Objective-To determine the prognostic value of exercise testing, valve area, and maximum transaortic pressure gradient in asymptomatic patients with aortic valve stenosis. Setting-The outpatient service of a tertiary referral centre for cardiology. Design-Prospective clinical study. Patients-66 consecutive patients with isolated severe aortic stenosis (aortic valve area < 1.0 cm 2 ) were selected over a 58 month period. Mean (SD) follow up was 14.77 (11.93) months. Interventions-At the initial visit Doppler echocardiography and exercise testing were performed to evaluate ST segment depression and the development of symptoms of aortic stenosis, ventricular arrhythmia, or inadequate rise of systolic blood pressure during exercise. Follow up clinical examinations were performed every three months thereafter to record the onset of symptoms. Main outcome measures-Sudden death or the development of symptoms. Results-Eight patients developed dizziness during exercise testing but made a rapid and spontaneous recovery. No other complications of exercise testing occurred. Survival curves, with or without the occurrence of end point events for the variables studied, showed significant diVerences for positive versus negative exercise testing (p = 0.0001) and aortic valve area < 0.7 cm 2 v > 0.7 cm 2 (p = 0.0021). There was no relation between the end points and transaortic gradient (p = 0.6882). In multivariate analysis, a hazard ratio of 7.43 was calculated for patients with a positive versus a negative exercise stress test. Although asymptomatic in daily life, 6% of the patients (4/66) experienced sudden death; all these had a positive exercise test and an aortic valve area of < 0.6 cm 2 . Conclusions-Exercise testing is safe and is of prognostic value in asymptomatic patients with aortic stenosis. (Heart 2001;86:381-386)

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In face of the pandemic of the novel coronavirus disease 2019 , the management of patients with cardiovascular risk factors and/or disease is challenging. The cardiovascular complications evidenced in patients with COVID-19 derive from several mechanisms, ranging from direct viral injury to complications secondary to the inflammatory and thrombotic responses to the infection. The proper care of patients with COVID-19 requires special attention to the cardiovascular system aimed at better outcomes.The analysis of 44,672 confirmed cases of COVID-19 in Wuhan has evidenced an overall case-fatality rate of 2.3%; however, among those with preexisting comorbidities, the casefatality rate was higher: 10.5% for CVD, 7.3% for diabetes and 6% for hypertension. 8 In addition, cardiovascular complications due to COVID-19, such as myocardial injury (20% of the cases), arrhythmias (16%), myocarditis (10%), heart failure (HF) and shock (up to 5% of the cases), have been reported. [9][10][11] This review was aimed at aiding healthcare professionals (clinicians, emergencists, cardiologists and intensivists) involved in the care of patients with COVID-19, proposing an

Extrinsic compression of the left main coronary artery (LMC) by the pulmonary artery (PA) is a very unusual and poorly understood entity, usually associated with the presence of adult congenital heart disease. We identified 12 patients (age range, 6 months to 55 years) with LMC stenosis (> or = 50%) presumably secondary to compression by a dilated main PA and related to various forms of heart disease (11 congenital, 1 pulmonary hypertension). In all cases, the main PA was dilated with the main PA/aortic root diameter increased (mean, 2.0; normal value, < or = 1.0), and in all but two, PA pressures were increased (> 30 mm Hg systolic). Left coronary trunk stenosis was usually visualized in only one angiographic view (best seen in 45 degrees left anterior oblique, 30 degrees cranial projection). The LMC also appeared to be inferiorly displaced and in close contact with the left aortic sinus (mean angle between sinus and LMC was 23 degrees +/- 13 degrees, a control group was 70 degrees +/- 15 degrees ). In one patient, surgical correction of the dilated PA was associated with a reduction in LMC stenosis from 85% to < 50% and less inferior left main displacement (from 25 degrees to 50 degrees ). Patients with a dilated main PA may exhibit extrinsic LMC compression leading to significant eccentric narrowing and downward displacement of the LMC. In the presence of significant dilatation of the main PA from any etiology, functional and/or anatomic studies should be performed to exclude significant LM obstruction.

SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient’s survival.