Short Term Failure after Residual Intra Mitraclips Regurgitation Treated with Transcatheter Implantation of an Amplatzer Ventricular Septal Defect Device

<p>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.</p>

Venous Baffle Thrombosis and Pulmonary Haemorrhage Following Atrial Septal Defect Repair Diagnosed Utilising a Novel Imaging Technique of Dynamic Pulmonary Perfusion Computed Tomography

<p>Perfusion Computer Tomography is becoming a more utilised technology in the diagnosis of vascular abnormailities in medicine. We report a case of pulmonary haemorrhage and baffle thrombosis post sinus venosus atrial septal defect (SV-ASD) repair in a 56 year old patient diagnosed utilising a novel imaging protocol of contrast enhanced dynamic Pulmonary Computed Tomography Perfusion (PCT-P) scan. This novel protocol facilitated the diagnosis and subsequent surgical thrombectomy and conduit repair, leading to full recovery of the patient where traditional computer tomography pulmonary angiography, bronchoscopy and surgical exploration did not reveal a diagnosis. </p>

Bivalirudin Inhibits Thrombin-Mediated Tissue Factor Expression in Human Endothelial Cells

<p><span style="font-family: Times;"><span style="font-size: medium;">Thrombosis is the main pathophysiological mechanism in Acute Coronary Syndromes (ACS), and involves the activation of platelets and of Tissue Factor (TF)-dependent extrinsic coagulation pathway. TF-mRNA and antigen are detectable in the adventitia of normal vessels. On the contrary, little TF immunoreactivity is measurable in the smooth muscle cells of uninjured vessels and unperturbed endothelial cells, being in contact with circulating blood, usually do not express TF activity. However, several stimuli are able to induce TF in endothelial cells, including thrombin. Thus in an acute "scenario", thrombin might be responsible for creating a prothombotic milieau. Bivalirudin (BIVA) is a synthetic, reversible direct thrombin inhibitor actually considered a valuable alternative to heparins in patients who need anticoagulation in the setting of ACS and percutaneous coronary intervention to avoid acute thrombotic events. In the present study we have investigated whether BIVA, by inhibiting thrombin, might have effects on TF expression and procoagulant activity in endothelial cells. Human Umbilical Endothelial Cells (HUVEC) were stimulated with thrombin or with the activated coagulation factors FVIIa/FXa for 2 hrs to evaluate TF-mRNA transcription by real-time PCR and for 6 hrs to measure TF expression/activity </span><span style="font-size: medium;">on cell surface by FACs analysis and procoagulant activity. In additional experiments HUVEC were </span><span style="font-size: medium;"> </span><span style="font-size: medium;">pre-treated with BIVA for 1 hr before being stimulated and processed as above. Thrombin induced TF-mRNA transcription as well TF expression/activity on HUVEC shifting them to a procoagulant phenotype. On the contrary, the activated coagulation factors FVIIa/FXa did not affect TF expression/activity, indicating that thrombin plays a pivotal role in mediating this phenomenon. BIVA was able to prevent these thrombin deleterious effects. Data of the present study, although in vitro, suggest that BIVA, in the context of ACS, might significantly reduce thrombogenicity not only by acting as direct thrombin inhibitor but through its effects on TF expression/activity too.</span><span style="font-size: medium;"> </span></span></p>

Non-Invasive Programmed Stimulation in Hypertensive Patients with Heart Failure and ICD after Renal Sympathetic Denervation

<p>A recent study reported in patients with ICDs and refractory ventricular arrhythmias, that renal sympathetic denervation (RSD) was associated with reduced arrhythmic burden with no procedure-related complications. Our results show that after RSD becomes more difficult to induce VT/VF using NIPS protocol in comparison to patients who received only increase the dosage of β-blocker, and also that the number of subjects who developed VT/VF was 40% lower in the group submitted to RSD, in the third month after ICD implantation.</p>

Pharmacological Use of NLRP3 Inflammasome Inhibitors: Novel Intervention Strategies in Diabetes-Associated Vascular Complications

NLRP3 inflammasome has emerged as a key regulator of glucose and insulin homeostasis. Several studies have shown that activation of the NLRP3 inflammasome contributes to obesity-induced inflammation and insulin resistance . Increased oxidative stress may also contribute to NLRP3 inflammasome activation during diabetes and its complications . Therefore, selective inhibition of NLRP3 inflammasome is a promising target to prevent diabetes and slow down the progression of its complications.

Coronary Artery Rupture After Bioresorbable Vascular Scaffold Implantation Resolved with Graft Stent: Optical Coherence Tomography Assessment

Coronary artery perforation (CAP) is an infrequent and life-threatening complication of percutaneous coronary intervention (PCI). We report a 52-year-old male admited with NSTEMI. During percutaneous coronary intervention on left anterior descending artery with bioresorbable vascular scaffolds the patient suffered a type III coronary artery perforation and pericardiocentesis and graft stent implantation was needed. To the best of our knowleadge this is the first case reported of stent graft assessment by optical coherence tomography (OCT) after coronary artery perforation with a bioabsorbable vascular scaffold (BVS). In the acute phase by OCT, the backscattering does not allow see though the graft stent, nevertheless in the follow up it does. We describe a early positive remodeling on the BVS segment.

The Complex Cardiac Atherosclerotic Disorder: The Elusive Role of Genetics and the New Consensus of Systems Biology Approach

<p>The present technological status of genetics and genomics or the genome-wide association studies (GWAS) are insufficient to explain complex diseases like atherosclerosis and coronary artery disease (CAD). It appears that the genetic risk variants of atherosclerosis are activated concurrently with functionally active specific environmental risk factors. With the systems biology methodological approach the atherosclerotic process and CAD are better explained and studied as a unified entity with significant clinical consequences.</p><p>Systems biology is an alternative approach for the study of atherosclerosis and CAD. With the systems biology approach the follow-up of the atherosclerotic process requires four conceptual areas of study: 1) the two potential directions, the bottom-up direction (functional composition from genes to phenotypes) and the top-down direction (functional decomposition from phenotypes to genes); 2) the four disciplines or levels of complexity: the genomic, the cellular, the modular and the model (clinical phenotype) level; 3) the concept of network construction; 4) the atherosclerotic plaque development and progression across all levels of complexity.</p><p>The systems biology methodology is holistic in conception. The proposed systems patterns are able to follow up the progressive nature of atherosclerosis and to explain the appearance of the clinical cardiovascular phenotypes. The phenotypes of CAD are integrated clinical wholes that determine through constrains and therapeutic procedures the behavior of the biological parts in the lower levels of complexity. This way of thinking is leading from genomics, through networks, to the mainstay of clinical cardiology. </p>

Leadless Cardiac Pacemaker as a Novel Intervention Modality for Atrioventricular Conduction Disturbance in Hypertrophic Cardiomyopathy

Atrioventricular conduction disturbance is a common complication of cardiovascular diseases, such as hypertrophic cardiomyopathy. Moreover, the most common form of atrioventricular conduction disturbance is atrioventricular block. Until recently, cardiac pacing was considered to be the most reliable long-time management of atrioventricular block. However, cardiac pacemakers have several limitations and complications. When the first generation of leadless pacemakers was invented in the 1980s, it was multi-component. Nowadays, self-contained or single component leadless pacemakers have been developed and have become popular amongst cardiac electrophysiologists. In particular, in 2013, St. Jude Medical developed a novel design for a cardiac pacemaker called the Nanostim^TM Leadless Pacemaker. In 2015, Medtronic released a smaller leadless pacemaker called the Micra^TM Transcatheter Pacing System.^1,2 Although Nanostim^TMand Micra^TMrepresent state of the art technology; a few studies have documented some of their limitations.^3-6 More research is needed to confirm and solve these problems

Transcatheter Aortic Valve Replacement (TAVR) in Low Flow-Low Gradient Severe Aortic Stenosis without Cardiac Reserve

<p>With accumulating positive evidence in favour of <em>transcatheter aortic valve replacement</em> (TAVR) over a surgical <em>approach</em>, it has replaced surgical AVR to become the mainstay of treatment for severe symptomatic aortic stenosis in patients with prohibitive and high surgical risk. There is significant surgical mortality and morbidity associated with surgical aortic valve replacement in patients with low flow-low gradient (LFLG) true severe aortic valve stenosis (AS) and severely reduced left ventricular ejection fraction (rEF) without contractile reserve (CR). CR is measured following use of dobutamine in an attempt to increase cardiac output by more than 20% while differentiating severe from pseudostenosis in some cases. The value of <em>transcatheter aortic valve replacement</em> (TAVR) over a surgical <em>approach</em> for these patients with rEF LFLG true severe AS and no CR is uncertain. We present a patient with LFLG severe AS and low left ventricular EF without contractile reserve who underwent TAVR and experienced significant improvement in their clinical status without complications.</p>

Pharmacological Monotherapy versus Renal Artery Denervation in Controlled Hypertensive Patients

<p><strong>Aim: </strong>The aim of this prospective observational non-inferiority study was to compare the capacity for control of essential hypertension between renal sympathetic denervation (RSD) and either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB).</p><p><strong>Methods and results</strong>: Seventy-four previously controlled essential hypertensive patients on ACEI/ARB monotherapy were evaluated; eleven patients agreed to proceed with RSD and had their antihypertensive agent withdrawn on the day of the procedure. During the six months of follow-up, there was no significant change in mean 24-hour ambulatory blood pressure measurements (ABPM) from baseline to three and sixmonths in the ACEI/ARB group (118±8/80±3 <em>vs.</em> 116±8/79±3 and 115±8/79±4 mmHg, respectively). No change was also observed in the RSD group (117±8/81±2 <em>vs.</em> 115±6/80±2 and 114±7/79±3 mmHg, respectively). There were no differences between groups at interval time points. There were also no changes in renal function or echocardiographic parameters, during follow-up.</p><p><strong>Conclusions:</strong> For the first time, this study reports possible non-inferiority of RSD when compared to ACEI or ARB monotherapy in the control of essential hypertension. A randomized trial with appropriate concealment of treatment, more patients and an extended follow-up period is needed to evaluate the potential benefits of RSD in comparison to ACEI/ARB use in patients with controlled hypertension.</p>