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Extracorporeal membrane oxygenation (ECMO) represents a therapeutic option for cardiopulmonary support in patients with high‐risk pulmonary embolism (PE); however, no definite consensus exists on ECMO use in high‐risk PE. Hence, we aim to provide insights into its real‐world use pooling together all available published experiences. We performed a systematic review and pooled analysis of all published studies (up to April 17, 2020) investigating ECMO support in high‐risk PE. All studies including at least four patients were collectively analyzed. Study outcomes were early all‐cause death (primary endpoint) and relevant in‐hospital adverse events. A total of 21 studies were included in the pooled analysis (n = 635 patients). In this population (mean age 47.8 ± 17.3 years, 44.5% females), ECMO was indicated for cardiac arrest in 62.3% and immediate ECMO support was pursued in 61.9% of patients. Adjunctive reperfusion therapies were implemented in 57.0% of patients. Pooled estimate rate of early all‐cause mortality was 41.1% (95% CI 27.7%‐54.5%). The most common in‐hospital adverse event was major bleeding, with an estimated rate of 28.6% (95%CI 21.0%‐36.3%). At meta‐regression analyses, no significant impact of multiple covariates on the primary endpoint was found. In this systematic review of patients who received ECMO for high‐risk PE, pooled all‐cause mortality was 41.1%. Principal indication for ECMO was cardiac arrest, cannulation was chiefly performed at presentation, and major bleeding was the most common complication. [ABSTRACT FROM AUTHOR]

Aims: Aortic stenosis (AS) grading by 2D‐transthoracic echocardiography (2D‐TTE) aortic valve area (AVA) calculation is limited by left ventricular outflow tract (LVOT) area underestimation. The combination of Doppler parameters with 3D LVOT area obtained by multidetector computed tomography (MDCT) can improve AS grading, reconciling discordant 2D‐TTE findings. This study aimed to systematically evaluate the role of 3D‐transesophageal echocardiography (3D‐TEE) in AS grading using MDCT as reference standard. Methods and results: 288 patients (81 ± 6.3 years, 52.4% female) with symptomatic AS underwent 2D‐TTE, 3D‐TEE, and MDCT for transcatheter aortic valve implantation. Doppler parameters were combined with 3D LVOT areas measured by manual and semi‐automated software 3D‐TEE and by MDCT to calculate AVA, reassessing AS severity. Both 3D‐TEE modalities demonstrated good correlation with MDCT, with excellent intra‐observer and inter‐observer variability. Compared to MDCT, 3D‐TEE measurements significantly underestimated AVA (PANOVA <.0001), although the difference was clinically acceptable. Compared to 2D‐TTE, 3D‐TEE manual and semi‐automated software reclassified severe AS in 21.9% and 25.2% of cases, respectively (P <.0001), overcame grading parameters discordance in more than 40% of cases in patients with low‐gradient AS (P <.0001) and reduced the proportion of low‐flow states in nearly 75% of cases when combined to stroke volume index assessment (P <.0001). 3D‐TEE imaging modalities showed a reduction in the proportion of patients with low‐gradient and pathological AVA as defined by 2D‐TTE, and improved AVA and mean pressure gradient agreement with current guidelines cutoff values. Conclusion: 3D‐TEE AVA calculation is a reliable tool for AS grading with excellent reproducibility and good correlation with MDCT measurements. [ABSTRACT FROM AUTHOR]

The improvement achieved in recent years in early myocardial infarction (MI) mortality poses several new clinical challenges, owing to late consequences of myocardial loss and the significant incidence of heart failure (HF) observed thereafter. A still unaddressed residual reperfusion injury (RI) contributes to final infarct size, acute MI mortality and longer-term HF development. Despite many cardioprotective lines of research in the setting of MI, no treatment has significantly altered clinical practice or convincingly improved outcomes either. Left ventricular mechanical unloading before culprit vessel reopening may reduce RI and prime (biologically and mechanically) the myocardium for reperfusion, thus limiting infarct size and preventing subsequent adverse remodeling. Aim of this review is to summarize key pre-clinical and clinical experiences furnishing a rationale to the approach of mechanical unloading before myocardial reperfusion with a translational outlook on its implications for the management of MI patients. • A high proportion of MI patients develops HF as a consequence of myocardial loss. • Limiting infarct size is warranted to prevent subsequent adverse remodeling. • LV unloading before culprit vessel reopening may prime myocardium for reperfusion. • This may translate in early and long-term improved outcomes for MI patients. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate real-world clinical outcome of patients needing short dual antiplatelet therapy (S-DAPT) following PCI with Ultimaster® thin-strut, biodegradable polymer sirolimus-eluting stent (BP-SES), which was supposed to induce faster stent endothelialization and reduce device thrombogenicity. In this sub-group analysis of patients enrolled in the ULISSE registry, two groups were identified: 1) patients discharged with S-DAPT (≤3-month) due to high bleeding risk or need for urgent major non-cardiac surgery and 2) patients discharged with recommended DAPT (R-DAPT) duration (≥6-month). The primary ischemic-safety and bleeding-safety endpoints were TLF (composite of cardiac-death, target vessel MI, and clinically driven target lesion revascularization), and BARC major bleedings (≥type-3a) at 1-year follow-up. To account for events occurring before DAPT discontinuation we performed 3-month landmark analysis. 82 patients (5%) were discharged with ≤3-month DAPT (57 ± 27 days), and 1558 patients (94%) were discharged with ≥6-month DAPT (318 ± 75 days). No significant differences between S-DAPT and R-DAPT group were observed in TLF at 1-year (7.9% vs. 4.6%). The rate of BARC major bleeding resulted significantly higher in S-DAPT group (3.9% vs. 0.3%; p = 0.001), with the majority of bleeding events occurring within 3 months. The landmark analysis showed no significant differences in BARC major bleedings between groups (1.4% vs. 0.3%; p = 0.142). As compared to those treated with R-DAPT (≥6-month), patients needing -S-DAPT (≤3-month) after PCI with Ultimaster® BP-SES had similar rates of 1-year TLF and BARC major bleedings following early DAPT discontinuation. • S-DAPT and R-DAPT after PCI with Ultimaster® BP-SES resulted in similar 1-year TLF. • S-DAPT group had higher bleeding risk and significantly higher BARC major bleedings. • Landmark analysis at 3-month showed similar BARC major bleedings between the groups. [ABSTRACT FROM AUTHOR]

Impella RP has been used to treat right ventricular failure (RVF) developing in various clinical settings that underlay different pathological mechanisms and lead to distinct prognostic implications. This is a single-centre retrospective study including all consecutive patients, from January 2015 to December 2018, with inferior STEMI due to acute thrombotic occlusion of right coronary artery (RCA) and unsuccessful primary percutaneous coronary intervention (PCI) complicated by refractory RVF managed with an Impella RP device. A total of 5 patients have been treated. The mean age was 73 ± 9 years, 80% were males. All patients, except one, were hemodynamically stable at hospital admission. In all patients, PCI resulted unsuccessful (final TIMI flow < 3), with subsequent development of refractory RVF and cardiogenic shock in the catheterization laboratory, despite the use of inotropes and intra-aortic balloon pump (IABP). In 80% of the cases, Impella RP was placed immediately after PCI. Hemodynamics improved immediately after initiation of Impella RP support, with an increase in systolic blood pressure from 91 ± 17 to 136 ± 13 mmHg, a decrease in central venous pressure from 16 ± 2.5 to 12 ± 4 mmHg and a resolution in lactates from 4.5 ± 2.5 to 1.6 ± 0.7 mg/dL. Mean duration of IABP and Impella RP support were 4 and 7 days, respectively. RV recovery occurred in 80% of the cases. All patients survived at 30-day. In patients with AMI complicated by unsuccessful revascularization of RCA and refractory RVF, the use of Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favourable survival at 30-day. • This is the first study focused on Impella RP in acute myocardial infarction setting. • Impella RP provides effective hemodynamic support. • A proper patient selection and timing for Impella RP offer good clinical outcomes. [ABSTRACT FROM AUTHOR]

Bicuspid aortic valve (BAV) is the most common congenital heart disease, with a prevalence of 1–2% and occurring in >20% of octogenarians referred for aortic valve replacement. However, BAV patients have been systematically excluded from pivotal randomized trials. Since TAVI indications are moving toward low-risk patients, an increase in the number of BAV patients who undergo TAVI is expected. BAV represents a challenge due to its unique morphological features (raphe, extreme asymmetrical valve calcifications, cusp asymmetry and aortopathy) and the lack of consensus about the accurate sizing method. The role of multi-slice computed tomography (MSCT) in the planification of the TAVI procedure is well-established, being useful to define the optimal valve sizing and the implantation strategy. New-generation devices, more experience of the operators and better planification of the procedure have been associated with similar clinical outcomes in bicuspid and tricuspid patients undergoing TAVI. [ABSTRACT FROM AUTHOR]

Left ventricle (LV) unloading during VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) reduces the risk of LV distention, stagnation and pulmonary congestion resulting from the increased afterload. Lacking direct comparisons between unloading strategies we used network meta-analysis to indirectly compare different unloading approaches. A literature research was performed to include all studies on VA-ECMO reporting data on mechanical LV unloading. The pre-specified outcome was in-hospital death. Literature search identified 389 studies: 16 were included in the analysis (3930 patients). Two strategies of mechanical LV unloading were compared: afterload reduction (IABP) and preload reduction (Impella pump, right upper pulmonary/trans-septal catheters, LV surgical vents). Any LV unloading strategy was associated with mortality reduction with overall OR = 0.54; 95% CI 0.42–0.70; p <.001. Targeting afterload was associated with reduced mortality (OR = 0.61 95% CI 0.46–0.81; p <.001; I 2 = 61%), as targeting preload (OR = 0.34 95% CI 0.21–0.55; p <.001; I 2 = 0%). Significant between group difference was observed (p =.04): to further explore this we performed a network meta-analysis. Indirect comparisons between afterload and preload reduction were estimated. Any unloading technique was confirmed better than none but preload targeting resulted better than afterload targeting. Any unloading strategy in VA-ECMO patients was associated with lower mortality as compared to no-unloading. Preload reduction strategies resulted superior to afterload reduction. • VA-ECMO increases LV afterload, leading to LV distention and pulmonary congestion. • Mechanical unloading (either reducing afterload or preload) reduces this risk. • No comparison between afterload-reducing vs preload-reducing techniques is available. • In this meta-analysis any mechanical LV unloading was confirmed better than none. • In this network meta-analysis preload reduction was superior to afterload reduction. [ABSTRACT FROM AUTHOR]

Measurement of cardiac index (CI) is crucial in the hemodynamic assessment of critically ill patients in the intensive care unit (ICU). The most reliable trans-thoracic echocardiography (TTE) technique for CI estimation is the left ventricular outflow tract (LVOT) Doppler method that requires, among other parameters, the LVOT cross-sectional area (CSA) measurement. However, inherent and practical disadvantages, mostly related to the ICU setting, hamper LVOT-CSA assessment. In this study, we aimed to validate a simplified formula, leveraging on LVOT-velocity time integral (VTI) and heart rate (HR) only, for non-invasive estimation of CI in ICU patients. We prospectively enrolled 50 consecutive patients admitted to our ICU requiring pulmonary artery catheterization (PAC) over a one-year period. For each patient we measured the CI by PAC (CI PAC) and TTE. The latter was obtained both with the "traditional formula" (traditional CI TTE), requiring LVOT-CSA assessment, and our new "simplified formula" (simplified CI TTE). The correlation between the simplified CI TTE and CI PAC was strong (r = 0.81) and resulted significantly greater than the traditional CI TTE and CI PAC correlation (r = 0.70; p < 0.05 for Pearson r coefficients comparison). Both TTE-based CI showed an acceptable agreement (+0.19 ± 0.48 L/min/m2 for simplified CI TTE and − 0.18 ± 0.58 L/min/m2 for traditional CI TTE) with the reference CI PAC. In this study, we validated a practical approach, leveraging on TTE LVOT-VTI and HR only, for non-invasive estimation of CI in ICU patients. • Cardiac index is a crucial hemodynamic measure in intensive care unit patients. • Doppler trans-thoracic echocardiography traditional method can estimate cardiac index. • Practical disadvantages hamper cardiac index assessment by the traditional method. • A new simplified echocardiography method can estimate cardiac index. • The simplified method outperformed the traditional one in intensive care unit patients. [ABSTRACT FROM AUTHOR]

Background: Transcatheter aortic valve implant (TAVI) is gaining momentum in the treatment of severe, symptomatic aortic valve stenosis, and its indication is expanding to lower surgical risk individuals, who are generally younger and have a long life expectancy. Therefore, transcatheter bioprostheses durability appears of critical importance. Aim of the present study is to evaluate mid-term outcomes of TAVI in a high-volume single center cohort.Methods: We analyzed all consecutive patients (n = 408) who underwent transfemoral TAVI at a single, high-volume center, between 2007 and 2014. Study objectives were all-cause death and bioprosthetic valve failure (BVF) at long term follow-up. Structural valve deterioration (SVD), BVF and valve-related death were defined according to current international standards. Follow-up was performed by in person visit and transthoracic echocardiography, which was obtained only in a minority of patients, or phone call as per patient preference.Results: At a median follow-up of 1821 days, overall mortality was 64.5%, with cardiovascular disease accounting for roughly half of total deaths. Valve-related deaths occurred in 10 patients. Seventeen patients were diagnosed with BVF, and 15 required repeat intervention. Moderate and severe SVD were observed in 10 and 7 patients, respectively. In the subgroup of patients with echocardiographic mid-term follow-up (n = 76), no significant increase of transprosthetic gradients nor increase of significant regurgitation was detected.Conclusion: In the present unselected, all-comers cohort, TAVI bioprostheses appeared to have excellent durability at long-term follow-up. [ABSTRACT FROM AUTHOR]

Intracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH. This is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed. The device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy. The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%. Percutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding. • Intracranial hemorrhage(ICH) represents the most serious complication of oral anticoagulant therapy(OAT) in patients with atrial fibrillation(AF), and AF patients with previous ICH represents a challenge for clinicians. Left atrial appendage(LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT • This is a multicenter retrospective registry that included all consecutive patients (n=120) with previous ICH that undergone LAA occlusion for nonvalvular AF and high thromboembolic risk. • The incidence of thromboembolic and bleeding events was less than expected with the CHA2DS2VASc and HASBLED scores. The procedural success rate was 100%. • Major complications in our registry were related to dual antithrombotic therapy. • After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of bleeding recurrence. [ABSTRACT FROM AUTHOR]

Complex percutaneous coronary intervention (PCI) is associated with increased procedural challenges and high contrast load. We aimed to evaluate the association between complex PCI and contrast-induced nephropathy (CIN). This single-center retrospective study included all-comers undergoing PCI between January 2012 and December 2016. Complex PCI was defined as a procedure with ≥1 of the following characteristics: 3 vessels treated, ≥3 stents implanted, two-stent bifurcation intervention, total stent length >60 mm, PCI on a chronic total occlusion, saphenous vein graft, or left main, protected PCI, use of rotational/laser atherectomy. CIN was defined as an increase in post-PCI creatinine of ≥0.3 mg/dl or ≥50% from baseline. We included 2660 patients (n = 1128 complex PCI, n = 1532 non-complex PCI). Complex PCI patients tended to be older, and had higher cardiovascular comorbidity and Mehran CIN risk score. They also had a higher prevalence of type B2/C lesions and need for mechanical circulatory support, and received a higher mean contrast volume (284 ± 137 vs. 189 ± 90 ml, p < 0.001). CIN incidence was similar in complex vs. non-complex PCI patients (12.1% vs. 11.5%, p = 0.63), as was the need for in-hospital dialysis (0.5% vs. 0.2%, p = 0.25). Upon multivariable adjustment, age, female sex, diabetes, ejection fraction, periprocedural hypotension, presentation with acute coronary syndrome, and contrast volume were independently associated with CIN, while complex PCI was not. Complex PCI is not associated with an increased risk of CIN in all-comers. Further studies should confirm our findings and investigate novel effective strategies to decrease the risk of this serious complication. • Complex PCI is associated with procedural challenges and higher contrast volumes. • Complex PCI might be linked to a higher risk for contrast-induced nephropathy. • CIN incidence was similar in complex vs. non-complex PCI (12.1% vs. 11.5%, p = 0.63). • Upon multivariable adjustment complex PCI was not independently associated with CIN. [ABSTRACT FROM AUTHOR]

Abstract Background There is controversy as to whether iso-osmolar contrast media (IOCM) are associated with lower risk of contrast-induced acute kidney injury (CI-AKI), compared with low-osmolar contrast media (LOCM). We aimed to evaluate if a differential risk of CI-AKI exists after percutaneous coronary intervention (PCI) according to different contrast media (CM) types. Methods We performed a single-center retrospective study in a cohort of all-comers undergoing PCI between January 2012 and December 2016. CI-AKI was defined as an increase in serum creatinine ≥0.3 mg/dl or ≥50% within 72 h from PCI. IOCM were represented by iodixanol, whereas four different LOCM were utilized (ioversol, iopromide, iomeprol, iobitridol). Multiple-treatment inverse probability of treatment weighting (IPTW)-adjusted logistic regression analysis was performed to identify whether CM type was an independent predictor of CI-AKI. Results We included 2648 subjects (ioversol, n = 272; iopromide, n = 818; iomeprol, n = 611; iobitridol, n = 460; iodixanol, n = 487). CI-AKI occurred in 300 patients (11.7%) overall, with no differences across CM groups (ioversol 13.0%, iopromide 11.5%, iomeprol 10.2%, iobitridol 13.9%, iodixanol 11.3%; p = 0.42). CI-AKI requiring dialysis was observed in 8 patients (0.3%) overall (p = 0.50). On IPTW-adjusted analysis, none of the LOCM was associated with a significantly different risk of CI-AKI compared with iodixanol: ioversol OR 0.986 (95% confidence interval [CI] 0.611–1.591), iopromide OR 0.870 (95% CI 0.606–1.250), iomeprol OR 0.904 (95% CI 0.619–1.319), iobitridol OR 1.258 (95% CI 0.850–1.861). Conclusions In a large cohort of all-comers undergoing PCI, there were no differences in the adjusted risk of CI-AKI across 4 LOCM, compared with iodixanol. Highlights • Contrast-induced acute kidney injury has a high incidence (11.7%) in all-comers undergoing (mostly complex) PCI • The unadjusted rates of contrast-induced acute kidney injury are similar across five different types of contrast media • Contrast-induced acute kidney injury requiring dialysis was observed in only 0.3% of patients • The adjusted risk of contrast-induced acute kidney injury was similar across low-osmolar and iso-osmolar contrast media [ABSTRACT FROM AUTHOR]

Abstract Background MitraClip implantation has evolved as a new tool for treatment of inoperable or high-risk patients with severe functional mitral regurgitation (FMR) due to dilated cardiomyopathy (DCM). Limited data are available regarding MitraClip outcomes comparing patients with ischemic and non-ischemic DCM. Methods From 2008 to 2016, 314 patients received MitraClip for FMR at four institutions: Brescia, Zurich and Milan. Patients were stratified according to MR aetiology in non-ischemic FMR (n = 99) and ischemic FMR (n = 215). Preoperative risk factors, operative variables and outcomes up to 2-year were evaluated. A multivariable Cox Proportional Hazards survival model with covariate adjustments was used to assess the relationship between FMR aetiology and 2-year cardiac mortality. Results As expected, patients with ischemic FMR had significantly more risk factors and comorbidities. Overall procedural success rate was 80% and in-hospital cardiac mortality was 3% without significant differences between aetiology. Two-year overall (25% vs. 19%, p = 0.574) and cardiac (18% vs. 16%, p = 0.990) mortality rates were comparable. No differences were detected in terms of re-hospitalization rates (32%), LVAD implantation (4.5%) and mitral valve surgery (1%). LVEF ≤ 25%, LVEDV > 216 ml, NT-proBNP ≥ 10.000 pg/ml and AF were the strongest baseline predictors of 2-year cardiac mortality. Greater improvements of 6MWT and NYHA functional class were observed in patients with non-ischemic FMR. Conclusions The ischemic or non-ischemic aetiology of DCM did not affect in-hospital and 2-year cardiac mortality after MitraClip in patients with FMR. In case of unfavorable baseline clinical condition, the indication for MitraClip should be carefully weighed in favour of conservative medical therapy alone or left ventricular assist device. Highlights • Greater improvements of 6MWT and NYHA functional class were observed in patients with non-ischemic FMR. • Non-/ischemic FMR aetiology did not affect 2-year cardiac mortality after MitraClip. • LVEF ≤25%, LVEDV >216 ml, NT-proBNP ≥10.000 pg/ml and AF were the strongest baseline predictors of 2-year cardiac mortality. [ABSTRACT FROM AUTHOR]