Coeliac disease (CD) is an autoimmune condition with a high prevalence among general population and multisystemic involvement: a more complex scene than a merely gastrointestinal disease. Therefore, an early diagnosis and treatment with a gluten-free diet is mainly important to reduce mortality and comorbidities. Together with autoimmune diseases (as Hashimoto thyroiditis, insulin-dependent diabetes mellitus, autoimmune liver disease and connective tissue diseases), also an accelerated progression of atherosclerosis and a higher prevalence of heart disease have been reported in coeliacs. In the present paper we tried to collect from literature the emergent data on the probable relationship between coeliac and cardiovascular disease, focusing on pathophysiological bases of vascular injury. Data and opinions on the development of cardiovascular risk in patients with CD are conflicting. However, the major evidence supports the theory of an increased cardiovascular risk in CD, due to many mechanisms of myocardial injury, such as chronic malabsorption, abnormalities of intestinal permeability, and direct immune response against self-proteins. The conclusions that come from these data suggest the utility of a careful cardiovascular follow up in coeliac patients.

Inflammation characterizes all stages of atherothrombosis and provides a critical pathophysiological link between plaque formation and its acute rupture, leading to coronary occlusion and heart attack. In the last 20 years the possibility of quantifying the degree of inflammation of atherosclerotic plaques and, therefore, also of vascular inflammation aroused much interest. 18Fluoro-deoxy-glucose photon-emissions-tomography (18F-FDG-PET) is widely used in oncology for staging and searching metastases; in cardiology, the absorption of 18F-FDG into the arterial wall was observed for the first time incidentally in the aorta of patients undergoing PET imaging for cancer staging. PET/CT imaging with 18F-FDG and 18F-sodium fluoride (18F-NaF) has been shown to assess atherosclerotic disease in its molecular phase, when the process may still be reversible. This approach has several limitations in the clinical practice, due to lack of prospective data to justify their use routinely, but it’s desirable to develop further scientific evidence to confirm this technique to detect high-risk patients for cardiovascular events.

Funding Acknowledgements Type of funding sources: None. Background Structural and functional remodeling of left and right atrium (LA-RA) are predictors of the risk of hospitalization and mortality. These are chronic and complex processes, dependent on an adaptive response implemented by the atrial myocytes against stressors of an electrical, mechanical and metabolic nature. Atrial fibrillation (AF) is the most common condition associated with remodeling of both atria, of which it can be cause and effect at the same time: atrial enlargement, interstitial fibrosis and myocardial distension. Often the first manifestation of AF is cryptogenic stroke (CS) which is associated with a high rate of recurrence and adverse long-term follow-up outcomes, mainly due to its unknown etiology often leading to secondary prevention ineffective. Asymptomatic (AF) may play an important pathophysiological role to detect CS. Evidence has demonstrated the efficacy of AF ablation in restoring the structure of the LA and, consequently, in favoring the maintenance of sinus rhythm. However, little is known regarding the evaluation of RA remodeling and its variation over time in patients with FA. Aim of the study Evaluate the relationship between echocardiographic parameters of LA and RA function, and the occurrence of AF revealed by continuous ECG monitoring through insertable cardiac monitors (ICM) implant in a cohort of patients with CS Methods Single-center retrospective study. A total of 204 patients who suffered from cryptogenic stroke underwent ICM between May 2013 and July 2022. All detected AF episodes lasting more than 30 seconds were considered, according to Guidelines. All patients underwent to Transthoracic Echocardiography (TTE) to study on LA and RA function, including both standard and longitudinal strain-derived parameters. Transesophageal Echocardiography (TEE) was also performed to exclude embolic sources. Results During a median follow-up period of 15.3 months (interquartile range, 7.4 / 23.5), continuous ECG monitoring revealed AF in 96 patients (47.0%). Many echocardiographic parameters, such as LA maximum and minimal volume were significantly associated with the occurrence of AF, suggesting the worst atrial function in the AF group. Furthermore, multivariable regression analysis revealed that peak atrial contraction strain of both atria were independently associated with AF (p < 0.001,respectively). Conclusion In patients with cryptogenic CS, LA and RA strain analysis are strong and independent predictors of the occurrence of AF despite clinical and morpho-functional echocardiographic parameters.

Aims Poor data exist about the leadless PM implantation through a bioprosthetic tricuspid valve. Bioprosthetic tricuspid valve has traditionally represented a relative contraindication to transvenous right ventricular pacing for possible tricuspid bioprosthetic valve damage and dysfunction. Therefore, epicardial pacing is usually preferred to transvenous right pacing through a bioprosthetic tricuspid valve for the deleterious effect of permanent pacing leads on tricuspid bioprosthetic valve function and regurgitation. Methods Our case focuses on a 62-year-old woman with mechanical mitral and biological tricuspid prosthesis due to rheumatic disease since 2007 and with a PM-DDDR for a postsurgical complete atrioventricular block. A lead was implanted in right atrium while another lead was implanted in the coronary sinus (CS) instead of in the right ventricle following the presence of a biological tricuspid prosthesis. In February 2022, she did a replacement of pacemaker (PM) generator to another hospital due to initial battery depletion. In March she described pain at the device pocket and consequent appearance of pocket infection. For this situation she was admitted to our cardiac department. A transesophageal echocardiography (TEE) was performed and showed normal biventricular size and function (LVEF 55%), normal function of valve prostheses and absence of vegetations both on the valves and atrial lead. Subsequently an angiography was performed and revealed little patency of the anonymous-caval-subclavian left axis. We made a diagnosis of pocket infection and decided to extract leads in March. We proceded through debridement of leads and removal of the PM generator. After placing Spectranetics (Philips) Lead Locking Device n.2 (LLD2) along the 2007 right atrial lead, we removed it through the use of a mechanical extractors (Cook 7-8.5 Fr). Then after placing Spectranetics (Philips)Lead Locking Device E (LLDE), the CS lead was completely removed through the use of a mechanical extractors (Cook 7-8.5 Fr) and specific delivery.The procedure was well tolerated and uneventful. Following the negative result of the post-extraction blood cultures, cultures of lead tips and pocket swab, together with the normalization of inflammation indices (WBC and CRP) and to the end of antibiotic therapy, we decided to reimplant the device.For the presence of valve prostheses and the patient's high infectious risk, we decided to implant a leadless PM. Results At the beginning of April we performed a leadless Micra AV PM implantation through 23-F Micra TPS delivery catheter across a tricuspid bioprosthetic valve in the right ventricular apex instead of the middle septum due to implantation difficulties for the concomitant presence of the bioprosthetic valve. The procedure was well tolerated and uneventful too. She was discharged after 72h in good conditions. Conclusions We present an unusual case of lead extraction for the second infection of the device pocket in a patient with mechanical mitral and biological tricuspid prostheses and a lead in coronary sinus for the presence of biological tricuspid prosthesis. Leadless PM implantation represents a new technology by eliminating the risks connected with the presence of the lead across the bioprosthetic valve.