Background mitral regurgitation (MR) is the second most common valvular heart disease in Europe. In the contest of functional (or secondary) MR recently has emerged a new entity, the atrial functional MR. This form is due to left atrial dilatation, it has no significant degenerative change in mitral valve complex or significant LV systolic disfunction. Conversely the ventricular functional mitral regurgitation (V-FMR) is due to systolic disfunction and left ventricular dilatation. Aim the aim of this study was to evaluate the differences in clinical characteristics and outcomes of patients with AFMR and VFMR treated with Mitraclip. Methods a retrospective analysis collected consecutive patients with functional MR who underwent transcatheter mitral valve repair using Mitraclip system in our division. A total of 161 patients were divided into the following two categories: VFMR (127 patients), defined as EF<40% or EF ≥40% with history of myocardial infarction, and AFMR (34 patients) identified as EF≥50% and LAVi >48 mL/m2. Baseline and clinical characteristics, echocardiographic parameters and 12 months clinical outcomes (overall mortality at 12 months, MACE at 12 months, re-hospitalization for heart failure (HF), re-hospitalization from other causes at 12 months and number of re-hospitalization at 12 months) were analyzed. Results compared to AFMR, patients with VFMR were younger (73 vs 78 years) had a higher man prevalence (72,4% vs 50%), higher rate of: hypercholesterolemia (79,5% vs 67,6%), smokers (14,2% vs 5,9%), diabetes (39,4% vs 20,6%), chronic kidney disease (55,9% vs 47,1%), NT-proBNP mean value (4403,437 pg/ml vs 2063,409 pg/ml), NYHA class ≥III (84.3 vs 52.9%) and lower rate of hypertension (85% vs 97.1%). In AFMR population there was higher prevalence of atrial fibrillation (70.6% vs 45.7%) and tricuspid valve regurgitation ≥2+ (82.3% vs 68,5%). Moreover, in this group, was lower the all-cause mortality rate at 12 months (9.4 vs 22%), MACE at 12 months (4.5 vs 24.5%), re-hospitalization for HF (15.6% vs 33.1%), re-hospitalization from other causes at 12 months (18.8% vs 31.6%) and number of re-hospitalization at 12 months ≥1 (31,3% vs 59.9%). Conclusion our analysis demonstrated that clinical outcomes at 12 months were lower for the AFMR group. These data are consistent with the literature, where AFMR is considered to have a better prognosis than VFMR, and underline the importance of differentiating these two types of population.

Hemorrhages represent one of the most frequent complications during TAVI. Their rapid recognition and a prompt treatment are necessary to avoid hemorrhagic shock, which can lead the patient to death in a short time. We report the case of a 79-year-old woman affected by severe and symptomatic aortic stenosis, who underwent TAVI in our Cath-lab. Through a right femoral echo-guided arterial access, implantation of a 26 mm self-expandable aortic bio-prosthesis and hemostasis in the site of puncture with 18F Manta vascular closure device were performed. At the end of the procedure, through radial artery, a femoral angiography was performed, showing an important leak of contrast medium upper the site of puncture, without any change in arterial pressure or heart rate. After echo-guided cannulation of left femoral artery with 8F sheath, implantation of endoprosthesis in the site of hemorrhage and hemostasis of left femoral artery with 8F AngioSeal VIP vascular closure device were performed. In cardiac intensive care unit (CICU) low dosage of vasoactive agents and blood were administered, guaranteeing a good arterial pressure. Computed tomography (CT) was performed after two days and confirmed the presence of a retroperitoneal hematoma, without active bleeding. After six days, the patient left CICU and was admitted to the cardiological ward, starting a gradual mobilization. However, after 48 hours she reported abdominal pain and became rapidly hypotensive, tachycardic and asthenic, requiring readmission in CICU. Serum exams showed low hemoglobin concentration, an abdominal CT was perfomed, showing an active bleeding from left femoral artery and a homolateral retroperitoneal hematoma. The patient was rapidly lead in the cath lab. Angiography confirmed the hemorrage and an endoprosthesis was successfully implanted in the left femoral artery. Blood and vasoactive agents were administered with a progressive improvement in hemodynamic and clinical conditions of the patients. Post-operative course was complicated by fever and empiric antiobiotic therapy was administered until blood culture revealed no bacterial growth. A third CT showed the stability of the hematomas and the absence of active bleeding, allowing hospital discharge of the patient. Vascular complications are frequent and sneaky during TAVI procedures. A prompt treatment is of paramount importance to prevent hemorrhagic shock. TAVI operators should have experience in the field of peripheral intervention for the management of vascular complications.

An 87-year-old male patient with worsening dyspnea was admitted to our institution. The patient had a history of acute myocardial infarction treated with coronary stenting of the left descending artery (LAD), diagonal (Diag), right coronary artery (RCA), and chronic kidney disease. For acute pulmonary edema, the patient was admitted to our cardiac intensive care unit and rapidly treated with non-invasive positive-pressure ventilation with continuous positive airway pressure (C-PAP), IV high dosage diuretic therapy, inotropes, and vasoactive agents. Chest X-ray revealed cardiomegaly (cardiothoracic ratio, 56%) and pulmonary congestion. Electrocardiogram revealed sinus tachycardia and diffuse ST-segment abnormalities. An echocardiogram demonstrated left ventricular apical akinesia, with a left ventricular ejection fraction (LVEF) of 25% and severe mitral regurgitation. Blood tests revealed very high levels of NT-pro-brain natriuretic peptide (NT-proBNP) (>30000 pg/ml) and myocardial necrosis markers (hs-Trop 5055 ng/l; CK-MB 72 ng/ml). After 24 hours, the patient was placed on intra-aortic balloon pump (IABP) support to further hemodynamic support through the right femoral artery, nonetheless, he showed no improvement in symptoms or urine output. Because of a state of hypoxemic and hypercapnic respiratory failure, non-invasive ventilation (NIV) was given to the patient with a gradual improvement in blood gas analysis. The optimization of diuretic therapy allowed to treat the state of acute oliguric kidney disease, avoiding dialytic treatment. After 48 hours, because of a new worsening in hemodynamic state, we decided for a percutaneous left ventricular assist device (Impella CP, Denver, Massachusetts, USA). After placing the Impella device, coronary angiography was performed, showing critical stenosis of the left main (LM), involving the origin of the left anterior descending artery and a collateralized chronic occlusion of the circumflex artery and the LAD, after the origin of a large first diagonal branch. Because of the high procedural risk, we decided to perform only percutaneous coronary intervention and stent implantation of LM. After 3 days his symptoms improved, the required dose of inotropic agents and furosemide decreased and Impella was removed. After 12 days the patient was admitted to the cardiological ward and discharged after 21 days because of a urinary infection requiring antibiotic therapy. The management of acute heart failure in very old patients is challenging, limiting in many cases the use of invasive procedures such as coronary angiography or left ventricular assist devices. In this case, although the patient presented a very high-risk profile considering age and comorbidities, the use of Impella resulted to be safe and guaranteed hemodynamic support during the procedure of revascularization and in the immediate post-operative phase.

Aims Patients affected by severe functional Mitral Regurgitation (MR) complaining symptoms despite optimal medical therapy should undergo intervention. When the surgery, the gold standard, is not indicated due to high surgical risk, the transcatheter edge-to-edge repair (TEER) should be considered, if feasible. In patients undergoing TEER, the clinical outcome is not always optimal and strongly correlates to the patient's clinical conditions, so a correct selection of the patients is essential. In this regard, some studies have evaluated the RV-PA coupling as an important predictor of outcome in patients with Heart Failure (HF). In clinical practice, RV-pulmonary artery (PA) coupling could be estimated in a non-invasive way through the relationship between TAPSE (systolic excursion of the annular plane of the tricuspid valve) /PAPs (systolic pressure of the pulmonary artery) ratio that gives information about the state of contractility and adaptability to the load of the RV. In this study, we sought to evaluate how the TAPSE /PAPs ratio at baseline may improve prognostic stratification in patients undergoing TEER with the MitraClip system. Methods and Results Data from 236 patients with symptomatic, moderate to severe functional MR, subjected to implantation of MitraClip between March 2012 and June 2021, were obtained from the University's MITRA-CTV, multicenter observational register comprising data from the Magna Graecia University of Catanzaro (Italy), the University of Turin (Italy) and the University of Vigo (Spain). The median follow-up was 686 days (IQR 393-1131 days), with a 1-year follow-up in 224 of 236 (95%) patients. We divided the population into two groups based on the median value of the ratio TAPSE / PAPs ≤ 0.35 and TAPSE / PAPs> 0.35. The primary endpoint of this study includes Re-hospitalization for HF and Death from all causes at one-year follow-up. At Cox regression analysis, Hospital stay> 10 days (HR 1.67, 95% CI [1.03-2.77], p = 0.039) and the TAPSE / PAPs ratio ≤ 0.35 (HR1.58, 95% CI [1, 01-2.48], p = 0.0488) independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan Meier analysis, a TAPSE / PAPs ratio of ≤ 0.35 was related to an increased incidence of the primary endpoint of Rehospitalization for HF and Death (HR 1.54, 95% CI [ 1-2.41], p = 0.0464). Conclusion In our study, the right ventricular-arterial coupling, estimated through TAPSE/PAPs Ratio, was identified as a predictor of outcome in patients with severe functional MR undergoing TEER.