Midventricular Takotsubo cardiomyopathy complicated by a ventricular septal rupture: a surgical management Takotsubo cardiomyopathy, also known as ‘Broken Heart Syndrome’, is a form of acute heart failure, featured by a reversible impairment in cardiac contractility. About 20% of patients during hospitalization experience complications including cardiogenic shock, stroke, left ventricular thrombosis or death. Ventricular rupture has already been reported in Takotsubo cardiomyopathy in patients with typical apical ballooning pattern. We report one of the first cases of a midventricular ballooning Takotsubo cardiomyopathy in a 57-year-old woman complicated by ventricular septal rupture, successfully repaired with a surgical interrupted suture technique. Correspondence to Dr Nunzio Davide de Manna, MD, Cardiac Surgery, University Hospital, University of Verona, P.le A. Stefani 1, 37126, Verona, Italy Tel: +39 340 0730490; fax: +39 045 8123307; e-mail: d.demanna91@gmail.com Received 14 March, 2019 Revised 4 July, 2019 Accepted 6 August, 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.

Aortic valve-in-valve implantation requiring valve fracturing via a subclavian access: new insights with a word of caution The valve-in-valve treatment of small aortic bioprostheses is still matter of debate. In this setting, high-pressure balloon fracturing may represent an option to treat patients with a previously implanted small biological heart valve in order to improve the transvalvular gradient and to reduce the risk of patient-prosthesis mismatch. The feasibility of this approach was recently demonstrated but long-term resutls of large series are not available. We here report a trans-subclavian access for this procedure. However, after successful implantation and uneventful discharge, the patient suffered from sudden cardiac death. Correspondence to Marco Russo, MD, Department of Cardiac Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria. Tel: +43 1 40400 47031; e-mail: mar.russo1987@gmail.com Received 28 March, 2019 Revised 13 June, 2019 Accepted 6 August, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Echocardiographic score for prediction of pulmonary hypertension at catheterization: the Daunia Heart Failure Registry Background Right heart catheterization (RHC) is recommended by guidelines for the diagnosis of pulmonary hypertension, the definition of hemodynamic impairment and responsiveness to drug therapy. However, RHC is an invasive test with associated risk of complications. Noninvasive echocardiographic tools, possibly predictive of pulmonary hypertension at RHC, could be therefore extremely useful. Methods Sixty-four consecutive patients with suspected pulmonary hypertension were enrolled in the study and assessed by echocardiography and RHC. Diagnosis of pulmonary hypertension was based on mean pulmonary artery pressure (≥25 mmHg) at RHC. Results Of 64 consecutive patients enrolled, 77% were diagnosed as having pulmonary hypertension after RHC. On the basis of significant differences between patients with pulmonary hypertension at RHC and those without on echocardiographic assessment, a multiple logistic regression model was constructed to predict the presence of pulmonary hypertension at RHC. The score was calculated using right atrium and ventricular diastolic area, tricuspid regurgitation Vmax, tricuspid regurgitation severity degree and left ventricular ejection fraction. The score area under the curve was therefore 0.786 (P = 0.0001), higher than for tricuspid regurgitation Vmax (P = 0.06). A score value more than 57 was associated with a 93% sensitivity, a 67% specificity, a 91% positive predictive power, a 73% negative predictive power, and an odds ratio 27 (P < 0.001) of pulmonary hypertension at RHC, significant even after correction at multivariable analysis. Accuracy of the prediction model was assessed in a validation cohort with comparable results (P = n.s.). Conclusion A simple noninvasive echocardiographic score can be useful in predicting the diagnosis of pulmonary hypertension at RHC and may be considered for the selection of patients who should undergo or could avoid RHC. Correspondence to Natale D. Brunetti, MD, PhD, FESC, Department of Medical & Surgical Sciences, University of Foggia, Viale Pinto 1, 71122 Foggia, Italy Tel: +39 338 9112358; fax +39 0881 745424; e-mail: natale.brunetti@unifg.it Received 20 June, 2018 Revised 7 April, 2019 Accepted 24 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

The role of physical activity in individuals with cardiovascular risk factors: an opinion paper from Italian Society of Cardiology-Emilia Romagna-Marche and SIC-Sport Regular physical activity is a cornerstone in the prevention and treatment of atherosclerotic cardiovascular disease (CVD) due to its positive effects in reducing several cardiovascular risk factors. Current guidelines on CVD suggest for healthy adults to perform at least 150 min/week of moderate intensity or 75 min/week of vigorous intensity aerobic physical activity. The current review explores the effects of physical activity on some risk factors, specifically: diabetes, dyslipidemia, hypertension and hyperuricemia. Physical activity induces an improvement in insulin sensitivity and in glucose control independently of weight loss, which may further contribute to ameliorate both diabetes-associated defects. The benefits of adherence to physical activity have recently proven to extend beyond surrogate markers of metabolic syndrome and diabetes by reducing hard endpoints such as mortality. In recent years, obesity has greatly increased in all countries. Weight losses in these patients have been associated with improvements in many cardiometabolic risk factors. Strategies against obesity included caloric restriction, however greater results have been obtained with association of diet and physical activity. Similarly, the beneficial effect of training on blood pressure via its action on sympathetic activity and on other factors such as improvement of endothelial function and reduction of oxidative stress can have played a role in preventing hypertension development in active subjects. The main international guidelines on prevention of CVD suggest to encourage and to increase physical activity to improve lipid pattern, hypertension and others cardiovascular risk factor. An active action is required to the National Society of Cardiology together with the Italian Society of Sports Cardiology to improve the prescription of organized physical activity in patients with CVD and/or cardiovascular risk factors. Correspondence to Anna V. Mattioli, MD, Associate Professor of Cardiovascular Diseases, Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, Via del Pozzo, 71-41124 Modena, Italy Tel: +39 0594224043; fax: +39 0594223229; e-mail: annavittoria.mattioli@unimore.it Received 20 December, 2018 Revised 18 March, 2019 Accepted 13 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.

Electrocardiographic changes in focal takotsubo syndrome: a case report No abstract available

Atrial natriuretic peptide predicts disease progression and digital ulcers development in systemic sclerosis patients Aims Systemic sclerosis (SSc) is an autoimmune disease characterized by micro/macrovascular damage due to the underlying fibrosis. Markers able to predict the progression of cardiovascular damage, including digital ulcers, in SSc are warranted. We aimed at characterizing the relevance of N-terminal proatrial natriuretic peptide (NT-proANP) and N-terminal probrain natriuretic peptide plasma levels in relation to cardiovascular damage and digital ulcers in a cohort of Italian SSc patients. Methods Seventy patients were enrolled (64 women and six men; mean age 56.7 ± 14 years) with a disease duration of 11.1 ± 8.3 years. Clinical, instrumental (nailfold videocapillaroscopy, ECG, transthoracic echocardiography, pulmonary function test with diffusion lung CO), NT-proANP and N-terminal probrain natriuretic peptide plasma levels measurement were performed at baseline. The clinical follow-up lasted 24 months. The statistical approach used to achieve the study objectives included multivariate analysis, receiver operating characteristic curve, Kaplan–Meier and Cox regression analyses. Results Both NT-proNPs levels correlated with systolic pulmonary arterial pressure, but only the NT-proANP level correlated with right heart dimension. Both NT-proNPs levels were higher in patients experiencing events at follow-up but only the NT-proANP level significantly predicted the progression of cardiovascular damage, including development of pulmonary arterial hypertension (PAH). NT-proANP levels were higher in patients with digital ulcers and strongly predicted their development. Conclusion Our results show that the NT-proANP plasma level significantly correlates with disease progression such as new onset of PAH, worsening of pulmonary hypertension and development of digital ulcers in a cohort of SSc Italian patients. If future studies will confirm our findings, the plasma NT-proANP level could be used in clinical practice as a novel sensitive marker for PAH and digital ulcers development in SSc. Correspondence to Edoardo Rosato, MD, PhD, Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy Tel: +39 06 49972040; fax: +39 0649972072; e-mail: edoardo.rosato@uniroma1.it Received 5 February, 2019 Revised 30 May, 2019 Accepted 13 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

New drugs for the treatment of chronic heart failure with a reduced ejection fraction: What the future may hold Despite recent improvement in therapy, heart failure with reduced ejection fraction (HFrEF) remains a major cause of increased mortality and morbidity. We have reviewed recent advances in the medical treatment of the patients with HFrEF, including drugs introduced into clinical practice for the first time in the most recent guidelines and drugs undergoing active clinical research in major randomized trials. Sacubitril/valsartan for HFrEF treatment, empagliflozin for heart failure prevention in diabetic patients, ferric carboxymaltose for iron deficiency and potassium binders for hyperkalaemia belong to the first category, whereas drugs undergoing phase 3 clinical trials include omecamtiv mecarbil and vericiguat. A large trial with rivaroxaban has been recently concluded. In conclusion, new drugs recently introduced for HFrEF treatment need implementation in clinical practice, as well as further studies to possibly expand their indications. Ongoing trials will show the role of new drugs acting on cardiac and vascular function and new mechanisms potentially involved in HFrEF progression. Correspondence to Dr. Edoardo Sciatti, MD, Piazzale Spedali Civili 1, Brescia 25123, Italy Tel: +390303995536; fax: +390303995013; e-mail: edoardo.sciatti@gmail.com Received 27 February, 2019 Revised 5 June, 2019 Accepted 13 July, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

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.