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Transvenous lead extraction (TLE) of the Starfix coronary sinus (CS) active-fixation lead may be challenging, due to undeployment of fixation lobes and venous occlusion. We report our experience in Starfix TLE, in comparison with previous data. A 78-year-old male, implanted in 2009 with Starfix lead, was referred to our institution for TLE, due to infective endocarditis with lead-associated vegetations. The tip of Starfix lead was located in distant, anterior position, in the great cardiac vein, close to patent left internal mammary artery-to-left anterior descending artery anastomosis, and first-choice surgical removal had a prohibitive operative risk. Conventional dilatation beyond CS ostium, as well as the use of a standard delivery catheter, was ineffective. An off-label modification of the delivery, by cutting the distal soft tip, was successful. However, the tip of the lead fragmented and was trapped in the innominate vein. Then a gooseneck snare grasped the fragment, allowing complete retrieval. TLE of Starfix leads may be particularly challenging, especially when its tip is located in a distant anterior location. In these cases, important help may be obtained by dilatation within the CS, by means of conventional or modified delivery catheters. Only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads. Learning objective: TLE of Starfix leads may be challenging, particularly when the tip is located in a distant anterior position. Dilatation with conventional tools may be precluded. In these cases modifications of the delivery catheters may be useful. Surgery should be avoided as first-choice procedure; only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads.>

ObjectivesTo retrospectively evaluate the impact on daily activities of transcatheter closure of patent foramen ovale (PFO) versus medical therapy in patients with migraine and to analyze the role of the residual shunt after PFO closure.BackgroundWhile non-controlled observational studies reported an improvement of migraine after PFO closure, a randomized trial has shown no benefit of such an intervention. The role of residual shunt after PFO closure is also poorly known.MethodsOut of 217 patients with migraine and echocardiographic evidence of PFO, 89 were managed with percutaneous PFO closure (Group A) while 128 were medically treated (Group B). All MIDAS questionnaires were obtained at the first evaluation and repeated at least 6 months after the index evaluation or after the PFO closure. All the patients were also asked to give a subjective estimate of their migraine status. A postprocedural transcranial Doppler study was available in 70 patients in Group A.ResultsThe mean basal MIDAS score did not differ between the two groups (p=0.859). After a mean follow-up (FU) of 1399±982 days the MIDAS score decreased significantly in both groups (Group A baseline vs FU, p

OBJECTIVES We aimed to evaluate: 1) the behavior of electrical activity simultaneously in different atrial regions during atrial fibrillation (AF); 2) the difference of atrial activation between paroxysmal and chronic AF; 3) the atrial refractoriness dispersion; and 4) the correlation between the effective refractory periods (ERPs) and the FF intervals. BACKGROUND Little data exist on the electrophysiologic characteristics of the different atrial regions in patients with AF. A more detailed knowledge of the electrical activity during AF may provide further insights to improve treatment of AF. METHODS Right and left atria were extensively mapped in 30 patients with idiopathic AF (18 paroxysmal and 12 chronic). In different atrial locations, we analyzed 1) the FF interval duration; and 2) the grade of organization and, in case of organized electrical activity, the direction of atrial activation. Furthermore, in patients with paroxysmal AF, we determined the atrial ERP, evaluated the ERP dispersion and assessed the presence of a correlation between the ERPs and the FF intervals. RESULTS In patients with chronic AF, we observed a shortening of the FF intervals and a greater prevalence of disorganized activity in all the atrial sites examined. In patients with paroxysmal AF, a significant dispersion of refractoriness was observed. The right lateral wall showed longer FF intervals and more organized atrial activity and, unexpectedly, the shortest mean ERPs. In contrast, the septal area showed shorter FF intervals, greater disorganization and the longest mean ERPs. CONCLUSIONS Electrical activity during AF showed a significant spatial inhomogeneity, which was more evident in patients with paroxysmal AF. The mean FF intervals did not correlate with the mean ERPs.

The case of a 60 year-old woman who underwent successful tricuspid valve-in-valve implantation for an early degenerated bioprosthesis was previously described [1]. After 14 months of well-being the patient experienced once again exertional dyspnoea. Clinical examination was unremarkable: there were neither heart murmurs nor peripheral oedema. A cardiopulmonary test showed mild depression of functional capacity (VO2 peak of 19.7 ml/kg/min, 85% of the theoretical expected value), and moderate desaturation (SO2 88% after four minutes). At the transthoracic echocardiogram the Sapien XT prosthesis in tricuspid position was found to have a mean gradient of 4 mmHg, and minimal, physiological, central regurgitation (Fig. 1A). A bubble-contrast showed a rightto-left shunt at rest, through a patent foramen ovale (PFO)

Retrosternal pain can be caused both by cardiac and esophageal disease. This work presents the results of cardiac and esophageal investigations in 55 patients, who had atypical chest pain. Isolated esophageal disease was found in 45% of the subjects while 14.5% had significant coronary arterial disease. Both diseases were found in 10.9% of the patients and neither disease in 29%. We conclude that esophageal disease is very frequent in patients with atypical chest pain but it does not always completely account for the symptoms. Such patients should, in our opinion, be submitted to an electrocardiographic stress test. If the result is positive or non-diagnostic, coronary cineangiography should be performed, irrespective of the results of esophageal investigations. If the electrocardiographic stress test is negative, coronary investigations can be deferred. Esophageal investigations can account for the symptoms in about half of such cases.

Patterns of motion of the aortic valve were analyzed with echocardiography in 9 patients with discrete subaortic stenosis and 31 patients with idiopathic hypertrophic subaortic stenosis, 22 with and 9 without a resting intraventricular pressure gradient. The intention was to determine whether the early systolic closure of the aortic valve was a sensitive indicator of a resting pressure gradient across the left ventricular outflow tract. All 9 patients with discrete subaortic stenosis and the 22 patients with idiopathic hypertrophic subaortic stenosis with a resting pressure gradient showed early systolic closure of the aortic valve; however, the 9 patients without a resting gradient had normal motion of the aortic valve. Measured values for O-ESC (the interval from the opening point of the aortic valve to the point of early systolic closure of the aortic valve) in 9 patients with discrete subaortic stenosis and in 22 with idiopathic hypertrophic subaortic stenosis averaged 0.05 ± 0.01 (standard deviation) second and 0.14 ± 0.04 second for each group, respectively (P < 0.01). Twelve patients with idiopathic hypertrophic subaortic stenosis underwent operation to alleviate left ventricular outflow tract obstruction. In eight of these patients the resting pressure gradient was completely abolished and early systolic closure of the aortic valve was no longer present. The results indicate that in idiopathic hypertrophic subaortic stenosis, early systolic closure of the aortic valve is recorded only when there is a significant intraventricular pressure gradient at rest. The time of occurrence of early systolic closure differentiated patients with discrete subaortic stenosis from those with idiopathic hypertrophic subaortic stenosis in all observations.

Summary Two cases of horseshoe lung are described; one was suspected and the other was diagnosed preoperatively. Both underwent successful surgical treatment. The embryology of this anomaly is briefly reviewed with reference to the closely related scimitar syndrome (anomalous venous return of right lung to inferior atriocaval junction). Diagnostic studies are discussed with stress on the need for a thorough functional evaluation of both the heart and lungs before the surgical indication is made.

We report four cases of so-called absent pulmonary valve syndrome associated with absence or anomalous origin of the left pulmonary artery. The fate of the patients with this condition appears to be affected mainly by the occurrence of pulmonary complications (three of our patients died of pulmonary causes, two of them after surgery). The proper timing of corrective surgery is still uncertain. Preoperative investigations should strive to obtain a clear-cut identification of the pulmonary arteries, particularly the left one or, in its absence, of the anomalous vascular supply to the lung. Right ventriculography, as employed by us, is insufficient. Pulmonary angiography, aortography and pulmonary vein "wedge" angiography may be needed.

Recognition of thrombosis of a Bjork-Shiley aortic valve prosthesis 4 years after insertion in a patient was based upon sudden clinical deterioration, loss of prosthetic sounds, and development of new stenotic and regurgitant murmurs. Thrombotic fixation was confirmed by diagnostic alterations on the echocardiogram. All manifestations reverted to normal after successful surgical debridement of the prosthesis. Echocardiography is a valuable noninvasive adjunct in the differential diagnosis of prosthetic valve malfunction.