Aim The role of malnutrition among patients with severe heart failure (HF) is not well established. We evaluated the incidence, predictors, and prognostic impact of malnutrition in patients with severe HF. Methods and results Nutritional status was measured using the geriatric nutritional risk index (GNRI), based on body weight, height and serum albumin concentration, with malnutrition defined as GNRI ≤98. It was assessed in consecutive patients with severe HF, defined by at least one high‐risk ‘I NEED HELP’ marker, enrolled at four Italian centres between January 2020 and November 2021. The primary endpoint was all‐cause mortality. A total of 510 patients with data regarding nutritional status were included in the study (mean age 74 ± 12 years, 66.5% male). Among them, 179 (35.1%) had GNRI ≤98 (malnutrition). At multivariable logistic regression, lower body mass index (BMI) and higher levels of natriuretic peptides (B‐type natriuretic peptide [BNP] > median value [685 pg/ml] or N‐terminal proBNP > median value [5775 pg/ml]) were independently associated with a higher likelihood of malnutrition. Estimated rates of all‐cause death at 1 year were 22.4% and 41.1% in patients without and with malnutrition, respectively (log‐rank p < 0.001). The impact of malnutrition on all‐cause mortality was confirmed after multivariable adjustment for relevant covariates (adjusted hazard ratio 2.03, 95% confidence interval 1.43–2.89, p < 0.001). Conclusion In a contemporary, real‐world, multicentre cohort of patients with severe HF, malnutrition (defined as GNRI ≤98) was common and independently associated with an increased risk of mortality. Lower BMI and higher natriuretic peptides were identified as predictors of malnutrition in these patients.

BACKGROUND: Limited real-world data are available regarding the comparison about safety and efficacy of DOACs prescription in very elderly patients (≥85 years) with non-valvular atrial fibrillation (NVAF). Concern about the risk of bleeding with anticoagulation in very older patients still represents an important challenge for clinicians.OBJECTIVE: To evaluate the different prevalence of major bleeding and thromboembolic events between very elderly NVAF patients (≥85 years) compared to those non very elderly (<85 years). METHODS: Single center multidisciplinary registry including NVAF patients treated with DOACs. Primary safety endpoint was 2-year rate of major bleeding. Primary efficacy endpoint was 2-year rate of thromboembolic events. Event-free survival curves among groups were compared using Cox-Mantel test.RESULTS: 908 NVAF consecutive patients were included, of these, 805 patients were <85 years (89%) and 103 patients were very elderly patients with ≥85 years (11%). Compared to patients <85 years, those very elderly have higher CHA2DS2-VASc score (p=0.001), higher rate of hypertension (p=0.001), diabetes mellitus (p=0.030), previous bleeding events (p<0.001), previous stroke/TIA/SE (p=<0.001), heart failure (p=<0.001), and lower creatinine clearance (p<0.001). In terms of safety endpoints (overall ISTH-major bleeding) no significative difference between two groups (p=0.952) were observed up to 2-year follow-up. Systemic thromboembolic event (primary efficacy endpoint) was significantly higher in patients with ≥85 years (p=0.027). The incidence of all-cause death was significantly higher in very elderly patients (p<0.001).CONCLUSIONS: This single center registry, showed that the use of DOACs in very elderly NVAF was safe and is a therapeutic option to be pursued for stroke prevention especially for those who are at high risk of ischemic events.

Nature based solutions (NBS) have been put forward as an effective approach for improving human well-being in the cities during the last decade and many of them make use of vegetation (trees, grass, etc.). The role of vegetation in regulating air temperature and moisture availability is recognized together with its capacity to remove pollutants. Yet, cities lack of quantitative evaluation of these effects that may set the basis for the assessment of the impacts of new NBS. This study conducted within the framework of Life VEG-GAP project shows the impact of vegetation on temperature and, further, on air concentrations and deposition of ozone (O3), particulate matter (PM10) and nitrogen dioxide (NO2) in three European cities: Bologna, Madrid and Milan. The simulations were carried out with two state-of-the-art air quality modelling systems using the same meteorological model WRF with building effect parametrization (BEP) to account for the differences in urban morphology, but different chemical transport models (CTM): CMAQ for Madrid and FARM for Bologna and Milan. The emissions of biogenic volatile organic compounds (BVOC) were produced with the same species-specific model, called PSEM. The simulations were carried out over several nested domains from European to city level where the spatial resolution was 1 km2. The results show that vegetation effects on air temperature, pollutant concentrations and depositions depend on the characteristics of the city (morphology, geographic location and size), of the vegetation (extension and species) and on local chemical conditions (the cocktail of anthropogenic emissions, dispersion conditions, etc.). By applying this one-atmosphere approach for vegetation-meteorology-chemistry, the combined effect of pollutants removal, BVOC emissions distribution as well as changes of wind patterns, temperature, etc., leads to contrasting time-dependent variability patterns of vegetation effects across the cities.

Background: Left ventricular (LV) remodelling (REM) ensuing after ST-elevation myocardial infarction (STEMI), has typically been studied by echocardiography, which has limitations, or cardiac magnetic resonance (CMR) in early phase that may overestimate infarct size (IS) due to tissue edema and stunning. This prospective, multi-center study investigated LV-REM performing CMR in the subacute phase, and 6 months after STEMI.Methods and results: patients with first STEMI undergoing successful primary angioplasty were consecutively enrolled. CMR was done at 30-days and 6-months. Primary endpoint was prevalence at 6 months of LV-REM [>= 12% increase in LV end-diastolic volume index (LV-REMEDV)]; LV-REM by end-systolic volume index in-crease >= 12% (LV-REMESV) was also calculated. Of 325 patients enrolled, 193 with a full set of research-quality CMR images were analyzed. LV-REMEDV and LV-REMESV were present in 36/193 (19%) and 34/193 (18%) patients, respectively. At follow up, LV ejection fraction (EF) improved in patients with or without LV-REMEDV, whilst it decreased in those with LV-REMESV (p < 0.001 for interaction). Considering predictors of LV-REM, IS in the highest tertile was clearly separated from the two lower tertiles. In LV-REMEDV, the highest tertile was associated with significantly higher LV-EDV, LV-ESV, and lower EF.Conclusions: In a contemporary cohort of STEMI patients studied by CMR, prevalence of LV-REMEDV was lower than previously reported. Importantly, our data indicate that LV-REMEDV might not be "adverse" per se, but rather "compensatory", being associated with LV-EF improvement at follow-up. Conversely, LV-REMESV might be an "adverse" phenomenon associated with decreased LV-EF, driven by IS.

ABSTRACT Erdheim-Chester disease (ECD) is a rare multisystemic disorder of non-Langerhans histiocytic cells with a pleomorphic clinical presentation. It affects bones, skin, central nervous system, pituitary gland, ocular tissue, kidneys and perirenal tissue and lungs. Cardiac involvement presents usually with pericardial effusion and right atrial masses, but rarely with conduction system infiltration and subsequent arrhythmic events. Following the discovery of mutations of activating signaling kinase proteins (BRAF, MEK, ALK), the therapeutic landscape has changed to a more precise targeted treatment. Currently vemurafenib is approved for patient with end-organ dysfunction and BRAF-V600E mutation and the prognosis has dramatically improved. Here we present a case of ECD with electrical instability as main clinically relevant manifestation of cardiac involvement.

Intra-Aortic Balloon Pump (IABP) efficacy is critically affected by the inflation/deflation timing. Balloon deflation may cause a sucking effect, and a steal phenomenon on carotid flow. Delaying IABP deflation reduces the degree of this flow reversal, but at the same time exposes patients to the risk of increased proto-systolic afterload with detrimental effects on the LV. The purpose of this study was to investigate the effects of a delayed IABP deflation timing on cerebral blood flow and LV hemodynamics, by means of simultaneous carotid artery ultrasonography, trans-thoracic echocardiography and central aortic pressure analysis. Delaying IABP deflation trigger to the beginning of QRS effectively increased the cerebral blood flow by 20%, mostly by reducing the reverse component flow caused by the diastolic balloon deflation. Extending the deflation to the early systole was safe and favourably impacted on cardiac mechanics, increasing CO by 15% without prolonging LV isovolumetric contraction and ejection phases.

Abstract Background Acute heart failure (AHF) with left ventricle (LV) dysfunction is characterized by a condition of afterload mismatch without preload reserve. LV ejection fraction (LVEF) and stroke volume (SV) become thus dependent on the afterload. Owing to its arteriolar vasodilator properties, sodium nitroprusside (SNP) may reduce LV afterload and result particularly beneficial in this setting, improving LV ejection and ventriculo-arterial coupling (VAC). Hypothesis We aimed to assess the effect of SNP on LV afterload (arterial elastance, Ea), LV contractility (end-systolic elastance, Ees) and VAC (Ea/Ees ratio) in AHF patients. Methods Patients with AHF receiving SNP were prospectively enrolled and underwent Ea and Ees estimation with a single-beat echocardiographic method, before and after SNP infusion. The method was described by Chen et al (J Am Coll Cardiol, 2001) and Kelly et al (Circulation, 1992). Echocardiography was analyzed by a physician blinded to the images timing. Results A total of 36 AHF patients [69% male, age 70 (68, 76) years] received SNP infusion and were enrolled. Patients were admitted for acute coronary syndrome (47%) and for worsening heart failure (53%). SNP median dose was low: 0.30 (0.21-0.57) mcg/kg/min. SNP led to a trend to SBP reduction [140 (131-150) vs 158 (140-168) mmHg; p=0.002]. Heart rate did not change: 84 (75, 92) vs 83 (72, 94) bpm; p=0.800. Afterload (Ea) was reduced following SNP infusion: 2.2 (1.9, 2.7) vs 2.8 (2.4, 3.4) mmHg/mL; p<0.001. LV contractility (Ees) was unchanged: 1.3 (0.8, 2.2) vs 1.5 (0.9, 3.4) mmHg/mL; p=0.13. End-diastolic volume did not change: 148 (110, 205) vs 146 (108, 213) mL; p=0.880. These effects led to an increased SV: 56 (47, 67) vs 50 (38, 56) mL; p<0.001; p<0.001 and, subsequently to an increased EF [40 (30, 50) vs 30 (20, 40)%; p<0.001]. The VAC did not significantly change after SNP infusion: 1.5 (0.9-2.8) vs 1.6 (0.9-2.7); p=0.64. Conclusion In this report on consecutive AHF, low-dose SNP did not significantly affect VAC but led to a significant reduction in LV afterload and to a significant increase in SV and LVEF.

BACKGROUND:In contemporary Cardiac Intensive Care Unit (CICU), bedside intra-aortic balloon pump (IABP) insertion under echocardiographic guidance may be an attractive option for selected patients with cardiogenic shock (CS). Currently available data on this approach are limited.AIM:This study aimed to assess the feasibility and safety of bedside IABP insertion, as compared to fluoroscopic-guided insertion in the Catheterization Laboratory (CathLab), and to describe the clinical features of patients receiving bedside IABP insertion using a standardized technique in real-world CICU practice.METHODS:We prospectively evaluated all patients admitted the CICU who received transfemoral IABP between June 2020 and October 2021. The overall study cohort was divided according to implant strategy in bedside and CathLab groups. The primary outcome was correct radiographic IABP positioning at the first bedside chest X-ray obtained after insertion. Secondary outcomes included IABP-related complications.RESULTS:Among 115 patients, bedside IABP insertion was performed in 35 (30.4%) cases, mainly presenting with CS-related to acute decompensated heart failure (ADHF) (68.6 vs 33.8%; p < 0.001), with lower LVEF, higher proportion of right ventricular involvement and higher need of inotropes/vasopressors, compared to those receiving CathLab insertion. Bedside IABP insertion resulted feasible and safe, with similar rates of correct IABP positioning (82.9 vs. 82.5%; p = 0.963) and IABP-related major vascular complications (5.7 vs. 5.0%; p = 0.874), as compared to CathLab positioning.CONCLUSION:This study suggests the feasibility and safety of bedside IABP insertion, which could be of relevant interest in patients with ADHF-related CS who may not need coronary angiography or other urgent CathLab procedures.

Abstract Background Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, literature data are progressively accumulating, attesting to the possible prognostic role of cardiac troponins in patients who need hospitalization because of COVID-19 infection. Purpose To assess whether myocardial injury (measured by high sensitivity troponins) is an independent cause of disease severity and prognosis. Methods We performed a patient-level metanalysis (PROSPERO ID: CRD42020213209) in unselected patients hospitalized because of COVID-19 infection in whom the severity of respiratory failure was also evaluated at admission. To allow for comparison, troponin values were normalized to their threshold levels to obtain a normalized troponin (nTn) value which was used as a continuous variable in all analysis. Results A total of 722 patients were included in the analysis. Of note, patients who had elevated troponins at hospital admission had a significantly lower oxygenation status than those with normal nTn (PaO2/FiO2 232±215 vs. 276±124 mmHg/%; p<0.001). On the contrary, those with cardiovascular comorbidities had similar PaO2/FiO2 but higher nTn than those without (5.6817 vs. 2.1110 ng/mL; p=0.002). After a median follow-up of 14 days, 180 deaths were observed. At multivariable regression analysis, age, male sex, moderate-severe renal dysfunction (eGFR <30 mL/min/m2) and lower PaO2/FiO2, were independent predictor of death (igure 1). The restricted cubic spline curves in Figure 2A and 2B show the hazard ratios (HRs) and 95% confidence interval for death according to nTn and PaO2/FiO2 levels as continuous variables. A linear increase in the HR is observed with lower PaO2/FiO2 values below the normal value of 300. On the contrary, the nTn spline curve is near-flat with large confidence interval for values above the normality thresholds. Conclusion In patients hospitalized for COVID-19, mortality is mainly driven by gender, age and respiratory failure while myocardial damage is not an independent predictor of worse survival when respiratory function is accounted for. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Aims Controversial data have been published regarding the prognostic role of cardiac troponins in patients who need hospitalization because of coronavirus disease 2019 (COVID-19). The aim of the study was to assess the role of high-sensitivity troponin plasma levels and of respiratory function at admission on all-cause deaths in unselected patients hospitalized because of COVID-19. Methods We pooled individual patient data from observational studies that assessed all-cause mortality of unselected patients hospitalized for COVID-19. The individual data of 722 patients were included. The ratio of partial pressure arterial oxygen to fraction of inspired oxygen (PaO 2 /FiO 2 ) and high-sensitivity troponins was reported at admission in all patients. This meta-analysis was registered on PROSPERO (CRD42020213209). Results After a median follow-up of 14 days, 180 deaths were observed. At multivariable regression analysis, age [hazard ratio (HR) 1.083, 95% confidence interval (CI) 1.061–1.105, P < 0.0001], male sex (HR 2.049, 95% CI 1.319–3.184, P = 0.0014), moderate-severe renal dysfunction (estimated glomerular filtration rate < 30 mL/min/m 2 ) (HR 2.108, 95% CI 1.237–3.594, P = 0.0061) and lower PaO 2 /FiO 2 (HR 0.901, 95% CI 0.829–0.978, P = 0.0133) were the independent predictors of death. A linear increase in the HR was associated with decreasing values of PaO 2 /FiO 2 below the normality threshold. On the contrary, the HR curve for troponin plasma levels was near-flat with large CI for values above the normality thresholds. Conclusion In unselected patients hospitalized for COVID-19, mortality is mainly driven by male gender, older age and respiratory failure. Elevated plasma levels of high-sensitivity troponins are not an independent predictor of worse survival when respiratory function is accounted for.

Aortic valve regurgitation is a not negligible complication of prolonged support with continuous-flow left ventricular assist device (LVAD) and is associated with recurrence of heart failure and reduced survival. Transcatheter aortic valve implantation has been described as a feasible option in this setting, usually with self-expanding prosthesis. Giving the absence of valvular calcification, a proper prosthesis oversizing should be guaranteed in order to achieve sufficient sealing and avoid prosthesis migration or paravalvular leak. Current self-expanding prosthesis may be too small to fit aortic annulus anatomies without calcification and with the need of significant oversize. We report the first case of 32 mm balloon expandable Myval prosthesis implantation in a patient with LVAD-related aortic regurgitation. Large balloon-expandable prosthesis can be considered when a significant oversize is needed.

EXTRACORPOREAL membrane oxygenation (ECMO) theoretically could be useful in patients with high-risk pulmonary embolism (PE). Current European Society of Cardiology guidelines give a low-grade recommendation for ECMO usage in patients with circulatory collapse or cardiac arrest, reporting that it may be considered (class IIb – level of evidence C) in combination with surgical embolectomy or catheter-based treatment.1Konstantinides S.V. Meyer G. Becattini C. et al.2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).Eur Heart J. 2020; 41: 543-603Crossref PubMed Scopus (1142) Google Scholar Caution is given regarding the use of ECMO in combination with systemic thrombolysis or as a stand-alone technique because of excessive risk of bleeding in one case and controversial efficacy in the other. The aim of the present study was to describe clinical characteristics and outcomes of high-risk acute PE patients treated with ECMO according to the first reperfusion strategy used (European Society of Cardiology guidelines–recommended strategy [surgical embolectomy or catheter-based treatment], systemic thrombolysis, or none). A systematic review of studies evaluating ECMO support in patients with acute PE was performed. PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched (until April 17, 2020). For this analysis, case reports, case series, and cohort studies clearly reporting patient-level data were included. Baseline clinical characteristics, clinical presentation details, reperfusion strategies, and in-hospital outcomes were extracted for each included patient and collected in a dedicated form. Patients were divided in the following three groups based on the first reperfusion strategy performed: surgical embolectomy or catheter-based treatment, systemic thrombolysis, or none. Continuous variables are presented as medians and interquartile ranges and were compared with the Kruskal-Wallis test; categorical variables are presented as numbers and percentages and were compared with the chi-square test. The effect of reperfusion strategy on in-hospital mortality was adjusted for relevant covariates by means of multivariate binary logistic regression. Statistical analyses were performed with STATA, Version 13.0 (Stata Corp, College Station, TX). A total of 74 articles reporting patient-level data for 140 patients were included in the final analysis (Supplementary Table 1). The first attempted reperfusion strategy was surgical embolectomy or catheter-based treatment in 59 patients (42.1%), whereas systemic thrombolysis was the first therapy used in 53 patients (37.9%) and no reperfusion therapy was implemented in 28 patients (20.0%). Cardiac arrest as indication for ECMO was significantly higher among patients who underwent systemic thrombolysis (81.1%) compared with patients who underwent surgical embolectomy or catheter-based treatment (57.6%) or who did not undergo reperfusion strategies (64.3%; p = 0.026). Rescue ECMO (bailout strategy) was more frequent in the systemic thrombolysis group (59.6%) compared with the surgical embolectomy or catheter-based treatment group (35.1%) and the no-reperfusion group (0.0%; p < 0.001); in contrast, immediate (upfront) ECMO support was more frequent in the no-reperfusion group (100%) compared with the surgical embolectomy or catheter-based treatment (64.9%) and systemic thrombolysis groups (40.4%; p < 0.001). Duration of ECMO support was significantly higher in the no-reperfusion group (p = 0.032). Details on reperfusion strategies adopted during hospital stay are reported in Table 1. Of note, surgical embolectomy and catheter-based treatment were performed as a secondary strategy (after systemic thrombolysis) in 15.1% and 11.3% of patients, respectively; systemic thrombolysis was performed as a secondary strategy (after surgical embolectomy or catheter-based treatment) in 1.7% of patients. In-hospital all-cause mortality, successful weaning from ECMO, and fatal bleeding were not significantly different among the three groups. A significantly higher rate of in-hospital major bleeding was observed in the systemic thrombolysis group (44.4%) compared with the surgical embolectomy or catheter-based treatment (22.9%) and no-reperfusion groups (14.8%; p = 0.013). After adjustment for age, cardiac arrest as ECMO indication, and use of immediate (upfront) ECMO, the first reperfusion strategy was not independently associated with in-hospital all-cause mortality (adjusted odds ratio 0.87, 95% confidence interval 0.29-2.60, p = 0.797 for systemic thrombolysis vs. surgical embolectomy or catheter-based treatment; adjusted odds ratio 0.87, 95% confidence interval 0.25-3.07, p = 0.825 for no-reperfusion vs. surgical embolectomy or catheter-based treatment).Table 1Baseline Characteristics, Clinical Presentation and ECMO Details, Reperfusion Therapy, and In-Hospital Clinical Outcomes According to the First Reperfusion Strategy UsedSurgical Embolectomy or Catheter-Based Treatment (n = 59)Systemic Thrombolysis (n = 53)No Reperfusion Strategy (n = 28)p-valueBaseline characteristics Age (y)50 (37-63)54 (37-65)52 (30-62)0.567 Female sex22/55 (43.6)30/45 (66.7)14/27 (51.9)0.070 Pregnancy5/53 (9.4)5/38 (13.2)1/24 (4.2)0.502 Smoking history2/53 (3.8)2/38 (5.3)1/24 (4.2)0.942 Oral contraceptives1/53 (1.9)1/38 (2.6)2/24 (3.5)0.339 Previous DVT or PE5/53 (9.4)1/38 (2.6)1/24 (4.2)0.370 Active cancer8/53 (15.1)6/38 (15.8)1/24 (4.2)0.347 Immobilization11/53 (20.8)7/38 (18.4)8/24 (33.3)0.357 Known thrombophilia4/53 (7.6)2/38 (5.3)1/24 (4.2)0.820 Recent surgery16/53 (30.2)13/38 (34.2)8/24 (33.3)0.913 Same hospitalization12/53 (22.6)6/38 (15.8)6/24 (25.0)0.624 Within 1 mo3/53 (5.7)6/38 (15.8)2/24 (8.3)0.262 Before 1 mo1/53 (1.9)1/38 (2.6)0/24 (0.0)0.738Clinical presentation and ECMO details ECMO for cardiac arrest34/59 (57.6)43/53 (81.1)18/28 (64.3)0.026 ECMO for cardiogenic shock25/59 (42.4)10/53 (18.9)10/28 (35.7)0.026 Immediate (upfront) ECMO37/57 (64.9)19/47 (40.4)25/25 (100.0)< 0.001 Rescue (bailout) ECMO20/57 (35.1)28/47 (59.6)0/25 (0.0)< 0.001 VA-ECMO59/59 (100.0)51/53 (96.2)25/28 (89.3)0.042 VV-ECMO3/59 (5.1)5/53 (9.4)4/28 (14.3)0.344 ECMO support duration (h)75 (36-144)48 (19-120)110 (72-144)0.032Reperfusion strategy Surgical embolectomy40/59 (67.8)8/53 (15.1)0/28 (0.0)< 0.001 Any catheter-based procedure21/59 (35.6)6/53 (11.3)0/28 (0.0)< 0.001 Transcatheter embolectomy12/59 (20.3)4/53 (7.6)0/28 (0.0)0.011 Ultrasound-assisted thrombolysis7/59 (11.9)1/53 (1.9)0/28 (0.0)0.026 Catheter-directed thrombolysis11/59 (18.6)2/53 (3.8)0/28 (0.0)0.004 Combined catheter-based technique7/59 (11.9)1/53 (1.9)0/28 (0.0)0.026 Systemic thrombolysis1/59 (1.7)53/53 (100.0)0/28 (0.0)< 0.001In-hospital clinical outcomes All-cause death15/59 (25.4)18/53 (34.0)6/28 (21.4)0.421 Successful ECMO weaning44/53 (83.0)34/39 (87.2)19/24 (79.2)0.697 Fatal bleeding2/48 (4.2)2/45 (4.4)0/27 (0.0)0.547 Major bleeding11/48 (22.9)20/45 (44.4)4/27 (14.8)0.013NOTE. Data are presented as median (interquartile range) or n/N (%).Abbreviations: DVT, deep vein thrombosis; ECMO, extracorporeal membrane oxygenation; PE, pulmonary embolism; VA, venoarterial; VV, venovenous. Open table in a new tab NOTE. Data are presented as median (interquartile range) or n/N (%). Abbreviations: DVT, deep vein thrombosis; ECMO, extracorporeal membrane oxygenation; PE, pulmonary embolism; VA, venoarterial; VV, venovenous. According to current European Society of Cardiology guidelines, ECMO may be considered in patients with high-risk acute PE presenting with shock or cardiac arrest, in combination with surgical embolectomy or catheter-based treatment.1Konstantinides S.V. Meyer G. Becattini C. et al.2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).Eur Heart J. 2020; 41: 543-603Crossref PubMed Scopus (1142) Google Scholar Considering the well-known ECMO-related complications and the potential effect on mortality of bleeding events,2Abrams D. Combes A. Brodie D. Extracorporeal membrane oxygenation in cardiopulmonary disease in adults.J Am Coll Cardiol. 2014; 63: 2769-2778Crossref PubMed Scopus (282) Google Scholar, 3Zangrillo A. Landoni G. Biondi-Zoccai G. et al.A meta-analysis of complications and mortality of extracorporeal membrane oxygenation.Crit Care Resusc. 2013; 15: 172-178PubMed Google Scholar, 4Aubron C. DePuydt J. Belon F. et al.Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation.Ann Intensive Care. 2016; 6: 97Crossref PubMed Scopus (118) Google Scholar, 5Harjola V.P. Mebazaa A. Čelutkienė J. et al.Contemporary management of acute right ventricular failure: A statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 226-241Crossref PubMed Scopus (283) Google Scholar a careful balance between expected benefits and risks is necessary in daily practice before applying each reperfusion therapy in PE patients needing invasive cardiopulmonary support. Despite current European Society of Cardiology guidelines recommendations, our systematic review showed that in the realworld, many PE patients ultimately receive ECMO along with systemic thrombolysis (at the expense of higher bleeding risk) or without any reperfusion therapy, apparently with similar in-hospital survival. None. Download .docx (.08 MB) Help with docx files

Abstract Funding Acknowledgements Type of funding sources: None. Aims and Methods Aim of this study was to assess the feasibility of a bolus-free, low-dose levosimendan infusion for acute decompensated heart failure (ADHF) with hypoperfusion. All consecutive patients who received levosimendan without intravenous bolus at our Department for ADHF in the last 6 months were included in this is a single-center retrospective study. To avoid abrupt drop in blood pressure, all patients started infusion at 0.01 mcg/kg/min, and gradual titration was achieved, up to 0.1 mcg/kg/min. Continuous variables are reported as medians (IQR), categorical as proportions. Paired measures were compared with the Wilcoxon signed-rank test. p-value was set at 5%. Analyses were performed using RStudio v1.3. Results We included 26 patients [males 84.6%; age 72 (59-76) years]. Patients had severe LV dysfunction [LVEF of 20 (20-25)%] and moderate/severe RV dysfunction in 46.2%. Most patients were admitted for cardiogenic shock (26.9%) or low-output state (61.5%); baseline serum lactate was 1.6 (1.2-3.2) mmol/L. Etiology was ACS in 26.9% patients, worsening HF in 53.8%, and valvular disease in 26.9%. All patients required inotropes: 73.1% required adrenaline [max dose 0.10 (0.05-0.15) mcg/kg/min]; 50.0% required noradrenaline [max dose 0.10 (0.05-0.18) mcg/kg/min]; 26.9% received levosimendan alone [max dose 0.05 (0.03-0.10) mcg/kg/min]. Levosimendan was used in combination with adrenaline in 69.2%, after 3 (0-4) days of adrenaline initiation. Duration of levosimendan infusion was 3 (1-4) days. MCS was pursued in 69.2% [57.7% IABP, 15.4% Impella CP, and 3.8% VA-ECMO]. Oro-tracheal intubation was required in 50.0%, CVVHDF was required in 11.5% patients. No patient required levosimendan interruption for hypotension/arrhythmia. In-hospital mortality was 7.7%. One patients underwent successful LVAD implantation, and one patient was referred for HTx. Invasive hemodynamic data, before and during levosimendan, was available for 7 patients. Initiation of levosimendan led to a non-significant drop in SVR [14.8 (13.3-16.9) vs 19.5 (14.6-25.4) WU; p = 0.093], but SBP was unchanged (p = 0.470). Left ventricular systolic performance was improved: CI [2.6 (2.4-2.7) vs 2.2 (2.0-2.3) Lt/min/m²; p = 0.016]; CPO [0.9 (0.8-1.0) vs 0.8 (0.8-0.9) W; p = 0.031]. Mean PAP (p = 0.297), and PCWP (p = 0.149) remained unchanged. Notably, no significant adjustments in diuretic (p = 0.422) or adrenaline (p = 0.999) doses, IABP counterpulsation ratio (p = 0.999), or Impella flow (p = 0.999) were recorded between these longitudinal assessments. As a result of improved myocardial function, LVEF increased from admission to discharge [20 (20-25) vs 25 (20-32)%; p = 0.024]. Discussion This preliminary study reports on a bolus-free, low-intensity levosimendan regimen for ADHF with hypoperfusion. Levosimendan improved indexes of myocardial performance. In this cohort, levosimendan often required concomitant inopressor and was started at a very low dose to avoid abrupt drop in blood pressure. Abstract Figure 1

BACKGROUND:Limited clinical data exist describing the use of direct oral anticoagulants (DOACs) in patient with extreme body weight. Thus, the International Society of Thrombosis and Haemostasis (ISTH) recommends avoiding DOACs in patients with weight >120 Kg, and on the contrary, no restrictions exist for underweight patients.OBJECTIVE:To evaluate the effects of extreme body weight on DOAC activity and to compare the clinical outcomes of patients with an extreme body weight versus patients with a normal weight (61-119 Kg) treated with DOACs.METHODS:Single tertiary care Italian centre multidisciplinary registry including nonvalvular atrial fibrillation (NVAF) patients treated with DOACs. Based on weight, three subcohorts were defined: (i) underweight patients (≤60 Kg); (ii) patients with a normal weight (61-119 Kg, as control group); and (iii) overweight patients (≥120 Kg). Primary efficacy endpoint was 2-year rate of thromboembolic events. Primary safety endpoint was 2-year rate of major bleeding. Event-free survival curves among groups were compared using Cox-Mantel test.RESULTS:812 NVAF patients were included, 108 patients weighed ≤60 Kg (13%, underweight), 688 weighed between 61 and 119 Kg (85%, normal weight), and 16 weighed ≥120 Kg (2%, overweight). In particular, among underweight patients, dabigatran was prescribed in 26% patients, apixaban in 27%, rivaroxaban in 28% and edoxaban in 22% ones. Instead, among overweight patients, 44% were treated with dabigatran, 25% with apixaban, 25% with rivaroxaban and 4% with edoxaban. Underweight patients were older, more frequently women, with lower creatinine clearance and a history of previous strokes, resulting in higher CHA2DS2-VASc score than in both remaining groups. Up to 2 years, no statistically significant difference was observed between the three groups of weight for thromboembolic events (P = .765) and for overall bleeding (P = .125), but a trend towards decreased overall bleeding rates was noticed as weight increased (24.1% vs 16.7% vs 12.5%, respectively).CONCLUSION:In this tertiary care centre registry, 15% of patients treated with DOACs presented an extreme weight. Compared to patients with a normal weight, no significant rates of thromboembolic events were observed for underweight or overweight patients. A trend towards decreased overall bleeding frequency as weight increased was highlighted up to 2 years. The present results should be considered as preliminary and hypothesis generating.

L’insufficienza aortica è una complicanza non trascurabile del supporto prolungato con sistema di assistenza ventricolare sinistra a flusso continuo (LVAD) ed è associata a recidiva di scompenso cardiaco e ridotta sopravvivenza. L’impianto transcatetere di valvola aortica è stato proposto in questo contesto, usualmente utilizzando protesi autoespandibili. Considerando l’assenza di calcificazioni valvolari, è necessario garantire un sufficiente sovradimensionamento della protesi per ottenere l’ancoraggio della medesima in assenza di rigurgito paravalvolare e riducendone il rischio di migrazione. Le protesi autoespandibili attualmente in commercio sono spesso troppo piccole per adattarsi a queste anatomie dell’anulus aortico, prive di calcificazioni e con necessità di significativo sovradimensionamento. Riportiamo il primo caso di impianto di protesi “balloon-expandable” Myval 32 mm per il trattamento di una insufficienza aortica correlata a LVAD. L’impianto di protesi “balloon expandable” di grossa dimensione può essere considerato quando è necessario un significativo sovradimensionamento della medesima.

Dual antiplatelet therapy combining aspirin with a P2Y12-receptor inhibitor reduces atherothrombotic events following an acute coronary syndromes (ACS), but the relative merits of different P2Y12 inhibitors remain unclear, despite several recent large-scale trials. We performed a network meta-analysis, representing the largest evidence to date to inform P2Y12 inhibitor choice in patients with ACS. Fourteen studies were included, for a total population of 145,019 patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review. A network meta-analysis using a frequentist approach with surface under the cumulative ranking probability calculation was performed. Major adverse cardiovascular events (MACE), all-cause death, myocardial infarction (MI), definite stent thrombosis (ST) and major bleeding at 30-day and 1-year all-cause death and MI were the study endpoints. At 30-day, prasugrel was superior to both clopidogrel and ticagrelor in MACE, all-cause death and definite ST endpoints. Both prasugrel and ticagrelor were superior to clopidogrel in MI endpoint. Ticagrelor also reduced all-cause death compared with clopidogrel. Ticagrelor, prasugrel, and clopidogrel resulted equivalent in terms of the safety outcome of 30-day major bleeding. No significant difference was found among clopidogrel, prasugrel, and ticagrelor with respect to 1-year MACE outcome. Both prasugrel and ticagrelor reduced the occurrence of 1-year all-cause death compared with clopidogrel. Prasugrel reduced 1-year MI rate as compared with clopidogrel, while ticagrelor did not. At probability analyses, prasugrel ranked best in all 30-day and 1-year efficacy and safety endpoints. In conclusion, in this network meta-analysis, prasugrel showed the highest efficacy in reducing adverse outcomes in ACS patients and had the highest probability of being the best P2Y12 inhibitor to reduce hard adverse events both at 30-day and 1-year follow-up.

BackgroundThis study was designed to confirm in a large population of unselected patients the promising results of Ultimaster® biodegradable polymer sirolimus-eluting stent (BP-SES) already shown in previous trial.MethodsULISSE is an observational, multicenter, national registry evaluating all patients undergoing PCI with the Ultimaster® BP-SES. Incidence of 1-year TLF (cardiac death or target vessel MI or clinically indicated TLR) was the primary endpoint. Pre-specified subgroup analysis was performed for diabetic patients and for those with lesion longer than 25mm, bifurcation and CTO lesions.Results1660 patients were enrolled in 9 Italian cardiology centers, 82% were males, mean age of 68±10years, and 29% were diabetics. Overall 2422 lesions were treated, 65% type B2/C lesions, 7% CTOs, 17% bifurcations and 38% long lesions. The incidence of 1-year TLF was 5%, with 3.2% of clinically indicated TLR. TLF occurred in 8% of the patients with diabetes mellitus, and 7% in bifurcation, 6.7% in CTO and 6.2% in long lesions. Definite overall ST was 0.9%, and 1.2% in patients treated for type B2/C lesions. Multivariate logistic regression analysis identified stenting on unprotected LMT (OR=4.80), stenting on ISR lesion (OR=3.19) and need for rotational atherectomy (OR=6.24) as the strongest independent predictors of TLF.ConclusionsThe results of this national all-comers registry show that the Ultimaster® BP-SES real-world performance was comparable with that observed in the clinical trial, with low rate of primary endpoint and TLR. Long term follow-up will be necessary to prove the theoretical advantage of the BP-SES over time.

BACKGROUND:Rotational atherectomy (RA)-related complications (e.g., no-reflow and perforation) may be associated with increased risk of contrast-induced nephropathy (CIN), causing hypotension, acute heart failure, and periprocedural myocardial infarction. Our aim was to evaluate the incidence of CIN in patients undergoing RA-based vs. non-RA-based percutaneous coronary intervention (PCI).METHODS:This single-center retrospective registry included all patients who underwent PCI between 2012 and 2016 for whom post-procedural creatinine was determined. Study endpoint was CIN, defined as an increase of serum creatinine ≥0.3 mg/dL or ≥50% from baseline within 72 h post-PCI. Propensity score matching (PSM) was performed to account for selection bias between RA and non-RA patients.RESULTS:Study population included 2580 patients: 70 (3%) had RA PCI and 2510 (97%) had non-RA PCI. Following PSM, there were 70 patients in RA and 280 patients in non-RA group with good overall adjustment between groups, although RA patients received larger contrast volume (263±126 vs. 224±118 mL, P=0.01) and showed higher Mehran risk score at baseline (11.1±6.6 vs. 8.9±4.8, P=0.01). The incidence of CIN was similar between RA and non-RA patients (15.7% vs. 13.2%, P=0.59). New need for dialysis was required in 0% vs. 0.7% patients, respectively (P=0.48). On multivariate analysis, RA PCI was not independently associated with development of CIN.CONCLUSIONS:Despite being performed in patients with a higher burden of comorbidities and with larger volumes of contrast, RA PCI is not associated with higher risk of CIN, compared with PCI in non-RA patients.