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Introduction Carcinoid heart disease occurs in more than 50% of patients with neuroendocrine gastrointestinal tumors, and it is the initial presentation of carcinoid syndrome in up to 20% of patients. The disease is characterized by pathognomonic plaque-like deposits of fibrous tissue in the endocardium of valvular cusps, cardiac chambers, and occasionally, the intima of the pulmonary arteries or aorta. The tricuspid and the pulmonary valve are most often affected by carcinoid disease, with several combinations of valve dysfunction (usually pulmonic stenosis + tricuspid regurgitation). Valvular dysfunction can lead to peripheral edema, ascites and right-sided heart failure, extreme cases may present with low cardiac output syndrome. Valve surgery may relieve symptoms and it should be considered in patients with controlled neoplasia. Case report a 47-years-old man with a history of operated neuroendocrine gastrointestinal tumor (ileal resection+right hemicolectomy+mesenteric lymphadenectomy) was admitted to our department for right heart failure. His clinical examination was remarkable for ankle swelling, flushing, liver congestion, ascites; moreover the patient reported progressive compromise of functional capacity and weight loss due to anorexia. Laboratory findings were in the normal range except for BNP 184 pg/ml (UNL The patient was discussed in Heart Team: right sided valves were both considered responsible for patient's symptoms, so he was scheduled for surgical intervention after achieving adeguate haemodinamic stability. Pre-surgery right catetherization showed normal pulmonary pressures. Coronary arteries were normal. Before, during and after surgery he was treated with octreotide to reduce the risk of Carcinoid Crisis in the perioperative period. The patient underwent surgical replacement of tricuspid and pulmonary valves with biological prosthesis Mosaic n°33 and Avalus n°23 respectively. Histological examination of the valves showed extensive deposits of fibrous tissue in the valvular endocardium. Post-surgical hospital stay was uneventful, the patient was discharged 14 days after surgery on normal sinus rhythm and in good clinical conditions. In order to prevent thromboembolic events anticoagulant therapy with Warfarin was introduced. Conclusion this is the report of a rare cardiac condition responsible for right heart failure symptoms. Heart Team discussion and multidisciplinary approach involving surgeons and oncologist are mandatory in order to establish the best treatment strategy and timing for interventions. However, since this is a rare condition, more evidence is needed to better understand long term clinical outcomes and treatment options (including future percutaneous perspectives).

We present the case report of a 67 year old man with no previous cardiovascular history, who was admitted to our emergency department (ED) for two days onset of right arm pain which was not responsive to painkillers. On admission, he was asymptomatic for typical angina. His BP was 190/100 mmHg, HR 80 bpm, SpO2 99% and apyretic. The clinical examination was unremarkable. The ECG showed sinus rhythm, complete right-bundle-branch-block (RBBB) and left-axis deviation, negative T-waves in V1-V2 and positive T-waves in V3 > V6 (figure 1A) (no previous ECGs were available). The blood samples showed normal renal function and blood count. Surprisingly, there was a progressive rise in troponin I levels 0.023 > 0.061 > 0.38 ng/ml (ULN 0.010 ng/ml). Echocardiography revealed preserved LVEF without major regional wall motion abnormalities (RWMA), nor any valvulopathy. Despite the atypical presentation and ECG, the troponin rise was strongly suggestive for an acute coronary syndrome (ACS), so the patient was sent to the Cath lab to undergo coronary angiography (CAG). At the time of the CAG he was asymptomatic. The exam revealed thrombotic occlusion of mid-segment left anterior descending artery (LAD). Primary PCI with DES implantation was performed obtaining TIMI 3 flow (figure2). The remaining hospital stay was uneventful, the patient was discharged asymptomatic after 4 days. Pre-discharge echocardiography reported normal LVEF with no RWMA. Discharge ECG showed persistency of the RBBB with negative T-waves from V1 to V4 (figure 1B). On 3 months follow up visit the patient is asymptomatic with preserved LVEF. On ECG there is persistency of RBBB and normalization of the T-waves in the precordial leads (figure 1C). Discussion This case report is an atypical presentation of acute thrombotic occlusion of an epicardial coronary artery, without the typical ST segment elevation (STEMI equivalent) and without the typical angina. RBBB may represent an uncommon ECG presentation of acute myocardial ischemia, with an incidence from 2 to 6% overall, with TIMI 0 flow in the infarct-related artery only in half of the cases. RBBB (especially new or presumably new onset RBBB) is also associated with increased mortality and morbidity, possibly due to delay in diagnosis and primary reperfusion strategies. Troponin dosage was fundamental to understand that we were facing an acute coronary syndrome, however we were not expecting complete occlusion of the LAD. In conclusion, the presence of RBBB on admission may delay primary reperfusion strategies, especially when symptoms are atypical. However, in case of unresponsive pain and presumably new-onset conduction disturbances on ECG it is mandatory to perform troponin assay and therefore drive the correct timing of coronary revascularization.

Aims Gorlin-Goltz syndrome or nevoid basal cell carcinoma syndrome (NBCCS) is a rare autosomal dominant, multisystem, tumor-predisposing disorder. The primary manifestation of NBCCS is the development of multiple basal cell carcinomas (BCCs) but is also associated with a variety of other benign and malignant tumors. Cardiac fibromas are increased in frequency in patients with NBCCS, developing in approximately 3 percent of affected individuals. They typically present in infancy. They are benign growths, and almost all develop within the ventricular myocardium. Although usually asymptomatic, they can result in impaired left ventricular function and conduction defects, necessitating resection. Methods and results we presented a case of a 59-years-old woman with a diagnosis of Gorlin-Goltz syndrome and no history of cardiovascular diseases who underwent a right knee arthroplasty in our hospital. After the surgery the patient was admitted to rehabilitation department. Electrocardiogram that showed sinusal rhythm with inverted T waves in lateral leads and a transthoracic echocardiography examination were performed. Echocardiography showed a large mass within the basal and middle segments of left ventricle lateral wall. Left ventricular ejection fraction was preserved. Cardiac magnetic resonance (CMR) revealed an intramyocardial mass with well-defined borders and several calcifications, hypointense on T1-weighted and T2-weighted images and delayed-contrast hyper-enhancement with hypoenhancing central cores. Based on these imaging features, the mass was suggestive of cardiac fibroma with calcifications. The patients was asymptomatic. Afterwards, a total body CT was performed to exclude other tumours in other sites. This case was discussed with cardiac surgeons and since the patient was asymptomatic with no conduction abnormalities or heart failure signs, urgent surgical intervention was excluded. The patient was discharged with a 3 months follow-up. Conclusion our case highlights the importance of echocardiography evaluation before surgery in patients with genetic syndrome like Gorlin-Goltz syndrome. Last guidelines published in 2021 recommend that all patients with NBCCS should be screened with a cardiac ultrasound and if cardiac symptoms occur in a patient with NBCCS, a cardiac ultrasound should be repeated to exclude a late-onset cardiac tumour. Furthermore, CMR plays an important role in characterizing cardiac masses and determining the management.

Transcatheter treatment of degenerated aortic bioprostheses is nowadays a well-established option (Valve-in-vale, ViV); however, some patients may pose some specific challenges. Perceval® is a sutureless, stent-mounted, aortic valve bioprosthesis that can be placed with a less invasive surgical technique. Its nitinol self-expandable stent frame is a bulky structure that anchors to the aortic annulus without the need of continuous suture, thus reducing aortic cross-clamp and cardiopulmonary bypass time. Performing transcatheter aortic valve replacement (TAVR) in Perceval® may be associated with increased risk of coronary obstruction, impaired coronary access and increased post-procedural gradients. Here we present the cases of two patients with Perceval® degeneration that have been treated with two different tailored approaches following a dedicated Heart Team evaluation. R.M. is a 74-year-old, very low-weight, woman with a history of diabetes, severe COPD, 3b stage CKD, rheumatoid arthritis and previous carotid surgery. She underwent surgical aortic valve replacement (SAVR) with Perceval® “S” bioprosthesis for severe aortic stenosis in 2016. After five years she was diagnosed with severe symptomatic degeneration of the aortic prosthesis (mean gradient 45 mmHg, NYHA class III). The patient was therefore discussed by the Heart Team and scheduled for percutaneous treatment. A ViV with a self-expandable Medtronic 23 mm Evolut™ R bioprosthesis was successfully performed. Hospital stay was uneventful and the patient was discharged on 6th post-operative day in good clinical conditions and good functional class. S.R. is a 70-year-old active smoker woman with a history of previous hemicolectomy for cancer that underwent SAVR in ministernotomy for severe aortic stenosis with Perceval® “L” in 2015. In 2016 she underwent PCI + DES implantation on OM of LCX for an acute coronary syndrome. In 2022 she was diagnosed with severe symptomatic degeneration of the bioprosthesis (mean gradient 40 mmHg, NYHA class II). The patient was referred to Heart Team discussion and scheduled for surgical reintervention. She underwent successful surgery with implantation of a Medtronic Avalus™ 23 mm bioprosthesis, followed by regular rehabilitation. In the first case the severe comorbidities and frailty made the surgical risk almost prohibitive for reintervention (STS-M 9,23%, STS-MM 23,7%, Euroscore II 6,18%). Moreover, there was very little concern about the risk of impaired coronary access afterwards. The second patient, instead, had an acceptable risk for surgery (STS-M 2,2%, STS-MM 10,6%, Euroscore II 4.45%); there was also a significant concern about the risk of impaired coronary access in case of ViV, since she already had a history of percutaneous coronary revascularization. Furthermore, from a lifetime management point of view it is possible to hypothesize easier future reintervention with a TAVR in SAVR instead of a complex TAVR in TAVR in SAVR. Thus, although ViV was technically feasible in both cases with predictable good short-term outcomes, we decided for opposite treatments by looking at individualized long-term needs. In Conclusion the choice between surgical and transcatheter intervention must be based not only on careful evaluation of clinical, anatomical and procedural characteristics but also on future perspectives, especially in patients with longer life expectancy.

The durability of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is uncertain. We aimed to compare the long-term outcomes of CTO PCI with those of complex non-CTO PCI. We built a single-center registry including all patients who underwent CTO and complex non-CTO PCI between 2012 and 2017. Complex non-CTO PCI was defined as: 3 vessels treated, ≥3 stents implanted, total stent length60 mm, saphenous vein graft intervention, 2-stent bifurcation intervention, left main PCI, protected PCI, or rotational/laser atherectomy. The primary endpoint was target-lesion failure, a composite of cardiac death, myocardial infarction, and target-lesion revascularization. A total of 2,396 patients were included (n=609 CTO PCI, n=1,787 complex non-CTO PCI). Patients who underwent CTO PCI were younger and had higher prevalence of cardiovascular comorbidities. CTO PCI patients exhibited worse procedural metrics and success rate (74% vs 98%, p0.001). They also suffered a higher incidence of coronary perforation (3.5% vs 2.0%, p = 0.04) and cardiac tamponade (0.8% vs 0.1%, p = 0.001). However, there was no difference in the overall incidence of in-hospital major adverse cardiac and cerebrovascular events (4.1% vs 5.0%, p = 0.40). At 36 months, there were no differences in the incidence of target-lesion failure (10.1% vs 9.9%, p = 0.91) or its individual components, between the CTO and complex non-CTO group. This finding was confirmed on multivariable analysis. In conclusion, CTO PCI is associated with lower success rates and higher risk for coronary perforation and tamponade compared with complex non-CTO PCI. The incidence of other in-hospital and long-term adverse events is similar and reasonably low.

Aims We present the case of an 80-year-old woman without prior cardiovascular history, recent instrumental diagnosis of peritoneal carcinomatosis and ongoing oncologic diagnostic work up. Methods and results The patient was admitted to our ED for acute-onset worsening dyspnoea. On first clinical evaluation, she denied typical angina, remarkable clinical features were dyspnoea, tachycardia and hypotension. Admission ECG showed sinus rhythm with posterior and inferior ST elevation (leads DII, aVF, V5, V6) with reciprocal ST segment depression in leads V1–V2. Echocardiography confirmed infero-postero-lateral akinesia determining moderate reduction of LVEF (35–40%), normal aortic root, no pericardial effusion. Laboratory tests revealed normal WBC count, mild anaemia (HB 10.7 g/dl), normal renal function, elevated C-reactive protein (139 mg/l, n.v. < 8). Cardiac troponin I (cTnI) was normal on admission, with significant delta on second determination (0.012 > 2.5 ng/ml, nv 15 000 ng/l. Repeat echocardiography on day 2 reported complete akinesia of all the apical segments of the LV with normo-hyperkinesia of the mid-basal segments (apical ballooning pattern) and severely depressed systolic function (FE 32–35%). During the following days patient’s symptoms improved, with rapid weaning from oxygen therapy and stable haemodynamic parameters. After 10 days the patient repeated echocardiography, which revealed improvement of global LVEF and persisting mild apical hypokinesia, suggesting the diagnostic hypothesis of Tako-Tsubo Syndrome (TTS) or TTS-phenocopy (unfortunately cardiac MRI was not performed). The patient was therefore transferred to oncology department to complete the diagnostic work-up; primary mammary neoplasia was identified, moreover associated with metastasis in the liver and the brain. Unfortunately, the patient died a month later due to non-cardiac causes. This is the case report of an uncommon MINOCA, which presented mimicking inferolateral acute STEMI, but subsequent ECG and echocardiographic evolution showed the more typical TTS pattern, with apical ballooning on echo and deep negative T waves in anterior leads. Conclusions The prevalence of MINOCA is estimated to be 6% to 8% among patients diagnosed with MI, especially women, however it is more common in patients with NSTEMI compared with STEMI; moreover in cases of TTS presenting with ST elevation, usually the elevation is found in anterior leads without reciprocal ST depression; in this patient instead ST elevation was inferolateral with reciprocal anterior ST depression. Absence of obstructive CAD and clinical/echocardiographic evolution allowed us to confirm the diagnosis of MINOCA/TTS.

Aims Ischaemic heart disease is rare in young women, especially in the absence of a positive family history and strong cardiovascular risk factors, such as insulin-dependent diabetes. However, the correct diagnosis of ischaemic heart disease in young population is mandatory, and the specific aetiology should be identified to ensure a proper treatment. Methods and results We present the case of a 35-year-old caucasian woman who underwent ambulatory cardiological evaluation after episodes of chest pain and worsening dyspnoea (NYHA class II). The patient was asymptomatic at rest, BP was normal, heart rate was 80/minute in sinus rhythm, with no clinical signs of acute heart failure. ECG showed sinus rhythm with Q wave (lead DIII) and negative T waves (inferior leads). At echocardiographic evaluation LV was severely dilated (EDVi 105 ml/mq, EDD 66 mm) with akinesia and scar in the infero-posterior wall determining moderate reduction in ejection fraction (LVEF 40%), associated with secondary moderate mitral regurgitation; the right ventricle, the other valves and the aortic root were normal. The young lady was then admitted to Cardiology Unit for further investigations. She underwent cardiac MRI, which confirmed LV dilatation and dysfunction (EDV 198 ml/mq, LVEF 42%), associated with akinesia and infero-postero-lateral wall scar, with transmural myocardial fibrosis in the same segments, and subendocardial fibrosis on the basal segment of the anterior wall. Analysis of blood samples revealed elevated haemoglobin levels (Hb: 17.5 g/dl, n.v. 12–16 g/dl) and extremely elevated platelet count (PLT 945 000/mmc, n.v. 130 000–400 000/mmc). Cardiac troponin I (cTnI) was negative on serial determinations. All findings were suggestive for subacute infero-posterior myocardial infarction. Coronary angiography was performed via radial access: the exam was negative for significant stenosis in any coronary segment, only mild stenosis of proximal dominant left circumflex (LCX) artery was identified; moreover, there were no angiographic signs of coronary dissection. Eventually, SCAD and aortic defects were ruled out by coronary CT scan, which was negative for both coronary and aortic dissection. New blood samples examinations confirmed high values of Hb and PLT. Low levels of EPO (1.4 mU/ml) and JAK-2 mutation V617F positivity suggested the clinical diagnosis of essential thrombocythemia, later confirmed by bone marrow aspiration. Hydroxyurea was prescribed, as well as haematologic follow-up. Conclusions This is an interesting case of ischaemic heart disease, confirmed by ECG, echocardiography, and cardiac MRI, in presence of non-obstructive coronary artery disease. The aetiology of this specific case of MINOCA is potentially to be sought in the haematologic disorder. It is possible to hypothesize that a platelet/RBC clot might have determined acute obstruction of the proximal dominant LCX artery, then followed by spontaneous recanalization. Only mild stenosis on the proximal vessel was identified, and stenting was considered not appropriate for this lesion.

Introduction Based on recent data, the indication for transcatheter aortic valve implantation (TAVI) is expanding to individuals at lower surgical risk, who are generally younger than subjects historically treated for severe aortic stenosis. Indeed, younger patients have traditionally been under-represented in current TAVI literature. The aim of the present study is to report about clinical features, procedural outcomes and mid-term outcomes of patients younger than 70 who underwent TAVI in a single high-volume center. Materials and methods Consecutive patients younger than 70 years of age who underwent TAVI for severe, symptomatic aortic stenosis between 2007 and 2019 at a single, tertiary referral center have been included in this retrospective study. Procedural and mid-term outcomes were analyzed, comparing 1st generation with 2nd generation devices. Results Between 2007 and 2019, 1740 TAVI procedures were performed in our center. Among these, one hundred twenty-nine (7.4%) patients were younger than 70 years at the time of the intervention and were included in the present analysis. Fifty-eight patients (45%) were implanted with a 1st generation prosthesis while seventy-one patients (55%) were implanted with a 2nd generation device. Reasons which lead to a transcatheter approach in this population were: previous CABG (27.9%); porcelain aorta (24%); severe left ventricular systolic dysfunction (21.7%); prior chest radiation (19.4%); severe lung disease (8.5%); hemodynamic instability (7.0%); advanced liver disease (4.6%) and active cancer (3.9%). Overall device success rate was 89%, with no differences among 1st and 2nd generation devices. Threeyears all-cause mortality was 34%, with no difference among the two groups. Low incidence of aortic-valve re-intervention was observed at mid-term follow-up (late valve re-intervention = 2.3%). Conclusions TAVI in young patient with appropriate indication for intervention is a safe procedure, associated with low rate of in hospital mortality and low rate of severe complications both with 1st and with 2nd generation devices. When considering long term durability, more data are needed; in our case series long-term follow up shows a good survival and also an extremely low rate of valve re-intervention.

OBJECTIVES The objective of this meta-analysis is to evaluate clinical efficacy of double layered mesh covered carotid stent systems in the clinical practice. BACKGROUND The need for an increase plaque coverage to decrease the risk of debris dislodgement through the stent struts, following carotid artery stenting (CAS), has brought to the design of a new generation of double layered carotid stents. Several small sized clinical studies evaluating two different devices have been recently published, unfortunately these are not sufficiently powered to test for device related and clinical endpoints and no comparison, between the two available devices, has been reported yet. METHODS Ten studies, enrolling 635 patients, were included in the present meta-analysis. Our study analyzed a composite endpoint of 30-day stroke and death and the occurrence of procedural unsuccess after CAS with the use of two different double layered carotid stent systems. RESULTS Thirty-day stroke and death rate was quite low (patients 635, event rate 0.02, 95% CI: 0.01-0.04, P

The 3rd generation Mitraclip XTr was recently introduced to improve device performance, through longer clip arms that should allow better grasping of the mitral leaflets, thus improving coaptation and results eventually. Several studies have demonstrated additional effects such as the reshape of the mitral annulus immediately after clip implantation. The aim of our study was to evaluate the mitral valve (MV) annular remodelling with MitraClip XTr. Between March 2018 and November 2018, 75 consecutive patients were enrolled. The population was divided in two groups: functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR). The 3D MV datasets at baseline and immediately after the procedure were acquired and then analysed with semiautomatic MVQ software (QLAB Cardiac 3DQ v.10.0; Philips Medical Systems). The software provides the following parameters: annular diameters (antero-posterior, AP, and inter-commissural, IC), circumference, area, height and ellipsicity (IC/AP ratio as percentage); saddle-index, defined as annular height to IC diameter ratio was derived. The 3D post-processing was feasible in 54 patients (108 3D datasets): 28 had FMR (52%) and 26 had DMR (48%). An average of 1.8 clips per patient were implanted: 2 clips in 38 (70%), 1 clip in 14 (26%) and 3 clips in 2 (4%) patients. The position was central in 93% of the procedures. Results are reported in table 1. In the FMR group, a reduction in the AP diameter (p=0.001), an increase in both IC diameter (p=0.001) and annular ellipsicity (p In the DMR group, an increase in annular ellipsicity (p=0,008) and in saddle-index (p Table 1 Functional mitral regurgitation (N=28) Degenerative mitral regurgitation (N=26) Pre-clip Post-clip P-value Pre-clip Post-clip P-value IC diameter (mm) 39.3±4.2 41.9±4.1 0.001 40.9±6.5 41.8±5.8 0.257 AP diameter (mm) 32.8±4.6 30.4±3.2 0.001 32.6±4.8 31.7±4.5 0.199 Annular Height (mm) 5.1±1.8 5.4±1.8 0.336 4.8±1.9 5.7±2.2 0.026 3D circumference (mm) 122.7±15.1 123.5±11 0.718 123.5±19.0 124.0±17.1 0.812 3D area (mmq) 1128.0±280 1113.7±206 0.752 1160±346.7 1156.8±318.0 0.926 Annular ellipsicity (%) 121.5±12.2 138.5±11.8 0.0005 125.9±9.6 132.4±10.7 0.008 Saddle index 13.0±4 13.0±4 0.957 11.8±4.2 13.6±4.2 0.048 Our study demonstrates that the XTr implantation produces a MV annular remodelling both in FMR and DMR probably with different mechanisms. In FMR the MV annulus resulted more elliptical, wheras in DMR the geometrical modifications involve both the ellipsicity and the saddle-shape morphology.

There is conflicting evidence regarding the safety and efficacy of transcatheter aortic valve implantation (TAVI) procedures in patients with severe aortic stenosis and low left ventricular ejection fraction (EF). The primary aim of this study was to determine the impact of TAVI on short- and long-term mortality in patients with low EF (EF50%); the secondary aim was to analyze the impact of TAVI procedure on EF recovery in the same setting of patients.Twenty-six studies enrolling 6898 patients with severe aortic stenosis undergoing TAVI procedure were included in the meta-analysis and analyzed for 30-day, 6-month and 1-year all-cause and cardiovascular mortality; a further meta-analysis was also performed in patients with low EF to assess EF changes post TAVI. In low EF patients, both all-cause and cardiovascular short- and long-term mortality were significantly higher when compared to patients with normal EF (30-day-all-cause mortality: 0.13; 95% confidence interval [CI]: 0.01 to 0.25, I(2)=49.65, Q=21.85; 1-year-all-cause mortality: 0.25; 95% [CI]: 0.16 to 0.34, I(2)=25.57, Q=16.12; 30-day-cardiovascular mortality: 0.03; 95% [CI]: -0.31 to 0.36, I(2)=66.84, Q=6.03; 1-year-cardiovascular mortality: 0.29; 95% [CI]: 0.12 to 0.45, I(2)=0.00, Q=1.88). Nevertheless, in low EF patients TAVI was associated with a significant recovery of EF, which started at discharge and proceeded up to 1-year-follow-up.Patients with low EF severe aortic stenosis have higher mortality following TAVI compared to normal EF patients, despite a significant and sustained improvement in EF.

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.

Objectives The aim of this meta-analysis was to evaluate and compare the efficacy of the 2 different neuroprotection systems in preventing embolization during carotid artery stenting (CAS), as detected by diffusion-weighted magnetic resonance imaging (DW-MRI). Background Data from randomized and nonrandomized studies comparing both types of embolic protection devices revealed contrasting evidence about their efficacy in neuroprotection, as assessed by the incidence of new ischemic lesions detected by DW-MRI. Methods Eight studies, enrolling 357 patients, were included in the meta-analysis. Our study analyzed the incidence of new ischemic lesions/patient, comparing filter cerebral protection and proximal balloon occlusion. Results Following CAS, the incidence of new ischemic lesions/patient detected by DW-MRI was significantly lower in the proximal balloon occlusion group (effect size [ES]: −0.43; 95% confidence interval [CI]: −0.84 to −0.02, I2 = 70.08, Q = 23.40). Furthermore, following CAS, the incidence of lesions at the contralateral site was significantly lower in the proximal protection group (ES: −0.50; 95% CI: −0.72 to −0.27, I2 = 0.00, Q = 3.80). Conclusions Our meta-analysis supports the concept that the use of proximal balloon occlusion compared with filter cerebral protection is associated with a reduction of the amount of CAS-related brain embolization. The data should be confirmed by a randomized clinical trial.

Controversial data exist regarding the impact of body mass index (BMI) on TAVI outcomes. Thirteen TAVI studies were included and analyzed for the incidence of procedural complications, 30-day, and long-term all-cause mortality. Three comparisons were executed: (1) underweight versus normal weight, (2) overweight versus normal weight, and (3) obese versus normal weight patients. Underweight patients (BMI 30 kg/m(2)) had similar 30-day all-cause mortality rates compared with the normal weight category, whereas they displayed a significant better survival at long-term (hazard ratio 0.79, 95% CI 0.67 to 0.93, p = 0.004). Procedural complications did not differ between obese and normal body weight patients. In conclusion, a low BMI is linked to a significantly worse prognosis after TAVI. Therefore, BMI represents an important and handily tool that might be used in the risk prediction of patients to be addressed for TAVI.

Aging is a well-known cardiovascular risk factor and cardiovascular diseases (CVD) are estimated to be the most common cause of death in the elderly. Peripheral arterial disease (PAD) represents an important clinical manifestation of CVD leading to increase morbidity and mortality, especially in elderly population. The correct management of PAD population includes the prevention of cardiovascular events and relief of symptoms, most commonly intermittent claudication. Progressive physical activity is an effective treatment to improve walking distance and to reduce mortality and cardiovascular events in patients with PAD, however the ability to effectively engage in physical activity often declines with increasing age. The maintenance and increase of reserve functional capacity are important concepts in the elderly population. Ultimately, the goal in participation of physical activity in the healthy elderly population is maintenance and development of physical functional reserve capacity. Therefore, for individuals suffering of PAD, appropriate physical activity in the form of supervised exercise may serve as a primary therapy. Although there are few direct comparisons of therapeutic exercise programs vs. pharmacological or surgical interventions, these increases in walking distance are greater than those reported for the most widely used agents for claudication, pentoxyphylline, and cilostazol. Despite a reduction in mortality and improvement of quality of life caused by physical activity in the PAD population, the molecular, cellular, and functional changes that occur during physical activity are not completely understood. Therefore, this review article aims at presenting an overview of recent established clinical and molecular findings addressing the role of physical activity on PAD in the older population. © 2014 Schiattarella, Perrino, Magliulo, Carbone, Bruno, De Paulis, Sorropago, Corrado, Bottino, Menafra, Abete, Toscano, Giugliano, Trimarco and Esposito.

Background Epigenetic regulation by Histone Deacetylases (HDACs) plays an important role in multiple pathophysiological processes, including tumor growth and cardiovascular diseases. HDAC inhibitors (HDACi) have emerged as important therapeutic agents for multiple human cancers, and several randomized clinical trials have been recently undertaken to test their safety and efficacy in cancer patients. Although HDACi have shown beneficial effects in several preclinical models of cardiovascular diseases, concerns have emerged regarding their potential cardiac toxic effects. The present study assessed the extent and possible significance of cardiovascular adverse effects induced by HDACi administration. Methods and results Based on the available published clinical trials reporting cardiovascular effects of HDACi therapy in cancer patients, 62 studies for a total patient population of 3268 were included to perform a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) requirements. A further analysis was conducted to evaluate cardiovascular effects of the different drugs among the HDACi class. Overall, only a minority of studies reported cardiovascular effect of HDACi, and showed mild but frequent cardiovascular side effects after HDACi treatment in cancer patients. Conclusions Future studies will be required to better determine the role and the mechanisms underlying cardiovascular effects of HDACi in the context of oncological therapy and beyond.

Purpose Atherosclerosis is a systemic disease and coronary artery disease is frequently associated with peripheral artery disease. As aortic and mitral valvular calcification (VC) share some etiopathogenetic mechanisms with atherosclerosis, we analyzed the risk profile and the echocardiographic characteristics of patients admitted for first acute coronary syndrome (ACS) to investigate whether the presence of VC could be a marker of asymptomatic hemodynamically significant peripheral atherosclerosis. Methods A total of 151 patients admitted for ACS without previous history of cardiovascular disease were consecutively enrolled. The presence of VC was identified by echocardiography; a carotid stenosis ≥50% by ultrasound identified carotid artery disease (CarAD); an ankle–brachial index ≤0.9 or ≥1.4 identified lower extremity artery disease (LEAD). Significant peripheral atherosclerosis was defined by the presence of CarAD and/or LEAD. Results Peripheral atherosclerosis was diagnosed in 82 (54.3%) patients; isolated CarAD in 24, isolated LEAD in 20, both diseases in 38 patients. VC was present in 103 (68.2%) patients. By multivariate analysis, age (OR = 1.059, 95% CI 1.007–1.113, P = 0.025), diabetes mellitus (OR = 5.068, 95% CI 1.480–17.351, P = 0.010), VC (OR = 7.422, 95% CI 2.421–22.880, P

The aim of this meta-analysis was to evaluate and compare the efficacy of the 2 different neuroprotection systems in preventing embolization during carotid artery stenting (CAS), as detected by diffusion-weighted magnetic resonance imaging (DW-MRI).Data from randomized and nonrandomized studies comparing both types of embolic protection devices revealed contrasting evidence about their efficacy in neuroprotection, as assessed by the incidence of new ischemic lesions detected by DW-MRI.Eight studies, enrolling 357 patients, were included in the meta-analysis. Our study analyzed the incidence of new ischemic lesions/patient, comparing filter cerebral protection and proximal balloon occlusion.Following CAS, the incidence of new ischemic lesions/patient detected by DW-MRI was significantly lower in the proximal balloon occlusion group (effect size [ES]: -0.43; 95% confidence interval [CI]: -0.84 to -0.02, I(2) = 70.08, Q = 23.40). Furthermore, following CAS, the incidence of lesions at the contralateral site was significantly lower in the proximal protection group (ES: -0.50; 95% CI: -0.72 to -0.27, I(2) = 0.00, Q = 3.80).Our meta-analysis supports the concept that the use of proximal balloon occlusion compared with filter cerebral protection is associated with a reduction of the amount of CAS-related brain embolization. The data should be confirmed by a randomized clinical trial.

Atherosclerosis is an inflammatory disorder that can evolve into an acute clinical event by plaque development, rupture, and thrombosis. Plaque vulnerability represents the susceptibility of a plaque to rupture and to result in an acute cardiovascular event. Nevertheless, plaque vulnerability is not an established medical diagnosis, but rather an evolving concept that has gained attention to improve risk prediction. The availability of high-resolution imaging modalities has significantly facilitated the possibility of performing in vivo regression studies and documenting serial changes in plaque stability. This review summarizes the currently available non-invasive methods to identify vulnerable plaques and to evaluate the effects of the current cardiovascular treatments on plaque evolution.

Transcatheter aortic valve implantation (TAVI) is an effective alternative therapy in selected patients with severe aortic stenosis. The role and effects of coexistent moderate to severe mitral regurgitation (msMR) in patients who undergo TAVI remain unclear. Thirteen studies enrolling 4,839 patients who underwent TAVI, including patients with msMR, were considered in a meta-analysis and analyzed for all-cause-mortality; a further meta-analysis was performed to assess mitral regurgitation (MR) evolution after TAVI. In patients with msMR, all-cause-mortality after TAVI was significantly increased at 30-day (effect size [ES] −0.18, 95% confidence interval [CI] −0.31 to −0.04, I 2 = 46.51, Q = 7.48), 1-year (ES −0.22, 95% CI −0.36 to −0.08, I 2 = 56.20, Q = 11.41), and 2-year (ES −0.15, 95% CI −0.27 to −0.02, I 2 = 0.00, Q = 2.64) follow-up compared with patients with absent or mild MR, independent of baseline left ventricular ejection fraction. Interestingly, the impact of msMR on outcomes was statistically stronger when the CoreValve system was used. TAVI was also associated with an improvement in MR entity at 3- and 6-month follow-up (overall ES −0.19, 95% CI −0.37 to −0.01, I 2 = 61.52, Q = 10.39). In conclusion, the presence of preoperative msMR in patients with severe, symptomatic aortic stenosis who undergo TAVI negatively affects outcomes after TAVI. In addition, in the same group of patients, a trend toward a reduction in MR severity was observed. Whether the decrease in MR severity affects mortality after TAVI remains to be defined.