Looking for the right way: right coronary artery originating from a left anterior descending acutely occluded just distally to the bifurcation We describe the case of a patient referred to our cathlab due to anterior ST segment elevation myocardial infarction. Through the right radial artery route, after multiple attempts to cannulate the right coronary artery (RCA), we proceeded to left coronary angiography, which showed an abnormal origin of RCA from the middle segment of the left anterior descending (LAD), that was occluded just distally to the bifurcation. We performed a primary angioplasty of the LAD throughout a direct stent implantation, with a good angiographical result and the evidence of a myocardial bridging below the implanted stent. The patient was discharged, asymptomatic, after 7 days. Correspondence to Marco Di Maio, MD, Department of Cardiology, University of Campania Luigi Vanvitelli, Naples, Italy Tel: +39 3454489003; e-mail: marcodimaio88@gmail.com Received 7 January, 2019 Revised 10 February, 2019 Accepted 4 May, 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.

Mechanical atrial recovery after cardioversion in persistent atrial fibrillation evaluated by bidimensional speckle tracking echocardiography Background Atrial fibrillation induces reversible electrical and mechanical modifications (atrial remodeling). Atrial stunning is a mechanical dysfunction with preserved bioelectrical function, occurring after successful atrial fibrillation electrical cardioversion (ECV). Two-dimensional speckle tracking echocardiography is a new technology for evaluating atrial mechanical function. We assessed atrial mechanical function after ECV with serial two-dimensional speckle tracking echocardiography evaluations. The investigated outcome was left atrium mechanical recovery within 3 months. Methods A total of 36 patients [mean age 73 (7.9) years, 23 males] with persistent atrial fibrillation underwent conventional transthoracic and transesophageal echocardiography before ECV. Positive global atrial strain (GSA+) was assessed at 3 h, 1, 2, 3, 4 weeks and 3 months after ECV. Mechanical recovery was defined as the achievement of a GSA+ value of 21%. Results Independent predictors of GSA+ immediately after ECV (basal GSA+) were E/e′ ratio and left atrial appendage anterograde flow velocity. During the follow-up, 25% of patients suffered atrial fibrillation recurrence. In 12/36 patients (33%) left atrium mechanical recovery was detected (mechanical recovery group), while in 15/36 (42%) recovery did not occur (no atrial mechanical recovery group). At univariate analysis, the variables associated with recovery, were basal GSA+ (P = 0.015) and maximal velocity left atrial appendage (P = 0.022). Female sex (P = 0.038), N-terminal pro-B type natriuretic peptide (P = 0.013), E/e′ (P = 0.042) and the indexed left atrium volume (P = 0.019) were associated with the lack of left atrium mechanical recovery. Conclusion In almost half of the patients, the left atrium did not resume mechanical activity within the 3 months after ECV, despite sinus rhythm recovery. The left atrium of these patients was larger, stiffer and their E/E′ was higher, suggesting a higher endocavitary pressure compared with mechanical recovery patients. These findings might suggest an increased thromboembolic risk. Correspondence to Antonio Vincenti, MD, FESC, Ospedale San Giuseppe Multimedica IRCCS, Via San Vittore 12, 20123 Milano, Italy Tel: +00 39 330237357; e-mail: antonio.vincenti@multimedica.it Received 22 May, 2019 Revised 8 August, 2019 Accepted 8 August, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Diagnostic ‘nightmares’ in an HIV patient with a cardiac mass and a previous history of tuberculosis No abstract available

When the bundle skips a beat… Intermittent bundle branch block is generally a functional phenomenon because of heart rate variation. It commonly depends by a dependent tachycardia or bradycardia bundle branch block. A rare alternative cause is the Wenckebach phenomenon in bundle branch. We show a singular case of concealed 3:2 Wenckebach phenomenon in the right bundle branch. Correspondence to Carmelo Buttà, MD, Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, via Consolare Valeria, 98124 Messina, Italy Tel: +390902212341; fax: +390902212087; e-mail: carmelob147@tiscali.it Received 9 June, 2019 Revised 5 August, 2019 Accepted 8 August, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

In heart failure with reduced ejection fraction patients’ left ventricular global longitudinal strain is enhanced after 1-year therapy with sacubitril/valsartan compared with conventional therapy with angiotensin-converting enzyme-inhibitors or AT1 blockers: results from a retrospective cohort study No abstract available

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.

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.