Chronic Total Occlusion of the Left Main and Severe Aortic Stenosis.

Concomitant aortic stenosis and coronary artery disease in the elderly population is frequent and the proper therapeutic approach is a matter of debate. We present 2 challenging cases of patients affected by severe aortic stenosis and chronic total occlusion of the left main, demonstrating the safety and feasibility of transcatheter aortic valve replacement, performed both with balloon-expandable and self-expanding valves.

Patient-specific computer simulation of transcatheter aortic valve replacement in patients with previous mechanical mitral prosthesis: A case series.

Transcatheter aortic valve replacement performed in patients with previously implanted mechanical mitral prosthesis represents a high risk procedure with several potential complications. We report a systematic use of a prediction model based on artificial intelligence to plan the interventional strategy in this challenging scenario.

Use of a steerable delivery sheath to obtain coaxial alignment in left atrial appendage occlusion after mitral transcatheter edge-to-edge repair: a case report.

Background: Patients with atrial fibrillation (AF) have a five-fold increase in stroke events, and ∼90% of the thrombi develop in the left atrial appendage (LAA). Left atrial appendage occlusion (LAAO) has emerged as a safe and feasible alternative to oral anticoagulation (OAC) for stroke prevention in selected patients with non-valvular AF and contraindications to OAC. Atrial fibrillation is closely associated with mitral disease, and there is a growing interest in combined procedures. More than half of patients undergoing a mitral transcatheter edge-to-edge repair (M-TEER) suffer of AF and many have high or unacceptable bleeding risk. Case summary: We present a case of an 80-year-old woman suffering from paroxysmal AF, right carotid siphon aneurysm, and primary mitral regurgitation, with a high bleeding risk, who underwent a combined intervention of M-TEER and LAAO. Discussion: The combination of these two procedures is a logical step once the access to the left atrium is obtained with a transseptal puncture (TSP) and a transesophageal echocardiography (TEE) is in place to guide both procedures. The turning point in LAAO procedure is a correct TSP allowing coaxial alignment of the sheath with the LAA neck. Steerable delivery sheaths are promising dedicated tools, particularly in challenging anatomy or during combined procedures requiring different TSP positions.

Danon disease in a Sardinian family: different aspects of the same mutation-a case report.

Background: Danon disease (DD) is a rare X-linked disorder due to mutations in the lysosome-associated membrane protein 2 gene. It is characterized by a clinical triad of hypertrophic cardiomyopathy, skeletal myopathy, and a variable degree of intellectual disability. Case summary: In this case series, we describe a mother and her son affected by DD, highlighting consistent clinical severity despite the expected variability related to gender. The mother (Case 1) presented isolated cardiac involvement, with an arrhythmogenic phenotype that evolved into severe heart failure requiring heart transplantation (HT). Danon disease was diagnosed 1 year after this event. Her son (Case 2) showed an earlier age onset of symptoms with complete atrioventricular block and fast progression of cardiac disease. Diagnosis was established 2 years after clinical presentation. He is currently listed for HT. Discussion: In both of our patients, diagnostic delay was extremely long and could have been avoided by emphasizing the relevant clinical red flags. Patients affected by DD may present clinical heterogeneity in terms of natural history, age of onset, and cardiac and extracardiac involvement, even in the same family. Early diagnosis that phenotypic sex differences may impact is a crucial factor in managing patients with DD. Considering the rapid progression of cardiac disease and the poor prognosis, early diagnosis is important and close surveillance should be mandatory during follow-up.

Diagnosis and management of cardiovascular risk in rheumatoid arthritis: main challenges and research agenda.

INTRODUCTION: Rheumatoid arthritis (RA) exhibit a cardiovascular (CV) risk that is 1.5-2.0 times higher compared to the general population. This CV risk excess is likely caused by the involvement of chronic inflammation and immune dysregulation. Therefore, conventional algorithms and imaging techniques fail to fully account for this risk excess and provide a suboptimal risk stratification, hence limiting clinical management in this setting. AREAS COVERED: Compelling evidence has suggested a role for adaptations of conventional algorithms (Framingham, SCORE, AHA, etc) or the development of RA-specific algorithms, as well as the use of a number of several, noninvasive imaging techniques to improve CV risk assessment in RA populations. Similarly, in-depth analyses of atherosclerosis pathogenesis in RA patients have shed new light into a plethora of soluble biomarkers (such as inflammatory cytokines, vascular remodeling mediators or autoantibodies) that may provide incremental value for CV risk stratification. EXPERT OPINION: Extensive research has demonstrated a lack of performance of chart adaptations in capturing real CV risk in RA population, as well as for RA-specific algorithms. Similarly, limitations have been detected in the use of soluble mediators. The development of a novel, RA-specific algorithm including classical and non-traditional risk factors may be advisable.

The Happiness for Italy's Victory at the European Soccer Championships Costs a "Happy Heart Syndrome".

Takotsubo syndrome (TTS) is usually caused by physical or emotional negative stressors. Sometimes positive emotions trigger a rare form of Takotsubo syndrome, called the "happy heart" syndrome. We discuss the management of a 52-year-old female with happy heart syndrome, the differences between these stress cardiomyopathies and the relationship with hyperthyroidism. LEARNING POINTS: The happy heart syndrome is less common than other stress cardiomyopathies but emergency doctors, cardiologists and all specialists in internal medicine should take into account this cardiomyopathy, which occurs in patients with previous positive emotions. It is triggered by opposite stressors to Takotsubo syndrome and sometimes it may be misdiagnosed. Beyond triggers it has some different clinical features, and the management is similar. It is a rare disease, and is therefore underdiagnosed.Everybody experiences positive emotions in life but only a small percentage develop stress cardiomyopathy. A susceptibility is needed to trigger these cardiomyopathies such as hyperthyroidism, which has to be promptly treated with an endocrinologist's help.In clinical practice it is common to diagnose stress cardiomyopathies without following up the patients. We need to follow up these patients especially looking for concomitant conditions such as hyperthyroidism or hypersympathetic activity, which could present during follow-up.

Severe neurologic impairment and respiratory failure after fall and hip fracture in an elderly woman.

Fat embolism syndrome is a rare complication of long bone fractures and orthopedic surgery. We report a case of a 90-year-old woman who developed severe neurologic impairment and respiratory failure few hours after an accidental fall complicated by fracture of the left femur neck and left humerus.

Intravascular Lithotripsy and Impella Support to Assist Complex LM Angioplasty.

Coronary and peripheral calcifications are associated with increased procedural complexity and suboptimal results in both coronary and peripheral percutaneous interventions. Intravascular lithotripsy (IVL) has recently entered the clinical scenario as a new technology for plaque modification, with promising results. We present a case of high risk left main (LM) percutaneous coronary intervention (PCI), in which peripheral Shockwave IVL was used to facilitate the delivery of an Impella CP via a 14 F sheath and coronary IVL was used to prepare a very calcific left main bifurcation lesion before stent deployment.

Percutaneous Trans-septal Mitral Valve-in-Ring Implantation Using a Transcatheter Balloon-Expandable Transcatheter Heart Valve With Elective Intra-Procedural Artero-Venous ECMO in a Patient With Severely Reduced Left Ventricular Ejection Fraction.

Percutaneous mitral valve-in-valve implantation is an emerging option in patients with surgical bioprosthesis failure or failing mitral annuloplasty and increased surgical risk. We present a case of transcatheter transvenous trans-septal mitral valve-in-ring (TMVinR) procedure, in a patient with severe left ventricular dysfunction and severe mitral regurgitation, after surgical mitral annuloplasty, managed with periprocedural mechanical circulatory support (MCS) with VA-ECMO.