Cardiovascular Medicine

Unusual presentation of acute pulmonary hypertension in a patient with bilateral pneumonia and hypertrophic cardiomyopathy The incidence of acute pulmonary hypertension (APH) in hospitalized patients with pneumonia is not known with certainty, although a mild and/or moderate pulmonary hypertension is often detected by transthoracic echocardiography in these patients. We describe a rare case of pneumonia of uncertain etiology that clinically manifested with APH and S1Q3T3 pattern on ECG in a patient with hypertrophic cardiomyopathy. In the present case, a pre-capillary component due to severe acute lung injury and simultaneously a post-capillary component due to elevated left ventricular filling pressures were the two main pathophysiological mechanisms of APH. Correspondence to Andrea Sonaglioni, MD, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123 Milano, Italy Tel: +00 39 333 9237137; e-mail: sonaglioniandrea@gmail.com Received 3 February, 2019 Revised 5 March, 2019 Accepted 14 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Prolonged sustained ventricular fibrillation in a patient with dextrocardia and a left ventricular assist device No abstract available

Mid-term outcome following second-generation cryoballoon ablation for atrial fibrillation in heart failure patients: effectiveness of single 3-min freeze cryoablation performed in a cohort of patients with reduced left ventricular systolic function Purpose Currently, information on the mid-term outcome of cryoballoon ablation (CB-A) for drug-resistant atrial fibrillation in patients with reduced left ventricular systolic function is limited. Methods Thirty-eight consecutive patients with paroxysmal or persistent atrial fibrillation (84.2% male), with median left ventricular ejection fraction of 37.3% were included in our study. All patients underwent the procedure with the 28-mm cryoballoon advance. Results There were no mayor complications related to the CB-A procedure. Median follow-up was 26.5 ± 13.7 months. The freedom from atrial fibrillation after a blanking period of 3 months was 42.9% in our cohort of patients. During the follow-up period, 13 patients underwent at least a new electrophysiological procedure. After a single procedure, the univariate predictors of clinical recurrence after the blanking period were age and persistent atrial fibrillation. Conclusion Second-generation CB-A of atrial fibrillation seems feasible and safe in patients with heart failure with reduced ejection fraction and heart failure with mid-range ejection fraction, in terms of complications rate and number of applications per vein. All pulmonary veins could be isolated with the 28-mm cryoballoon advance only. Correspondence to Gian B. Chierchia, MD, PhD, Heart Rhythm Management Center, UZ Brussel-VUB, Laarbeeklaan 101, 1090, Brussels, Belgium. Tel: +32 024766009; fax: +32024776851; e-mail: gbchier@yahoo.it Received 18 January, 2019 Revised 19 June, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Percutaneous coronary interventions for stable ischemic heart disease in Italy Aims Although the benefits of percutaneous coronary interventions (PCIs) in patients with stable chronic ischemic heart disease (SIHD) are controversial, a large number of PCIs are currently performed in SIHD patients, frequently after coronary angiography (ad-hoc procedures), without the use of fractional flow reserve (FFR) to identify patients most likely to benefit from PCI. Methods Assessment of regional variations in PCI for SIHD performed in Italy in 2017 and correlation of the regional number of PCI per million inhabitants with the use of FFR were performed using the data reported in the registry of the Italian Society of Interventional Cardiology (SICI-GISE) registry for the year 2017. Results PCI for SIHD accounted for 44.5% of all PCI performed in Italy with large variations among the Italian regions. There was a significant and inverse relationship between the use of FFR and the PCI number per million inhabitants performed for SIHD in the various Italian regions (P = 0.01). In the Veneto region, where local authorities mandated Heart Team reports to select the most appropriate treatment choice in multivessel disease patients, the rate of ad-hoc procedures was significantly lower than the national average. Conclusion PCI for SIHD patients represent almost half of all procedures currently performed in Italy with regional variations inversely related to physiologic guidance use. The mandatory assessment by the Heart Team to select the most appropriate treatment choice in multivessel disease patients is associated with a significantly lower number of ad-hoc procedures. Correspondence to Stefano De Servi, MD, FESC, Unita' di Cardiologia, IRCCS Multimedica, Milan, Italy Tel: +39 02 24209590; e-mail: stefano.deservi@multimedica.it Received 24 February, 2019 Revised 25 March, 2019 Accepted 28 April, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Does mitral regurgitation reduce the risk of thrombosis in atrial fibrillation and flutter? Aims Blood stasis is the main cause of left atrial thrombosis (LAT) in atrial tachyarrhythmias. The high-velocity flow inside the left atrium, due to mitral valve regurgitation, may prevent clot formation but the topic has never been investigated in large-scale studies. The aim of our study was to evaluate whether the presence and degree of mitral regurgitation have a protective role against LAT risk. Methods A total of 1302 consecutive adult patients with paroxysmal or persistent atrial fibrillation or flutter undergoing cardioversion, submitted to transesophageal echocardiography, were retrospectively enrolled in the study. The study population was divided into three groups according to the mitral regurgitation degree: absent, mild-to-moderate and severe. Results Among 1302 patients enrolled in the study, patients without mitral regurgitation were 248 (19%), those with mild-to-moderate 970 (75%), whereas 84 had severe mitral regurgitation (6%). LAT incidence was significantly lower in patients with severe mitral regurgitation compared with those with mild-to-moderate (mitral regurgitation) (2.4 vs. 8.9%, P < 0.05), and similar to subjects without mitral regurgitation (2.4%). Conclusion Despite patients with severe regurgitation having clinical and echo characteristics predisposing to LAT (higher age, heart failure, higher atrial size, lower ventricular function) thrombosis prevalence was significantly lower than for those with mild-to-moderate mitral regurgitation. The percentage of LAT in severe mitral regurgitation cases was very low and similar to that of cases without regurgitation which were characterized by lower age, normal left ventricular function or other risk factors, reinforcing the hypothesis of a protecting role against atrial thrombosis of mitral regurgitation. Correspondence to Ugo Limbruno, MD, Cardiological Department, Misericordia Hospital, Via Senese, 58100 Grosseto, Italy E-mail: ulimbru@tin.it Received 26 March, 2019 Revised 1 May, 2019 Accepted 1 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Reliability of noninvasive hemodynamic assessment with Doppler echocardiography: comparison with the invasive evaluation Aims The study aimed at evaluating the reliability and reproducibility of various noninvasive echocardiographic techniques for the estimation of the main hemodynamic parameters in clinical practice. Methods A total of 84 patients with a generic indication of right heart catheterization (RHC) executed a transthoracic echocardiography shortly before or after the RHC. All the parameters necessary for a noninvasive hemodynamic evaluation of right atrial pressure, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure, pulmonary vascular resistance and cardiac output were acquired and the agreement with the invasive measures was evaluated by a Bland–Altman analysis. Results Noninvasive evaluation of right atrial pressure showed a moderate and low correlation with RHC using inferior vena cava parameters (r = 0.517) and tricuspid E/E′ ratio (sensitivity 0.23, specificity 0.72), respectively. PAPs estimation from the tricuspid regurgitation peak velocity had a good correlation (r = 0.836) and feasibility (82.1%), as well as PAPm from tricuspid regurgitation mean gradient (r = 0.78, applicability 72.6%) and from pulmonary acceleration time (sensitivity 0.85, specificity 0.5, applicability 92.9%). Pulmonary capillary wedge pressure multiparametric evaluation, as suggested by the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations, showed a good correlation (sensitivity 0.96, specificity 0.59). The noninvasive evaluation of pulmonary vascular resistance and cardiac output did not prove to be clinically accurate. Conclusion Various hemodynamic parameters can be adequately estimated with noninvasive methods. In particular, a multiparametric approach for the evaluation of left ventricle filling pressures is advisable and the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations are reliable even in a heterogeneous population with a significant quota of precapillary pulmonary hypertension. Correspondence to Marco de Scordilli, Department of Medical Science, Surgery and Health (DCSMCS), University of Trieste, Ospedale di Cattinara, Via Rossetti, 51, 34141 Trieste, Italy Tel: +39 3497644274; e-mail: marco.descordilli@gmail.com Received 14 March, 2019 Revised 4 July, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Multimodality imaging for early diagnosis and treatment of primary cardiac diffuse 'double-expressor' lymphoma Primary cardiac double-expressor lymphoma represents a rare subtype of diffuse large B-cell lymphoma, especially in immunocompetent patients. To date, only a few sporadic cases of primary cardiac double-expressor lymphoma have been reported in medical literature. Multimodality imaging can be very helpful in these patients for early diagnosis and treatment of this type of lymphoma, allowing potential improvement of the outcome. Correspondence to Loris Roncon, MD, Department of Cardiology, Santa Maria della Misericordia Hospital, Via Tre Martiri 140, 45100 Rovigo, Italy Tel: +39 0425393286; e-mail: loris.roncon@aulss5.veneto.it Received 30 April, 2019 Revised 9 July, 2019 Accepted 10 July, 2019 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jcardiovascularmedicine.com). © 2019 Italian Federation of Cardiology. All rights reserved.

Mid-term repair durability after MitraClip implantation in patients with functional mitral regurgitation Background The aim of this study was to identify variables that are associated with the durability of percutaneous repair of secondary mitral regurgitation at 6-month follow-up. Methods and results Thirty-five consecutive patients with functional mitral regurgitation scheduled for MitraClip implant were enrolled. Left ventricular (LV) volumes and function and mitral valve characteristics were assessed before and immediately after MitraClip implantation using three-dimensional transesophageal echocardiography. Five patients with an unsuccessful procedure were excluded. The other patients were subdivided according to repair durability: group 1 with a durable repair (19 patients, 65%) and group 2 with significant mitral regurgitation recurrence (11 patients, 35%). At baseline, group 1 patients had smaller and more elliptical mitral valve annulus (1055 ± 241 vs. 1273 ± 359 mm2, P = 0.02 and 125 ± 11 vs. 117 ± 16%, P = 0.02), a smaller left atrial volume (54.1 ± 26 vs. 71.5 ± 20 ml, P = 0.005) and lower systolic pulmonary artery pressure (38 ± 11 vs. 49 ± 12 mmHg, P = 0.03). Baseline LV end systolic volume had a linear correlation with the 3D annulus area (P = 0.048) and an inverse correlation with annulus ellipticity (P = 0.021). Group 1 patients showed an increase in annulus ellipticity after MitraClip (125 ± 17 vs. 141 ± 23%, P = 0.014). Conclusion Percutaneous mitral valve repair leads to a significant and stable mitral regurgitation reduction in a large number of patients. Annulus dimensions and remodeling as well as left atrial area and pulmonary hypertension seem to be associated with durability of the procedure. Correspondence to Sara Cimino, MD, Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, 'Sapienza' University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Roma, Italy Tel: +39 6 49979048; fax: +39 6 49979060; e-mail: sara.cimino@uniroma1.it Received 3 January, 2019 Revised 1 July, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Prognosis in patients with microvascular angina: a clinical follow-up The prognosis of patients with microvascular angina (MVA) has been reported to be good. In 10–20% of the cases, the symptoms of angina progressively worsen during follow-up, becoming more frequent and prolonged, absorbing lower workloads or even increasing at rest and becoming less sensitive, or even refractory, to drug therapy. The frequency and intensity of angina episodes require frequent medical visits, hospital admissions, absences from work, thus determining a high social cost of the disease. To obtain further information on this clinical controversy, we performed a clinical follow-up of of 132 patients with diagnosis of microvascular angina. Correspondence to Vincenzo Sucato, MD, Unit of Cardiology, ProMISE Department, Paolo Giaccone Hospital, University of Palermo, Via Del Vespro n 129, 90127 Palermo, Italy E-mail: odisseos86@gmail.com Received 11 February, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Performance of the Durata implantable cardioverter defibrillator lead: results of an independent multicenter study Aims The high rate of implantable cardioverter defibrillator (ICD) lead failures related to the Sprint Fidelis' and Riata's design have raised serious concerns about the reliability of ICD leads. The St. Jude Medical Durata family of leads replaced the preceding Riata line following increased rates of lead failure (1.17% per year). The aim of our study was to evaluate the long-term performance of the Durata lead. Methods Eight hundred and eighteen Durata ICD leads were implanted in 11 Italian centers. The incidence of lead failure, defined as a sudden rise in long-term pacing or defibrillation impedance and/or a sudden change in R-wave amplitude and capture thresholds, was assessed. The incidences of lead dislodgment and lead perforation were also evaluated. Results During a median follow-up of 1353 days (3.7 years; 25–75th interquartile range 806–1887 days) lead failure occurred in 16/818 leads (0.54%/year). The overall survival, free of lead failure, was 98.9% at 3 years, 98.2% at 4 years and 97.5% at 5 years. Lead dislodgment occurred in 12/818 leads with an incidence of 0.4%/year. No cases of cardiac perforation were reported. No major adverse events were reported except for two cases of inappropriate shocks as a consequence of failure or dislodgment. Conclusion Our study suggests that the Durata lead does not engender a higher risk of failure. Overall survival, free from lead failure, was found to be higher than previously reported for the Riata lead. Correspondence to Roberto Rordorf, MD, Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology – Foundation IRCCS Policlinico San Matteo, P.le Golgi 19, 27100 Pavia, Italy Tel: +39 0382 501276; fax: +39 0382 503161; e-mail: r.rordorf@smatteo.pv.it Received 19 February, 2019 Revised 27 May, 2019 Accepted 7 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Alexandros Sfakianakis
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alsfakia@gmail.com