Acute pulmonary embolism (PE) is one of the leading causes of in-hospital mortality and the third more frequent cause of cardiovascular mortality. The optimal management of PE patients is a clinical conundrum since the spectrum of PE manifestations varies largely depending on clinical and hemodynamic features. According to international guidelines, systemic thrombolysis ranks as first-line treatment for high-risk PE complicated by hemodynamic instability. However, a not negligible proportion of PE patients present contraindications to systemic thrombolysis. Among hemodynamically stable patients with right ventricular dysfunction (“intermediate risk” PE), anticoagulation alone remains the standard treatment but is still associated with relevant risk. Novel interventional techniques including catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches have been developed to facilitate reperfusion while mitigating the risk of bleeding. In this review, we provide a comprehensive and contemporary overview of pharmacological and interventional treatments for PE, moving from clinical evidence to practical recommendations and future directions.

The Swiss Ticino regional pulmonary embolism response team (PERT) features direct access to various pharmacomechanical PE management options within a hub/spoke system, by integrating evidence, guidelines’ recommendations and personal experiences. This system involves a collaborative management of patients among the hospitals distributed throughout the region, which refer selected intermediate–high or high PE patients to a second-level hub center, located in Lugano at Cardiocentro Ticino, belonging to the Ente Ospedaliero Cantonale (EOC). The hub provides 24/7 catheterization laboratory activation for catheter-based intervention (CBI), surgical embolectomy and/or a mechanical support system such as extracorporeal membrane oxygenation (ECMO). The hub hosts PE patients after percutaneous or surgical intervention in two intensive care units, one specialized in cardiovascular anesthesiology, to be preferred for patients without relevant comorbidities or with hemodynamic instability and one specialized in post-surgical care, to be preferred for PE patients after trauma or surgery or with relevant comorbidities, such as cancer. From April 2022 to December 2023, a total of 65 patients were referred to the hub for CBI, including ultrasound-assisted catheter-directed thrombolysis (USAT) or large-bore aspiration intervention. No patient received ECMO or underwent surgical embolectomy.

Aims: Microvascular obstruction (MVO) following ST-elevation myocardial infarction (STEMI) is associated with greater infarct size, adverse left-ventricular (LV) remodeling and reduced ejection fraction. We hypothesized that patients with MVO may constitute a subgroup of patients that would benefit from intracoronary stem cell delivery with bone marrow mononuclear cells (BMCs) given previous findings that BMCs tended to improve LV function only in patients with significant LV dysfunction. Methods and Results: We analyzed the cardiac MRIs of 356 patients (303 M, 53 F) with anterior STEMIs who received autologous BMCs as part of 3 clinical trials that included the Cardiovascular Cell Therapy Research Network (CCTRN) TIME trial and its pilot (n=157), the multi-center French BONAMI trial (n=91) and the SWISS-AMI trial (n=108). All patients received 100 - 150 million intracoronary autologous BMCs or placebo / control 3 - 7 days following primary PCI and stenting. LV function, volumes, infarct size and MVO were assessed prior to infusion of BMCs and 1 year later. Patients with MVO (n=210) had reduced LVEF and much greater infarct size and LV volumes compared to patients without MVO (n=146) (all p < 0.01) (TABLE). At 12 months, patients with MVO who received BMCs had significantly greater recovery of LVEF compared to those patients with MVO who received placebo (absolute difference = 2.7 %; p < 0.05). Similarly, the changes in left-ventricular end-diastolic (LVEDV) and end-systolic volumes (LVESV) were consistent with significantly less adverse remodeling in patients with MVO who received BMCs compared to placebo ( % change; LVEDV = -9.7%; p < 0.05 and LVESVI = -14.7 %; p = 0.006). In contrast, patients without MVO experienced no benefit of BMC administration compared to placebo. Conclusion: The presence of MVO on cardiac MRI following STEMI identifies a subgroup of patients who may benefit from intracoronary stem cell delivery of BMCs.

AIMS:The Swiss national registry on percutaneous mitral valve interventions (MitraSwiss) was established in 2011 to monitor safety/efficacy of percutaneous mitral valve repair (PMVR) with the MitraClip device. The aim of this analysis was to report the outcome after PMVR in a real-world, all-comers population and its predictors after inclusion of more than 1,200 patients, stratifying the results according to mitral regurgitation (MR) aetiology. Here we report the in-hospital, short and midterm outcomes of all patients prospectively enrolled. METHODS AND RESULTS:Since 2011, MitraSwiss has enrolled 1,212 patients with moderate and severe MR of functional (FMR) or degenerative (DMR) aetiology treated with PMVR in 10 centres. Pre-specified endpoints included clinical, echocardiographic and functional parameters with follow-up planned up to five years. Outcomes are compared according to MR aetiology. Acute procedural success was achieved in 91.5% of cases, with no differences between FMR and DMR and sustained good midterm results. NYHA class and pulmonary pressure improved significantly in both cohorts. Cumulative probability of death at five years was 54% (95% CI: 45-63) in FMR and 45% (95% CI: 37-54) in DMR (HR 1.15, p=0.009). Age, anaemia, impaired renal function and reduced left ventricular ejection fraction resulted in being independent predictors of death at five years. CONCLUSIONS:In a large contemporary cohort of non-surgical patients with severe MR, the safety and effectiveness of PMVR have been confirmed. At midterm follow-up, mortality and MACE were lower in DMR patients, though MR aetiology was not directly and independently associated with outcome.

BACKGROUND:Studies indicate no clear impact of intracoronary injection of bone-marrow unselected mononuclear cells (BM-MNC) after acute myocardial infarction (AMI) on left-ventricular function (LVEF). Strain parameters by cardiovascular magnetic resonance (CMR) have been proposed to be more sensitive to functional changes of the heart. The aim of the present study was to assess changes of global longitudinal (GLS) and circumferential strain (GCS) in a group of patients treated with BM-MNC after AMI. METHODS:One-hundred and forty-nine patients with successfully reperfused AMI and LV dysfunction (LVEF<45%) were retrospectively included into this sub-study of the SWISS-AMI multicentre trial. Patients were divided into control (N = 54), early (5-7 days after AMI, N = 51) and late BM-MNC treatment groups (3-4 weeks, N = 44). The endpoint was the change of GLS and GCS as obtained from cine sequences 4 and 12 months after AMI using feature tracking algorithm. RESULTS:In unadjusted analyses, the absolute change of GLS for the early treatment group from baseline to 4 months was 2.5 ± 4.3 (p < 0.01), to 12 months 2.7 ± 5.7% (p = 0.004). For late treatment, it was 1.5 ± 4.0% (p = 0.039, 4 months) and 2.5 ± 5.6% (p = 0.015, 12 months). For controls 0.7 ± 4.7% (p = 0.378), 0.8 ± 3.9% (p = 0.253) respectively. Adjusting for different baseline values, neither an overall treatment effect (both time-points) of BM-MNC nor a treatment time-related (only early or late) effect could be shown for all functional parameters. CONCLUSIONS:Among patients after AMI with successful reperfusion and LV dysfunction, intracoronary infusion of BM-MNC early or late after AMI did not improve global strain parameters at 4- or 12-months follow-up. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov. Unique identifier: NCT00355186.

Recent advances in different percutaneous treatments made insertion of large-caliber sheaths in the femoral veins more common. Venous punctures are historically managed by initial manual compression with subsequent application of a compression bandage and bed rest. We describe a modified “figure-of-eight” suture technique for minimizing the risk of accidental puncture of the vein while grabbing the subcutaneous tissue. We examined the safety and feasibility of this technique combined with early mobilization in a real-world setting. We performed a retrospective analysis on 56 consecutive patients undergoing percutaneous mitral valve repair using large femoral venous access. The patient population was heterogeneous and bleeding risk characteristics were common. Bleeding Academic Research Consortium Consensus (BARC)-classifiable bleeding complications occurred in eight patients (14%), BARC of two events or more in five patients (8.9%), and BARC of three or more event in only one patient (1.8%), which is a comparable success rate to large venous access closure with suture-mediated closure devices. No BARC Type 3b or BARC Type 5 bleeding occurred. During routine clinical follow-up, no groin-related problems were reported in all patients. Closure of large femoral venous access using a modified temporary subcutaneous figure-of-eight suture in combination of a light compression bandage and bed rest for 2 to 4 hours provides a safe and low-cost alternative to closure devices for early mobilization.

A 69-year-old male with the history of previous colon cancer in remission and structural post-traumatic epilepsy complained of dyspnoea and epigastric pain on exertion in the previous 6 months.He denied symptoms at rest or prolonged symptoms.During the previ-CARDIOVASCULAR MEDICINE -KARDIOVASKULÄRE MEDIZIN -MÉDECINE CARDIOVASCULAIRE 2018;21(1):22-24 THE INTERESTING ECG 22 ous week the symptoms had become worse and he visited his family physician.Figure 1 shows the resting ECG recorded by the family physician during a painfree period.A cardiac troponin T test during the visit was negative.

BACKGROUND:Both duration and morphology of the T-wave are regarded important parameters describing repolarization of the ventricles. Conventionally, T-wave concordance is explained by an inverse relation between the time of depolarization (TD) and repolarization (TR). Little is known about T-wave morphology and TD-TR relations in patients with heart failure.METHODS:Electro-anatomic maps were obtained in the left (LV) and right ventricle (RV) and in the coronary sinus (CS) in patients with heart failure with narrow (nQRS, n=8) and wide QRS complex with (LBBB, n=15) and without left bundle branch block (non-LBBB, n=7). TD and TR were determined from the thus acquired electrograms.RESULTS:In nQRS and non-LBBB patients, TD-TR relations had a slope between 0 and +1, indicating that repolarization followed the sequence of depolarization. In LBBB patients, repolarization occurred significantly earlier in the RV than in the LV, fitting with the idea that the discordant T-waves in LBBB are secondary to the abnormal depolarization sequence. However, the slopes of the TD-TR relations in the LV and CS were not significantly different from zero, indicating no major spatial gradient in LV repolarization, despite a considerable gradient in depolarization. Remarkable was also the large (~100ms) transseptal gradient in repolarization. Values of the slopes of the TD-TR relation overlapped between the three patient groups, despite a difference in T-wave morphology between LBBB (all discordant) and nQRS patients (all flat/biphasic).CONCLUSIONS:Discordant T-waves in LBBB patients are explained by interventricular dispersion in repolarization. T-wave morphology is determined by more factors than the TD-TR relation alone.

We here report the case of a patient with significant recurrent “intraclip” mitral regurgitation following the implant two Mitraclips for a functional mitral incontinence. An AMPLATZER Vascular Plug II deployed between the two clips with acute procedural success with post-procedural trans-esophageal echocardiography (TEE) showing a mild residual mitral regurgitation with trivial trans-valvuar gradients. Few months after the procedure, the patient was newly admitted for acute heart failure due to recurrent MR with a partial detachment of both clips and of the vascular plug forcing a surgical solution for the case.

AIMS:The aim of the study was to retrospectively evaluate safety and patient satisfaction of same-day discharge after elective radial coronary angiography/percutaneous coronary intervention (PCI) after the implementation of a radial lounge facility. METHODS:All patients admitted to our radial lounge with a planned same-day discharge after an uncomplicated coronary angiography/PCI, having a co-living caregiver, were day enrolled in the study. Rates of same-day discharge, unplanned overnight stay, and in-hospital and first complications [death, myocardial infarction (MI), unplanned coronary angiography, access site hematoma, bleedings requiring hospitalization] were analysed; satisfaction was also evaluated through a questionnaire. RESULTS:From February 2015 to January 2016, 312 patients with a mean age of 66.6 ± 10.8 years were admitted to the radial lounge (coronary angiography, n = 232; PCIs, n = 80). Of them, 245 (78.5%) were discharged the same day. Mean radial lounge monitoring was 6:35 h (interquartile range 5:30-7:30 h). No episodes of death/MI/unplanned coronary angiography were observed both in same-day discharged and postponed patients. Reasons to postpone discharge were: PCI deemed to need prolonged monitoring in 31, patient's preference in 14, femoral shift in 13, surgery in four, chest pain in four, and bleeding in one. At day 1, 11 access site hematoma and one hospitalization for access site bleeding were reported. Patients reported complete satisfaction in 97% of cases. Unplanned overnight stay was common among PCIs patients (RR 6.2, 95% CI 3.9-9.9, P < 0.001). CONCLUSION:A low rate of minor complications was observed in elective radial coronary angiography and PCIs showing the feasibility and safety of the development of an institutional protocol for same-day discharge after the implementation of a radial lounge facility.

Background: Percutaneous mitral valve repair (PMVR) using theMitraClip (TM) system has become a valuable alternative in patients with severe mitral regurgitation (MR) and high surgical risk. We sought to evaluate the prognostic value of the SYNTAX II score (SSII) in patientswith concomitant coronary artery disease (CAD) undergoing a Mitraclip procedure.Methods: In seventy-five consecutive patients who underwent PMVR at the University Heart Center Zurich and the Cardiocentro Ticino, the SSSII was calculated at baseline. Clinical endpoints comprised of all-causemortality, mitral valve surgery due to failure of PMVR or reoperation, hospitalization for congestive heart failure, heart transplantation and the composite of all four endpoints.Results: Patientswere followed for a median of 271 days. Andwere divided in tertiles of SSII: SSII low= 46.5 (n= 25), SSII mid 46.6-54.4 (n= 25) and SSII high = 54.5 (n= 25). Patients in the highest SSII tertile had a lower left ventricular ejection fraction (33% vs. 40% vs. 53%) with a higher log-BNP (3.6 vs. 3.45 vs. 3.16) when compared to SSII mid and SSII low, respectively. However, the anatomical syntax score (SS) did not differ significantly within the tertiles (9.1 +/- 6.3 (SSII Low) vs 9.5 +/- 7.6 (SSII Mid) vs 10.2 +/- 6.7(SSII High), p= 0.837). The primary endpoint occurred in 33% of patients (n = 25). By multivariate analysis patients in the high SSII tertile (OR = 6.12, 95% confidence interval, [CI] 1.45-25.86, p= 0.014) and patientswith a history ofMI (OR= 3.57, 95% confidence interval, [CI] 1.17-10.88, p = 0.025) were at significantly higher risk of experiencing adverse events. Furthermore, in a combined outcome ROC curve analysis, the SSII showed good discrimination with an AUC of 0.73, p= 0.001. A cutoff SSII N49 has been identified to have a sensitivity of 83% and specificity of 53% with approximately 45% of the patients experiencing an event during follow-up.Conclusion: Using SSII in CAD patients undergoingPMVR is feasible and of prognostic significance hencewidening its clinical utility in valvular heart disease. (C) 2017 Elsevier B.V. All rights reserved.

RATIONALE Intracoronary delivery of autologous bone marrow-derived mononuclear cells (BM-MNC) may improve remodeling of the left ventricle (LV) after acute myocardial infarction (AMI). OBJECTIVE To demonstrate long-term efficacy of BM-MNC treatment after AMI. METHODS AND RESULTS In a multicenter study, we randomized 200 patients with large AMI in a 1:1:1 pattern into an open-labeled control and 2 BM-MNC treatment groups. In the BM-MNC groups, cells were either administered 5 to 7 days (early) or 3 to 4 weeks (late) after AMI. Cardiac magnetic resonance imaging was performed at baseline and after 12 months. The current analysis investigates the change from baseline to 12 months in global LV ejection fraction, LV volumes, scar size, and N-terminal pro-brain natriuretic peptide values comparing the 2 treatment groups with control in a linear regression model. Besides the complete case analysis, multiple imputation analysis was performed to address for missing data. Furthermore, the long-term clinical event rate was computed. The absolute change in LV ejection fraction from baseline to 12 months was -1.9±9.8% for control (mean±SD), -0.9±10.5% for the early treatment group, and -0.7±10.1% for the late treatment group. The difference between the groups was not significant, both for complete case analysis and multiple imputation analysis. A combined clinical end point occurred equally in all the groups. Overall, 1-year mortality was low (2.25%). CONCLUSIONS Among patients with AMI and LV dysfunction, treatment with BM-MNC either 5 to 7 days or 3 to 4 weeks after AMI did not improve LV function at 12 months, compared with control. The results are limited by an important drop out rate. CLINICAL TRIAL REGISTRATION INFORMATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00355186.

Case reportA 45-year-old woman was admitted to our stroke unit because of acute right hemiparesis, aphasia and moderate frontal headache while running on a treadmill.She had no cardiovascular risk factors apart from previous smoking.F urthermore, no r ecent infections, blunt neck trauma, medical or surgical procedures or risk factors for bleeding were identified.Brain multidetector c omputed tomography (MDCT) showed neither acute ischaemic nor haemorrhagic l esions, while MDCT a ngiography a nd m agnetic resonance imaging angiography (MRA) revealed a 1-cm long subocclusive dissection of the left internal carotid artery (LICA) at the level of the cervical-petrous segment junction (figs 1A-B).Aortic MDCT angiography excluded the presence of Stanford type A aortic dissection.Treatment with aspirin and neurological follow-up were implemented for the LICA spontaneous dissection [1].

Erratum to: J. of Cardiovasc. Trans. Res. DOI 10.1007/s12265-014-9601-5. Please note that Cicero is the surname of coauthor Viviana Lo not Cicero, as the rendering of this coauthor’s surname at the foot of the title page of the article as published would lead readers to believe.

Tako-Tsubo cardiomyopathy (TTC) is an infrequent, mostly stress-related transient cardio myopathy, which mainly affects postmenopausal women.Inverted or basal TTC (B-TTC) episodes are rarer.Our case illustrates a rare example of B-TTC in a 30-year-old woman with an acute multiple sclerosis relapse as the associated stressor, possibly providing a hypothetical pathological substrate for this TTC episode.This uncommon case suggests that both factors of young age or neurological events may affect TTC pattern during one episode.Moreover, this case raises the question as to whether researchers on TTC should adopt a new perspective, embracing cardiovascular as well as neuroanatomical and -functional features.

BACKGROUND Multiple risk prediction models have been validated in all-age patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI); however, they have not been validated specifically in the elderly. METHODS We calculated the GRACE (Global Registry of Acute Coronary Events) score, the logistic EuroSCORE, the AMIS (Acute Myocardial Infarction Swiss registry) score, and the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in a consecutive series of 114 patients ≥75 years presenting with ACS and treated with PCI within 24 hours of hospital admission. Patients were stratified according to score tertiles and analysed retrospectively by comparing the lower/mid tertiles as an aggregate group with the higher tertile group. The primary endpoint was 30-day mortality. Secondary endpoints were the composite of death and major adverse cardiovascular events (MACE) at 30 days, and 1-year MACE-free survival. Model discrimination ability was assessed using the area under receiver operating characteristic curve (AUC). RESULTS Thirty-day mortality was higher in the upper tertile compared with the aggregate lower/mid tertiles according to the logistic EuroSCORE (42% vs 5%; odds ratio [OR] = 14, 95% confidence interval [CI] = 4-48; p <0.001; AUC = 0.79), the GRACE score (40% vs 4%; OR = 17, 95% CI = 4-64; p <0.001; AUC = 0.80), the AMIS score (40% vs 4%; OR = 16, 95% CI = 4-63; p <0.001; AUC = 0.80), and the SYNTAX score (37% vs 5%; OR = 11, 95% CI = 3-37; p <0.001; AUC = 0.77). CONCLUSIONS In elderly patients presenting with ACS and referred to PCI within 24 hours of admission, the GRACE score, the EuroSCORE, the AMIS score, and the SYNTAX score predicted 30 day mortality. The predictive value of clinical scores was improved by using them in combination.

This document aims at introducing the development and the construction of a pre-industrial automatic heart resuscitator, able to drastically reduce the X-Rays masking in the action zone. Thanks to lateral actuation of the massage and the carbon fiber choose for building the chest contact point bridge, it was possible to pass the limitations view under the action of a X-rays machine. This fact will help surgeon to operate having a complete and continuous view of the action area. Moreover, it allows a temporary pause (for short periods) during the coronary angioplasty procedure. Transparency tests made on a patient, submitted to the realized heart resuscitator, showed a total transparency with a negligible interference of it.

In this review we describe an unusual case report of familial fibromuscular dysplasia with involvement of coronary arteries which manifested as two distinct types of acute coronary syndrome.This case report allows us the opportunity to discuss the distinct forms of presentation of this rare disease, i.e., when there is an involvement of the coronary arteries, and highlighting pathophysiological, diagnostic and therapeutic issues.It underlines the potential role of genetic predisposition to this condition and discusses the role of vascular screening of the patients with suspected non-atherosclerotic coronary artery disease.