivo. In anamnesi riferiva pregressa tubercolosi, familiarità per cardiopatia ischemica, pregresso tabagismo ed iperomocisteinemia.Decorso clinico acutoI parametri vitali erano nella norma; all’ECG presentava sopraslivellamento del tratto ST nelle derivazioni laterali e sottoslivellamento nelle inferiori. Veniva posta diagnosi di STEMI laterale ed eseguita coronarografia d’urgenza risultata negativa. L’ecocardiogramma evidenziava lieve dilatazione del ventricolo destro (Vdx) con funzione conservata ed ipocinesia sottotricuspidalica. Agli esami ematochimici gli indici di flogosi risultavano lievemente aumentati; il picco di Troponina I è risultato 177600 ng/L. Veniva sottoposto a risonanza magnetica cardiaca (RMC) che concludeva per cardiomiopatia infiammatoria in fase acuta con riscontro di funzione sistolica del ventricolo sinistro (Vsn) ai limiti inferiori con focale ipocinesia della parete laterale media, funzione destra lievemente ridotta con ipocinesia in sede sottotricuspidalica e bulging sisto-diastolici in corrispondenza del tratto di efflusso e dell’angolo costofrenico del Vdx, oedema e late gadolinium enhancement (LGE) a distribuzione subepicardica (pattern non-ischemico) del Vsn coinvolgente anche il Vdx. Si concludeva per miocardite acuta. Indagando più a fondo si scopriva che: una zia paterna era morta improvvisamente a 50 anni; per cardiopalmo il paziente si era sottoposto ad ECG Holter delle 24 h con riscontro di frequenti BEV tipo BBdx/asse superiore. Veniva eseguita la biopsia endomiocardica: dei cinque frammenti prelevati due erano suggestivi di miocardite, tre mostravano fibroadiposi sostitutiva. Si concludeva per miocardite attiva negativa per virus cardiotropi. Dato il riscontro bioptico ed il coinvolgimento biventricolare veniva sospettata una hot-phase di cardiomiopatia aritmogena.Follow-upDopo 6 mesi all’ECG erano presenti bassi voltaggi nelle derivazioni periferiche ed onde T piatte in sede infero-laterale (Figure 1A). Alla successiva RMC persistevano le alterazioni di funzione e cinetica biventricolare, erano presenti sfumati spot di oedema, segni di infiltrazione adiposa della parete laterale media del Vsn e della parete libera del Vdx; inoltre venivano descritti estesi segni di LGE a distribuzione subepicardica circonferenziale del Vsn con coinvolgimento esteso del Vdx (Figure 2B). L’analisi genetica ha individuato la presenza di una variante nucleotidica rara c.c. 1652-1G>T nell’introne 11 del Gene DSC2 (desmocollina). Veniva posta diagnosi di Cardiomiopatia Aritmogena Biventricolare secondo i Criteri di Padova.Discussione La Cardiomiopatia Aritmogena è una malattia ereditaria del miocardio che raramente può manifestarsi con episodi simil-miocardite (hot-phase). In questi casi una corretta anamnesi personale e familiare, la caratterizzazione tissutale e la genetica rappresentano mezzi fondamentali per un corretto inquadramento diagnostico.

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Surgical treatment of functional mitral regurgitation (MR) is usually based on the correction of both annular dilation and leaflet disease to minimize the risk of recurrence of MR at follow-up. This combined approach may also represent an interesting strategy during transcatheter mitral valve repair systems. We report a successful case of combined Cardioband (Edwards Lifesciences, Irvine, California) and MitraClip (Abbott, Santa Clara, California) implantation for the treatment of functional MR, with good acute and medium-term clinical and echocardiographic outcomes.