Aortic regurgitation (AR) is a progressive valvular disorder whose prevalence increases with age. Current guidelines recommend prompt surgical intervention upon symptom onset per se, irrespective of additional markers of disease severity. Our study aims to identify cardiac and noncardiac determinants of symptoms in patients with severe AR undergoing aortic valve replacement (AVR). This retrospective study included 101 patients who underwent AVR for isolated severe AR at our Institution between 2015 and 2021. Exclusion criteria included aortic dissection, endocarditis, congenital heart disease, severe concomitant valvular disease, or concurrent coronary artery bypass grafting. Clinical and echocardiographic characteristics were compared between asymptomatic and symptomatic patients. At preoperative evaluation, one-third of patients were symptomatic. Symptomatic patients were older (68 ± 11 years) and more frequently affected by coronary artery disease (CAD) (p = 0.01) and moderate mitral regurgitation (MR) (p = 0.01). A Charlson Comorbidity Index (CCI) ≥3 showed a strong association with symptom presence (p < 0.001). In multivariate analysis, moderate MR, CAD, and CCI ≥3 emerged as independent predictors of symptoms. A model adjusted for CCI demonstrated improved predictive accuracy (AUC 0.82 vs. 0.73). Symptoms in severe AR result from both valvular overload and comorbidities. Current criteria may not fully capture disease severity in elderly. A high comorbid burden strongly influences symptom perception and complicates risk stratification. Incorporating multimorbidity assessments into clinical decision-making may refine patient selection and optimize surgical outcomes.

The natural history of tricuspid valve regurgitation (TR) is characterized by dismal prognosis and high in-hospital mortality when treated with isolated surgery. We report preliminary procedural and echocardiographic results of our experience with the TriClip System in a cohort of “real-life” patients with functional tricuspid regurgitation. From June 2020 to March 2022, 27 consecutive patients with > moderate TR have been screened, 12 underwent transcatheter TriClip repair. The anatomical feasibility was established through a complete transthoracic (TTE) and transesophageal echocardiogram (TEE), and a dedicated CT scan for the right cardiac chambers. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy. A total of 12 subjects (83% female) with significant comorbidities and at high surgical risk were included. The mean age was 82±4 years with an average EuroSCORE II of 8.5±4%. TR included functional (75%) and (25%) mixed etiology (lead-induced and functional) and all patients were classified as at least NYHA functional class III. Nine patients (75%) had severe, two patients (17%) massive and one patient (8%) torrential TR. The implant and procedural success were achieved in all cases, implanting one device in 8 patients (67%) and two in 4 patients (33%). The device was positioned antero-septal in 83% (10of12) and postero-septal in 50% (6of12) of cases. A TR reduction of≥1 grade after procedure was achieved in all patients; 5 (42%) subjects had moderate, 6 (50%) mild, and one patient (8%) with previous torrential TR treated with two clips had severe post-procedural TR because of partial leaflet detachment 48-hours post-procedure. On TTE, significant reductions in effective regurgitant orifice area (0.61±0.28 to 0.31±0.22 cm2; p<0.001) and regurgitant volume (56.3±16.7 to 27.5±16.6ml; p<0.001) occurred between baseline and before hospital discharge. We also observed a significant reduction of tricuspid annulus diameter (43.8±5.6 to 39.8±4.2 mm; p<0.001), right ventricular basal diameter (47.2±6.8 to 42.9±4.5 mm; p=0.001), right atrial area (28.8±8.8 to 26.7±9.4 cm2; p=0.033). While 3 patients demonstrated a reduced TAPSE/PASP ratio (<0.31 mmHg) before the intervention, the overall ratio significantly improved after device placement (0.37±0.1 to 0.46±0.1 mmHg; p=0.011). At 30-days-follow-up, there was significant and sustained improvement in NYHA class with all patients reaching class II or less without additional reported hospitalizations. In this single center experience, we have shown that treatment with the edge-to-edge TriClip device is safe and effective and is associated with marked clinical benefits and reduced rates of hospitalizations. The resulting echocardiographic improvements indicate leaflet grasping does not just significantly reduce the grade of TR, but also affects adjacent structures and improves right ventricular afterload adaptation. Type of funding sources: None.

Background: The natural history of tricuspid valve regurgitation (TR) is characterized by poor prognosis and high in-hospital mortality when treated with isolated surgery. We report the preliminary echocardiographic and procedural results of a prospective cohort of symptomatic patients with high to prohibitive surgical risk and at least severe TR who underwent transcatheter edge-to-edge repair through the TriClipTM system. Methods: From June 2020 to March 2022, 27 consecutive patients were screened, and 13 underwent transcatheter TriClipTM repair. In-hospital, 30-day and six-month clinical and echocardiographic outcomes were collected. Results: Nine patients had severe, three massive and one baseline torrential TR. Sustained TR reduction of ≥1 grade was achieved in all patients, of which 90% reached a moderate TR or less. On transthoracic echocardiographic examination, there were significant reductions in vena contracta width (p < 0.001), effective regurgitant orifice area (p < 0.001) and regurgitant volume (p < 0.001) between baseline and hospital discharge. We also observed a significant reduction in tricuspid annulus diameter (p < 0.001), right ventricular basal diameter (p = 0.001) and right atrial area (p = 0.026). Conclusion: Treatment with the edge-to-edge TriClip device is safe and effective. The resulting echocardiographic improvements indicate tricuspid valve leaflet approximation does not just significantly reduce the grade of TR but also affects adjacent structures and improves right ventricular afterload adaptation.

Abstract Background Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR), who are candidates for transcatheter tricuspid valve intervention (TTVI). Currently, echocardiography and computed tomography (CT) are available instruments to study the TV anatomy, guide the decision-making process and support the development of novel transcatheter therapies. Purpose The Tricuspid Regurgitation IMAging (TRIMA) study aimed to correlate CT parameters to commonly used echocardiographic variables. Methods This prospective, single-center study enrolled 22 consecutive patients with TR equal to or greater than severe (≥3+). All patients underwent transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) and cardiac CT study, in order to obtain anatomical dimensions of the tricuspid annulus and quantification of right-chambers remodeling and function. Novel CT scan measurements were analyzed. Correlation between measurements on echocardiography and CT imaging was assessed. Results Severe TR (3+) was present in 27.4% patients, massive (4+) in 4.8% and torrential (5+) in 3.2%. The mean right ventricle (RV) length, RV mid diameter, and right atrium area were 60.81±9.11 mm, 41.27±7.67 mm and 31.72±9.66 cm2, respectively. Tricuspid annular plane excursion, fractional area change, longitudinal myocardial velocity (S') were 16.09±3.25 mm, 33.36±9.47% and 9.18±1.94 cm/sec, respectively. The annular dimensions obtained by CT scan were generally observed to reduce from diastole to systole, except for eccentricity, angles and distance between the postero-septal and antero-posterior commissure and distance between centroid and antero-posterior commissure. A Kruskal-Wallis test showed a stepwise increase in the tricuspid anatomical regurgitant orifice area (AROA) values by CT across the expanded TR grades by TEE, χ2(2)=6,466, p=0.039. Using the Pearson correlation coefficient, we found a relationship between the AROA and TR grade (r=0.593; p<0.004), as well as ARO-perimeter and TR grade (r=0.470; p<0.027). Additionally, a significant correlation was found between septal lateral annulus diameter obtained by TEE and CT (r=0.637; p=0.001). Anyway, no correlations were found between novel CT variables and TR grade or RV function assessed by echocardiogram, as well as between CT systo-diastolic annulus variability and RV function. Conclusions Standard echocardiographic study provide invaluable information about the anatomy and function of the right-chambers, as well as an accurate grade of TR. Conventional and novel variables derived by CT scan may step up the anatomical assessment of the complex morphology of the TV apparatus, thanks to the high spatial resolution of the technique. Therefore, an integrated multimodality assessment is the key point of the screening process of TR candidates for TTVI. Funding Acknowledgement Type of funding sources: None.

Chemoradiation is the standard treatment in locally advanced NSCLC (LA-NSCLC) patients and thanks to recent combination with immunotherapy, median survival has reached unexpected improvements. In this new scenario, survivorship questions have become unmet needs, preventing toxicity a clear goal of the most current research. Cardiotoxicity is linked to thoracic irradiation with clinical manifestations such as pericardial disease, ischemic heart disease, nonischemic cardiomyopathy, valvular disease, conduction abnormalities, and arrhythmias.

Objective: Robot-assisted surgery has been recently adopted as an alternative strategy for minimally invasive mitral valve repair. We report our early experience with the "da Vinci S" HD Surgical System (Intuitive Surgical,Sunnyvale, Calif.). Methods: Since November 2011, 49 consecutive adult patients with severe mitral regurgitation underwent robotic mitral valve repair. All patients were male, with a mean age of 58.2 years (range 43 to 66). Preoperatively all patients underwent three-dimensional multislice computed tomography reconstruction of the chest in order to identify the correct position of the ports, to evaluate the thoracic and abdominal aorta and to assess groin vessels for safe cannulation for cardiopulmonary by-pass. Direct aortic cross clamping (Chitwood clamp) was used in the first 5 patients and aortic endoclamping in all the others. Custodiol crystalloid cardioplegia was used in all patients. Results: Mean cardiopulmonary bypass time was 157.8 min (range 110 to 191); mean aortic cross-clamp time was 118.6 min (range from 80 to 151 min). Mitral valve repair was successfully performed in all patients (PTFE neo-chordae on anterior and/or posterior leaflet, n = 29; triangular/quadrangular resection of posterior leaflet, n= 17; commissuroplasty, n=3). No conversion to standard sternotomy nor re-thoracotomy for bleeding occurred in any patient. Mean ventilation time was 7 hours. Mean ICU stay was 22.3 hours. Mean hospital stay was 5.2 days. At discharge there was absent or trivial mitral regurgitation evaluated by transthoracic echocardiography. Conclusion: In our preliminary experience, robotic assisted mitral valve repair has demonstrated to be safe with excellent early results, comparable to other strategies of minimal invasive mitral valve surgery.

In patients with acute myocardial infarction, a persistently occluded infarct related coronary artery, despite a correct thrombolysis, is associated with an unfavourable prognosis. Therefore, identification of variables predictive of ineffective thrombolysis is crucial to identify patients at higher risk of thombolysis failure. To investigate whether or not acquired or congenital thrombophilic factors had a role in the ineffective thrombolysis we designed this study in which patients treated with intravenous thrombolysis for a ST segment elevation myocardial infarction were blind tested for the thrombophilic factors on the occasion of the coronary angiography performed within 30 days from the thrombolytic treatment. Patients with known factors influencing metabolism and circulating levels of homocysteine were excluded from this study. From October 2003 to May 2004, 104 consecutive patients treated with intravenous thrombolysis for a ST segment elevation myocardial infarction were available for this study, 3of these refused to participate in the study All patients underwent,within 30 days from thrombolysis, a coronary angiography and of the 101 participating in the study, 40 resulted occluded while 61 had a patent artery. In these 101 patients we blind tested the levels of ATIII,PC,PS; moreover, we determined also the levels of homocysteine, the presence of Lupus Anticoagulant (by mean of DRVVT and Silica Clotting Time) and ACA of IgG type as well as the Plasminogen levels. Furthermore, blood samples were also analysed by PCR technique for the presence of Factor V Leiden, the G20210A Factor II mutation and the C677T mutation in the MTHFR gene. Surprisingly, patients with MTHFR 677TT homozygosis had a significantly higher prevalence of occluded infarct artery (73%) vs those with MTHFR 677CT/CC genotype (30%, P=0.0008); frequency of MTHFR 677TT homozygosis was 4-fold higher in patients with occluded vs those with a patent vessel (40% vs 10%, P=0.0008). MTHFR 677TT genotype predicted the risk of failed thrombolysis with a specificity of 90% and multivariate analysis showed that MTHFR 677TT homozygosis was independently associated with an occluded artery (odds ratio 3.8, 95% confidence interval 1.1–9.1; P=0.03). None of the other studied factors at multivariate analysis influenced the thrombolysis failure. Moreover, patients with occluded infarct vessel and MTHFR 677TT genotype had the highest homocysteine levels (P=0.011). Our findings indicate that in patients with acute myocardial infarction, MTHFR 677TT homozygous is independently associated with a persistently occluded infarct-related artery after thrombolysis.

Objectives We sought to evaluate interleukin-1 receptor antagonist (IL-1Ra) levels in patients with ST-segment elevation acute myocardial infarction (AMI) upon emergency department (ED) admission in order to assess the sensitivity of such a determination by comparison with common markers of myocardial necrosis.Background Inflammatory markers are elevated in patients with unstable coronary syndromes, but IL-1Ra levels during the early phases of AMI have not been previously investigated.Methods Levels of IL-1Ra were measured in 44 consecutive patients with AMI and compared with creatine kinase (CK), CK-MB, troponin I, myoglobin, and C-reactive protein (CRP).Results Upon admission, 82% of patients had elevated (>230 pg/ml) IL-1Ra levels, compared with 41% of patients with raised CK (p=0.001), CK-MB (45%, p=0.002), troponin I (57%, p=0.027), myoglobin (48%, p=0.004), and CRP (57%, p=0.019) levels. The IL-1Ra values were significantly higher in patients with heralded AMI than in those without pre-infarction angina (671 vs. 320 pg/ml, p=0.013). The sensitivity of IL-1Ra determination increased to 86% when chest pain duration was less than or equal to3 h and to 91% if heralded infarction occurred.Conclusions Our study indicates that, unlike markers of necrosis, an increase of IL-1Ra levels occurs early in patients with AMI, is more significant in those with heralded infarction and symptom onset less than or equal to3 h, and precedes the release of markers of necrosis. Thus, IL-1Ra determination may be an important early adjuvant toward the diagnosis of AMI in the ED.