Abstract Aims PlatypneaOrthodeoxiasyndrome (POS) is a rare clinical condition characterized by dyspnoea and arterial desaturation, typically occurring in orthostatism and vanishing in a supine position. The real pathophysiologic triggers are still not completely understood. Methods and results In January 2021, a 76-year-old female patient was admitted to our department for the management of a large mass in the right lung (69 × 54 × 76 cm). Pre-operative Computed Tomography (CT)-scan showed a lesion of the right lower lobe, with suspected infiltration of posterior costal pleura and bronchoscopy revealed distal occlusion of intermedious bronchus. Surgical treatment was planned: extrapleural lower bilobectomy with the removal of the VI rib to reduce intracavity space was performed, using postero-lateral thoracotomy approach. On the third post-operative day, an acute neurologic deficit with left-sided paralysis, associated with desaturation and hypotension, occurred during a new attempt to mobilize the patient. Nonetheless the patient showed complete resolution of symptoms in supine position. A new similar episode of severe desaturation (SO2 80%) was observed in the 7th post-operative day. Arterial blood gas test showed PO2 37 mmHg; PCO2 27 mmHg; SO2 80.3%, pH 7.61, tHb 12.4 g/dl; O2Hb 78.4%. CT pulmonary angiography excluded a suspicious of pulmonary embolism. A right to left atrial shunt was suspected. Contrast-enhanced transcranial Doppler ultrasound showed microembolic signals in the basal cerebral arteries. Transoesophageal echocardiography was performed, confirming an interatrial septum with an exuberant hyperdynamic movement and showing an abundant passage of contrast from the right atrium to the left, even without the Valsalva manoeuvre, compatible with an important patent foramen ovale (PFO). Patient was referred to the cardiac Catheterization Laboratory for percutaneous closure of PFO. The device was successfully placed via right femoral venous catheter access and on transesophageal echocardiogram guidance. The procedure was performed without any complications. The implanted device was noted to be in a stable position with trivial residual inter-atrial shunting immediately after the procedure. The day after implantation, positional discomfort improved remarkably and the patient was able to stand-up with no symptoms, maintaining normal saturation (SaO2 100%). The patient was discharged and sent home on the third post-implantation day. The 4 month follow-up examination showed a good andstable condition. Conclusions Platypnoea Orthodeoxia Syndrome after lobectomy is a rare cause of postoperative dyspnoea/hypoxia.It is the result of right-to-left shunt via interatrial communication. Mediastinal relocation, stretching of the atrial septum are among the functional elements necessary for the clinical manifestations. It is essential to have a high index of suspicion to detect POS in patient with dyspnoea given the subtle and positional nature of the symptoms. Physicians should always consider POS in patients with unexplained dyspnoea; hence the treatment modalities could alleviate symptoms and be potentially curative.

Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs. It carries a high risk of amputation and local infection. Moreover, cardiovascular complications remain a major concern. Although it is a well-known entity and new technological and therapeutic advances have been made, this condition remains poorly addressed, with significantly heterogeneous management, especially in nonexperienced centers. This review, from a third-level dedicated inpatient and outpatient cardioangiology structure, aims to provide an updated summary on the topic of CLI of its complexity, encompassing epidemiological, social, economical and, in particular, diagnostic/imaging issues, together with potential therapeutic strategies (medical, endovascular, and surgical), including the evaluation of cardiovascular risk factors, the diagnosis, and treatment together with prognostic stratification.

AIMS:Distal embolisation during carotid artery stenting (CAS) is the main cause of cerebral complications; thus, the amount of embolisation occurring during CAS can be considered as a surrogate endpoint of cerebral complications. Our aim was to find patient characteristics which are associated with a higher risk of embolisation during CAS.METHODS AND RESULTS:From January to December 2010 all consecutive patients undergoing CAS with embolic protection at three medium- to high-volume Italian centres were prospectively enrolled in this multicentre study. After CAS, the embolic debris was classified by visual inspection into two groups: "scarce" (no debris or hardly visible debris), and "relevant" (visible embolic debris) embolisation. Two hundred and thirty-six consecutive patients (79% males, 32.7% symptomatic) were enrolled. Open cell stents were used in 52.7% of the patients, distal filters were employed in 85.5% and proximal protection in 14.5%. Procedural success was achieved in 100% of procedures. Relevant embolisation was observed in 16.1% of patients, including those who suffered all the periprocedural complications (4.2%). At multivariate statistical analysis, high circulating LDL cholesterol and C-reactive protein levels were the only factors associated with relevant embolisation.CONCLUSIONS:In this study, high circulating LDL cholesterol and C-reactive protein levels were associated with relevant embolisation after CAS, opening up the hypothesis that therapy with statins before elective CAS may reduce plaque embolisation and improve outcome. (EudraCT number: 016737-95).

Carotid intima-media thickness (IMT) and aortic valve sclerosis (AVS) have recently emerged as important predictive factors for cardiovascular (CV) events. However, few data are available on their association and the respective roles of major CV risk factors in determining either condition. In this study, 479 asymptomatic subjects (mean age 58 +/- 13 years, 62% men) were assessed, without histories of CV disease, consecutively referred for comprehensive evaluations by echocardiography and carotid ultrasonography because of the presence of > or = 1 risk factor. Common carotid artery IMT and aortic valve morphology and function were analyzed. The mean IMT was 0.82 +/- 0.19 mm. The prevalence of increased carotid IMT (>0.80 mm) and AVS was 60.8% and 18.4%, respectively. The prevalence of increased IMT was 79.6% in subjects with AVS and 56.5% in those without AVS (relative risk 2.99, 95% confidence interval 1.72 to 5.21, p <0.001). On multivariate analysis, increased IMT was significantly and independently associated with hypertension, dyslipidemia, obesity, family history of CV disease, and age. Only age emerged as an independent predictor of AVS. The presence of both markers was independently associated only with hypertension and age. In conclusion, increased carotid IMT was strongly associated with AVS in a population of asymptomatic patients. IMT and AVS were differently related to individual CV risk factors, and their association seems to be correlated mainly with age and hypertension.

We analyzed in NYHA I hypertensives the interactions between Carotid Intima-Media Thickness (IMT), Hypertension and Cardiovascular (CV) risk factors and relationships between IMT, CV risk factors and left ventricular (LV) geometric remodelling. 198 asymptomatic, never treated, essential hypertensives (age: 58.2 ± 13) and 67 (age-gender matched) healthy subjects, were studied. Complete clinical examination, 2D Doppler echocardiography and vascular echography were performed in all study subjects. Major values of IMT are present in concentric LVH. Distribution of IMT among risk factors groups shows an higher IMT respect to increasing number of risk factors (P < 0.001). Significant correlation are present between pulse pressure and IMT (P < 0.006; r = 0.19) and IMT and LVM (P < 0.0001; r = 0.35). Altered patterns of LV geometry and carotid structural changes occur in many patients with essential hypertension. LVH or carotid remodeling are greater in elderly, in patients with higher systolic BP and with associated CV risk factors.

In young patients, acquired and genetic causes of deep vein thrombosis frequently interact. The association of congenital hypoplasia of the inferior vena Cava with antithrombin III deficiency has never been described in the literature as a causal factor of proximal deep vein thrombosis in young patients. We report the case of an 18-year-old patient affected by deep vein thrombosis due to this rare association without other common risk factors.

A large series of clinico-epidemiological studies, meta-analyses and experimental findings have concluded that there is a relationship between coronary heart disease (CHD) and passive smoking either after acute or chronic exposure. Cigarette smoking is the most important cause of premature death in industrialized countries because it is associated with an increased risk of developing several types of cancer and arterial disease. In family homes as well as in workplaces, environmental tobacco smoke (ETS) exposure is associated with an increased risk of CHD in exposed non-smokers when compared to un-exposed non-smokers. Different anatomical structures are damaged by ETS. The endothelium, artery wall and heart are target organs for passive smoking. Therefore, smoking cessation will benefit both smokers and those exposed to ETS.

Microalbuminuria, usually defined as an urinary albumin excretion(UAE)≥15μg/min,is associated with cardiovascular risk factors and predicts morbid events in non proteinuric essential hypertensive patients (EH). Much less known is the distribution of cardiovascular risk factors in presence of UAE values below the microalbuminuric threshold of 15μg/min. To address that point, we studied 141 never treated, glucose-tolerant male EH with UAE <15 μg/min (the median of three overnight collections). Data were analyzed by evaluating the distribution of 24-hr blood pressure (BP), cardiac structure and geometry (by echocardiography), BMI, common carotid artery intima thickness (IMT, high-sensitivity ultrasonography), insulin sensitivity (as approximated through the HOMA index: fasing insulin (μU/ml)/[22.5 X E-LN(GLUCOSE [MMOL/L])]) (tertile cut-off points: 4.6 and 7.8 μg/min, n=46, 47 and 48 respectively) across UAE tertiles. As compared with the intermediate and bottom thirds, patients in the top tertile showed higher 24-hr BP (143±19/93±12 vs 133±13/86±8 and 135±11/88±10 mmHg, p<0.01), thicker interventricular septum thickness (1.19±0.14 vs 1.1±0.13 and 1.04±0.1 cm, p<0.001), increased relative wall thickness (RWT, IVST+PWT/EDD) (0.47±0.06 vs 0.44±0.06 and 0.44±0.05, p<0.01), heavier body size(26.8±3.1 vs 25.2±2.4 and 25.9±2.2 Kg/m2, p<0.02). Left ventricular mass index (LVMI, 54±14 vs 51±12 and 52±12 g/m2.7) did not differ significantly, but the percentage of patients with a concentric hypertrophic pattern (LVMI> 51g/m2.7 & RWT>0.45) was more frequent in the top tertile (48 vs 18 and 11%, p<0.001). Lipids, carotid thickness (0.73±0.3 vs 0.77±0.2 and 0.75±0.2 mm), HOMA index (2.6±3.8 vs 2.5±1.2 and 2.4±1.1) did not differ. Some cardiovascular and metabolic parameters predictive of risk are linearly associated with UAE values below the conventional microalbuminuric thresholds. Normoalbuminuric EH with high-normal albuminuria are characterized by an adverse risk profile with potentially important negative prognostic consequences. These data might suggest to shift downwards the limits for diagnosing microalbuminuria in essential hypertension, a possibility to be tested in future studies.