Clinical predictors of pocket hematoma after cardiac device implantation and replacement Aims Pocket hematoma is a common complication of cardiac implantable electronic device (CIED) procedures. the aim of the study was to research the clinical factors associated with pocket hematoma formation after CIED implantation or replacement and to identify the best perioperative antithrombotic management. Methods We retrospectively analyzed 500 consecutive patients who underwent to CIED implantation or replacement at our center from November 2014. Results Among our population, 206 patients (41.2%) were on anticoagulant therapy at the time of the intervention: 68 (13.6%) on ongoing Warfarin; 111 (22.2%) on low-molecular-weight heparin (LMWH); and 27 (5.4%) on ongoing direct oral anticoagulants. Antiplatelet therapy was present in 262 (52.4%) patients: in particular, 50 (10%) were on dual antiplatelet therapy, 64 (12.8%) were on single antiplatelet therapy and anticoagulant therapy, whereas 12 (2.4%) were on anticoagulant with dual antiplatelet therapy. Incidence of pocket hematoma after CIEDs implantation was of 4.6%. Considering the different perioperative anticoagulant strategies, patients on LMWH presented the higher hematoma rate [11/100 patients (11.0%), P < 0.001]. At the multivariate analysis, anticoagulant with dual antiplatelet therapy (P = 0.021, OR 6.3, IC 1.3–30.8), left ventricular ejection fraction (LVEF) less than 30% (P < 0.001, OR 7.4, IC 2.7–20.4), and use of LMWH (P = 0.008, OR 3.8, IC 1.4–10.6) resulted the strongest predictors of pocket hematoma (Hosmer test = 0.899). Considering replacement procedures, incidence of pocket hematoma was of 4.4%. The incidence was higher after ICD/CRT-D replacement. The majority of pocket hematoma occurred in patients with mechanical valve prosthesis (3/4 cases, 75%, P < 0.001). Conclusion The use of LMWH and a low LVEF expose patients to a higher risk of pocket hematoma after CIED procedures. Anticoagulant with dual antiplatelet therapy and LMWH should be avoided. Correspondence to Sonia Ferretto, MD, Department of Cardiology, San Donà di Piave Hospital, Venice, Italy E-mail: ferrettosonia@gmail.com Received 7 June, 2019 Revised 20 October, 2019 Accepted 28 October, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

The eligible population of the PARADIGM-HF trial in a real-world outpatient clinic and its cardiovascular risk between 2005 and 2016 Background The PARADIGM-HF trial showed that sacubitril–valsartan – an angiotensin receptor-neprilysin inhibitor (ARNI) – is more effective than enalapril for some patients with heart failure. However, the eligibility of the PARADIGM-HF study to a real-world heart failure population was not well established. Methods We made secondary analysis of patients (n = 4872) with heart failure prospectively enrolled in the Swedish Heart Failure Registry from Sahlgrenska University Hospital/Östra Hospital, Sweden during 2005–2016. The eligibility of the PARADIGM-HF trial in the real world was studied based on patients whether they were either fully or partially compatible with the PARADIGM-HF population. Patients were judged to be fully eligible for the PARADIGM-HF trial if they completely met the inclusion and exclusion criteria, and partially eligible if they did not stay on target dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), despite their having been treated with ACEI/ARB for at least 6 months. Results Among patients who had heart failure with reduced left ventricular ejection fraction (≤40%) (HFrEF) (n = 2165), 653 (30%) and 958 (44%) patients were fully and partially compatible with PARADIGM-HF criteria, respectively. In both fully and partially eligible groups, patients were more male. Despite those fully eligible patients being younger (77.6 ± 12.7 vs. 84.0 ± 13.7 years) than noneligible patients, they were much older than in the PARADIGM-HF trial. Moreover, those fully eligible patients had lower all-cause mortality compared with both partially and noneligible patients. However, both fully and partially eligible patients had higher all-cause mortality than that in the PARADIGM-HF trial. Conclusion In a real-world outpatient clinical setting, around 1/3–1/2 of HFrEF were eligible for treatment of Sac/Val except that they are older, sicker, and carry higher risk for all-cause mortality than the PARADIGM-HF trial population. Correspondence to Xiaojing Chen, Section of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China Tel: +86 18190680855; e-mail: chenxiaojing_058@163.com Received 12 June, 2019 Revised 28 September, 2019 Accepted 5 October, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Unexplained recurrent syncopes in a young noncompetitive runner The anomalous origin from the opposite coronary sinus represents one of the most clinically significant abnormal findings among the wide spectrum of congenital coronary artery anomalies. Anomalous origins from the opposite coronary sinus patients having an intramural course have been associated with an increased frequency of sudden cardiac death in young athletes, especially during strenuous exertion. A prompt recognition of the coronary artery anomaly as well as an adequate risk stratification of cardiovascular events and adequate treatment strategies remain fundamental in these patients. Correspondence to Gianluca Rigatelli, MD, PhD, EBIR, FACP, FACC, FESC, FSCAI, Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy Tel: +39 03471912016; fax: +39 044220164; e-mail: jackyheart@libero.it Received 25 July, 2019 Revised 12 October, 2019 Accepted 19 October, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Clinical frailty and triggers in Takotsubo syndrome: the notable role of a new classification Aims Takotsubo syndrome (TTS) is a mainly transient and acute heart failure mimicking an acute coronary syndrome. Originally described in postmenopausal women, over time TTS has been associated with an increasingly advanced age. Emotional and physical triggers precipitating TTS have been correlated in most cases. The aim of our work was to detect differences between patients with or without recognizable triggers preceding the onset of symptoms. Methods We enrolled 22 consecutive patients. They were all women with an average age of 71 ± 12 (range 40–90) years. Twelve patients correlated the onset of TTS symptoms with a trigger (group 1) and 10 patients (group 2) denied any correlation with stressful events. Results Patients in group 1 showed a higher average age than group 2 (76 ± 10 vs. 64 ± 12 years; P = 0.023), a longer hospitalization period (22 ± 12 vs. 11 ± 10 days; P = 0.01) and greater value of frailty score (P = 0.004). Despite a decrease and subsequent recovery of systolic function, there was no significant difference between groups. Group 1 showed a longer corrected QT (QTc) (505 ± 53 vs. 453 ± 42 ms, P = 0.03), a greater decrease in QTc at discharge (−57 ± 44 vs. 0.3 ± 39 ms; P = 0.004), with the result that at discharge both groups showed a comparable QTc. Conclusion Our results emphasized that typical TTS female patients with precipitating triggers have advanced age, clinical frailty and QTc abnormalities. Correspondence to Flavio G. Biccirè, MD, Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University, 155 Viale del Policlinico, 00161 Rome, Italy Tel: +39 06 499 72597; e-mail: flaviogiuseppe.biccire@uniroma1.it Received 3 August, 2019 Revised 18 September, 2019 Accepted 27 October, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

The lesson of ‘the butler didn’t do it!’. Role of optical coherence tomography for going beyond appearance No abstract available

How to ‘safely’ manage delivery of a pregnant woman with congenital atrioventricular block? No abstract available

Distal embolic protection device transit through a left internal mammary artery for safely treating a saphenous vein graft anastomosed at a Y-configuration No abstract available

Restrictive ventricular septal defect resulting in systemic outflow obstruction in adults with Fontan circulation: challenging diagnosis of a serious and potentially fatal complication Fontan operation is a palliative intervention that allows survival in patients with functional univentricular heart by redirecting systemic venous flow to the pulmonary arteries. The result is an entirely passive pulmonary circulation. In this setting, increased afterload may interfere with Fontan's fragile balance and ultimately lead to severe complications including failure of Fontan circulation and sudden death. In patients with Fontan circulation for double inlet left ventricle or tricuspid atresia and discordant ventriculoarterial connections, a restrictive VSD acts haemodynamically as subaortic stenosis. Systemic outflow obstruction can occur late during follow-up and remains undiagnosed in some cases. We report three cases of late onset of subaortic stenosis that clearly illustrate the diagnostic difficulties and the importance of promptly addressing this issue. Correspondence to Flavia Fusco, MD, GUCH Unit - Division of Cardiology, Cardio-thoracic and Respiratory Sciences Department, AORN Monaldi Hospital, University of Campania ‘Luigi Vanvitelli’, Leonardo Bianchi Street 1, 80131 Naples, Italy Tel: +39 817062682; fax:+39 81267618; e-mail: flaviafusco90@gmail.com Received 24 August, 2019 Accepted 27 October, 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.

An odd couple: acalculous cholecystitis masking a fulminant myocarditis Acute myocarditis is an inflammatory cardiac disease with different underlying causes and a wide spectrum of clinical presentations from asymptomatic cases to sudden or rapidly evolving acute heart failure. Furthermore, the initial diagnosis can be challenging as it can mimic other respiratory or gastrointestinal disorders. We report the case of an otherwise healthy 24-year-old Caucasian man with a fulminant myocarditis successfully treated with mechanical circulatory support, which was initially misdiagnosed as an isolated uncomplicated acute acalculous cholecystitis. Correspondence to Michele Bellamoli, Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani, 1, 37126 Verona, Italy Tel: +39 3485693505; e-mail: bellamoli.michele@gmail.com Received 20 September, 2019 Revised 8 October, 2019 Accepted 27 October, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Multimodality imaging approach to paradoxical embolism: a cauliflower mass on the Eustachian valve No abstract available