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Sacubitril/valsartan reduces heart failure (HF)-related hospitalizations and cardiovascular mortality in PARADIGM-HF and has become a foundational treatment for HF with reduced ejection fraction (HFrEF). However, data of its routine real-world use are limited, and evidence from Italian settings is lacking. The REAL.IT study aimed to characterize the demographics, pharmacotherapy, clinical characteristics and outcomes of sacubitril/valsartan-treated Italian patients with HFrEF. Electronic medical records of patients initiating sacubitril/valsartan from October 2016 to June 2019 at nine specialized hospital outpatient HF centers across Italy were reviewed. Overall, 924 adults (mean age 64.5 years, 84.6% male) were included. At baseline, 38.7% had an ischemic HF etiology, 45.9% hypertension, 23.2% atrial fibrillation, 25.4% diabetes mellitus, 26.1% an implantable cardioverter-defibrillator and 31.9% coronary artery bypass grafting. There were no clear patterns of patient selection over time. During follow-up, NYHA class improved in 37.5% of patients after a mean of 5.3 ± 3.8 months; 36.1% and 16.7% of patients were in NYHA class III during characterization and after one year of follow-up, respectively. Left ventricular ejection fraction (LVEF) improved ≥5% in 56.3% of patients at one year; 39.7% had ≥30% reduction of N-terminal pro-B-type natriuretic peptide; 2.2% had hyperkalemia during characterization and 2.6% during follow-up; and 3.8% had hypotension during characterization and 12% during follow-up. A total of 50 (5.8%) of patients had device implantation (ICD/CRT) during follow-up. HF-related hospitalization was recorded in 19.6% of patients during follow-up; 3.8% of patients died, approximately 1.3% from cardiovascular causes. Our real-world data confirm the favorable effectiveness and tolerability of sacubitril/valsartan observed in pivotal randomized controlled trials.

Background Pulmonary hypertension (PH) is defined as a resting mean pulmonary artery pressure of 20 mmHg or above. The importance of identifying the underlying causes of PH is well known for a correct management and treatment. In particular, any cardiac causes, included shunt, must be investigated. Case Summary A 73-year-old woman presented to the emergency room for asthenia and dyspnea. First line exams as ECG and X-ray were executed resulting normal. Laboratory assessment showed an elevated brain natriuretic peptide at 675 pg/ml and a D-dimer value of 1116 ng/mlFEU (n.v. < 500 ng/mlFEU) so with the suspect of pulmonary thromboembolism a CT-scan with contrast was performed. It was negative for acute thromboembolism, but it revealed an enlarged pulmonary artery (with a diameter of 39 mm), a possible defect of interatrial septum and an anomalous drainage of inferior vena cava (IVC) into the left atrium (LA). A transthoracic echocardiogram confirmed the anomalous drainage of IVC into the LA that appears dilated but was not diagnostic for the interatrial defect. Furthermore, PH was suspected (systolic peak tricuspid regurgitation velocity of 3,5 m/s, RA area of 24 cm2, tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure of 0.26 mm/mmHg). A 6-minute walking distance was 376 m. The patient completed the exams with a transesophageal echocardiography that revealed an inferior-type caval vein defect and an over-developed Eustachian valve which divides the right atrium (RA) and connect the IVC with the LA directing the blood flow towards it through the inter-atrial septal defect. Discussion The Eustachian valve is an embryologic remnant at the junction of the IVC and RA. While it typically does not have any pathologic significance, veno-arterial shunting can rarely occur in patients with prominent eustachian valves and atrial septal defects.

Background Risk scores are important tools for the prognostic stratification of pulmonary arterial hypertension (PAH). Their performance and the additional impact of comorbidities across age groups is unknown. Methods Patients with PAH enrolled from 2001 to 2021 were divided in ≥ 65 years old vs Results Among 383 patients, 152 (40%) were ≥ 65 years old. Older patients had more comorbidities, with the exception of obesity and diabetes (number of comorbidities 2, IQR 1-3, vs 1, IQR 0-2 in Conclusions Risk scores have similar accuracy in the prognostic stratification of older vs younger PAH patients. REVEAL 2.0 had the best performance in older patients. Comorbidities increased the accuracy of risk scores only in younger patients.

It is known that the prognosis of patients affected by light-chain (AL) or transthyretin-related (TTR) amyloidosis is poor. TTR amyloidosis has usually shown a slower progression than AL amyloidosis, both hereditary TTR amyloidosis, where there is an inherited mutation in the DNA, and wild-type TTR amyloidosis, which usually affects the elderly. In this paper, the current literature about heart transplantation on cardiac amyloidosis patients is extensively reviewed. The two most frequent types of cardiac amyloidosis have been considered for heart transplantation: AL amyloidosis and wild-type TTR amyloidosis. According to this analysis, it is reasonable that heart transplantation may represent a valuable option in carefully selected patients. Moreover, it could improve prognosis, enabling autologous stem cell transplantation in the AL amyloidosis subgroup. In our humble opinion, it is mandatory to define a multidisciplinary approach to help select candidates to obtain the most effective results.

The use of low molecular weight heparin sometimes leads to major life threatening complications, such as acute abdominal haemorrhages. We report two cases of major haematoma of rectus abdominis. Computed tomography was very helpful to confirm the diagnosis in these cases.

Drug-eluting stent (DES) implantation has reduced angiographic and clinical restenosis that actually develops in less than 10% of treated patients. DESs also tend to delay the endothelialisation process increasing the risk of stent thrombosis. Subacute stent thrombosis may complicate long-term success of coronary angioplasty; it is a sudden event and usually causes acute myocardial infarction or sudden cardiac death. Patients undergoing DES implantation should be treated with dual antiplatelet therapy for at least 3-6 months. We describe two cases presenting with ST-elevation acute myocardial infarction due to stent thrombosis that occurred late after deployment of a paclitaxel-eluting stent, after discontinuation of antiplatelet therapy. It is important, for clinical cardiologists and general practitioners, to know the potential risk of late thrombosis of DES patients and, consequently, the implications regarding management of antiplatelet therapy.

With the exception of a few cases such as aborted sudden cardiac death, sustained ventricular tachycardia, and syncope of unexplained origin, there is no consensus on the clinical findings identifying patients with idiopathic dilated cardiomyopathy with an increased risk of sudden cardiac death or malignant ventricular arrhythmias.To verify whether electrocardiographic and arrhythmologic features could be useful for prognostic stratification, 78 consecutive patients with an invasive diagnosis of idiopathic dilated cardiomyopathy, but without symptomatic ventricular arrhythmias, were enrolled in a prospective study. Signal-averaged ECG, 24 to 48 hour ECG monitoring and electrophysiologic study were performed at the time of diagnosis to identify arrhythmogenic predictors of outcome. Transplant-free and arrhythmic event-free survival was evaluated on the basis of initial parameters.During a mean follow-up of 85 months, 9 patients died (6 of sudden cardiac death and 3 of congestive heart failure), 10 patients underwent cardiac transplantation for refractory heart failure, and 3 presented with sustained ventricular tachycardia. The independent predictors for death and cardiac transplantation were an HV interval55 ms and the combination of frequent repetitive ventricular ectopics with a poor left ventricular function. A strong index of arrhythmic events proved to be the association of a prolonged HV interval with a wide (110 ms) QRS complex (odds ratio 4.53, 95% confidence interval 1.57-13.04, p0.005).An accurate measurement of the HV interval and QRS duration at baseline evaluation may add prognostic information in patients with idiopathic dilated cardiomyopathy. In our experience, abnormal values of both parameters identified a group of patients with a very high risk of late occurring arrhythmic events.