Spontaneous coronary artery dissection managed with a conservative or revascularization approach: a meta-analysis Background The optimal treatment approach for spontaneous coronary artery dissection (SCAD) remains unclear. Objectives The study aims to compare in-hospital and long-term clinical outcomes of SCAD patients initially managed with medical therapy (conservative approach) versus percutaneous coronary intervention or coronary artery bypass grafting (revascularization approach) based on published data. Methods We identified relevant studies by performing a systematic search in the Ovid MEDLINE and Embase databases. Studies with N at least 10 that report in-hospital outcomes [death, myocardial infarction (MI) and revascularization] or long-term outcomes (death, MI, revascularization, SCAD recurrence, and heart failure) were included. Risk difference between conservative and revascularization approach was estimated with the inverse variance-weighted method in a fixed-effect or random-effect model. Results A total of 22 nonrandomized, observational studies were analyzed (N = 1435). Compared with the initial revascularization approach, the conservative approach was associated with a comparable risk of in-hospital outcomes [risk difference: death, −0.61% (95% confidence interval, −2.13–0.91%), P = 0.43; MI, −0.99% (−4.65–2.67%), P = 0.60; revascularization, −3.02% (−8.79–2.75%), P = 0.31] and long-term outcomes [death, −0.06% (−2.33–2.20%), P = 0.96; MI, 0.96% (−2.35–4.27%), P = 0.57; revascularization, −3.31% (−7.63–1.02%), P = 0.13; SCAD recurrence, 3.75% (−2.05–9.55%), P = 0.21; heart failure, −0.01% (−3.13–3.11%), P = 0.99]. There was no significant heterogeneity across these studies. Conclusion Pooled results suggest that SCAD patients initially managed with a conservative strategy may have similar in-hospital and long-term outcomes compared with those who received revascularization in the absence of ongoing ischemia or left main artery involvement. More data from prospective studies are warranted to validate these findings. Correspondence to Gerald Chi, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 930 Commonwealth Avenue #3, Boston, MA 02215, USA Tel: +1 617 975 9952; fax: +1 617 975 9955; e-mail: geraldcchi@gmail.com Received 4 July, 2019 Revised 29 September, 2019 Accepted 6 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.

PrevenTion of contrast-inducEd nephropAThy with urinE alkalinization: the TEATE study design Intravascular administration of iodinated contrast media is an essential tool for the imaging of blood vessels and cardiac chambers, as well as for percutaneous coronary and structural interventions. Along with the spreading of diagnostic and interventional procedures, the increasing incidence of contrast-induced nephropathy (CIN) has become an important and prognostically relevant problem. CIN is thought to be largely dependent on oxidative damage, and is a considerable cause of renal failure, being associated with prolonged hospitalization and significant morbidity/mortality. The most effective treatment strategy of this serious complication remains prevention, and several preventive measures have been extensively investigated in the last few years. Preprocedural hydration is the best-known and mostly accepted strategy. The administration of sodium bicarbonate has controversial effects, and is likely to be ineffective when the infused dose is unable to achieve adequate urine alkalinization. Since alkaline pH suppresses the production of free radicals, increasing urine pH would be an attractive goal for CIN prevention. In a prospective randomized controlled, open-label clinical trial we will test the hypothesis that urine alkalinization with either oral or intravenous bicarbonate on top of hydration alone is the main determinant of CIN prevention (primary endpoint) in a population of patients with moderate or severe chronic kidney disease scheduled for coronary angiography and/or angioplasty. If we then demonstrate nonsignificant differences in urine alkalinization and incidence of CIN between the two bicarbonate groups (secondary endpoint), a practical implication will be that oral administration is preferable for practical reasons over the administration of intravenous bicarbonate. Correspondence to Raffaele De Caterina, MD, PhD, Cardiovascular and Thoracic Department, University of Pisa, C/o Pisa University Hospital, Via Paradisa 2, 56126 Pisa, Italy Tel: +39 050 221 1848; e-mail: raffaele.decaterina@unipi.it Received 19 July, 2019 Revised 26 September, 2019 Accepted 3 October, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Emerging clinical setting of direct oral anticoagulants: atherothrombotic events prevention Despite substantial progress in the treatment of atherosclerotic disease a non-negligible rate of acute atherothrombotic events persists. Evidence suggesting a safer profile of direct oral anticoagulants (DOACs) compared with vitamin K antagonists and the involvement of coagulation in the atherosclerotic process has led to exploration of the role of DOACs in the prevention of atherothrombotic events. In this review, we discuss the findings of recent studies on DOACs, particularly rivaroxaban, in atherothrombotic disease which represents a new clinical setting for oral anticoagulants. Correspondence to Stefania A. Di Fusco, Cardiology Unit, San Filippo Neri Hospial, via Martinotti, 20, 00135 Rome, Italy E-mail: stefaniaa.difusco@aslroma1.it Received 23 July, 2019 Accepted 5 October, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Suspected Takotsubo syndrome recurrence and asymptomatic malignant ventricular arrhythmias: the possible role of wearable cardioverter defibrillators No abstract available

Prognostic impact of anemia according to frailty status in elderly patients with acute coronary syndromes Aims Anemia is associated with poorer outcomes in patients with acute coronary syndromes (ACS), but the magnitude of this association in elderly patients remains poorly understood. No study has assessed the prognostic impact of anemia according to frailty status in this setting. Methods The LONGEVO-SCA registry included unselected ACS patients aged at least 80 years. A geriatric assessment was performed during hospitalization, including frailty assessment using the FRAIL scale. Anemia was defined by the WHO criteria. We evaluated the impact of anemia on 6-month mortality according to the presence of frailty. Results A total of 517 patients were assessed. Mean age was 84.3 years, and a total of 236 patients (45.6%) had anemia. Patients with anemia had a higher prevalence of comorbidities and higher prevalence of frailty (30.6 vs. 22.3%, P = 0.007). A total of 60 patients (12.1%) died at 6 months [40 with anemia (17.5%) and 20 without anemia (7.5%), P = 0.001]. Anemia was independently associated with mortality at 6 months in the whole cohort (hazard ratio 2.28, 95% CI 1.13–457, P = 0.021). The association of anemia and mortality was different according to frailty status, being significant in patients without frailty (hazard ratio 3.94, 95% CI 1.84–8.45, P = 0.001), but not in frail patients (hazard ratio 1.17, 95% CI 0.53–2.57, P = 0.705), (P value for interaction = 0.035). Conclusion A high proportion of elderly patients with ACS have anemia, leading to a worse prognosis in the whole cohort. The association between anemia and mortality was especially significant in robust patients, whereas the poorer prognosis in frail patients was not modified by the presence of anemia. Correspondence to Albert Ariza-Solé, Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n. 08907, L’Hospitalet de Llobregat, Barcelona, Spain Tel: +34 932607924; fax: +34 932607618; e-mail: aariza@bellvitgehospital.cat Received 12 April, 2019 Revised 13 September, 2019 Accepted 21 September, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Let's go fishing: snaring a Reducer coronary sinus stent in the right atrium No abstract available

Percutaneous treatment of aortic root rupture after transcatheter aortic valve replacement procedure Annular rupture is a feared complication of transcatheter aortic valve replacement (TAVR), mainly after the use of balloon-expanding prosthesis. The treatment depends on the type of annular rupture and its clinical presentation. Therapeutic approaches reported in literature include conventional surgical procedure, isolated pericardial drainage, and conservative strategy. A discussion in a multidisciplinary setting is needed, to improve outcomes after TAVR. We report the case of a sovra-annular rupture after self-expanding TAVR, with a fistula between the aortic root and the right ventricle inflow tract, treated with urgent transradial embolization by vascular plug. This is the first ever reported successful case of transcatheter percutaneous intervention for annular rupture secondary to TAVR. Correspondence to Antonio Pignatelli, MD, Department of Cardiovascular Disease, Mater Dei Hospital, 70100 Bari, via S. Hahnemann 10, Italy Tel: +39 805076727; fax: +39 805076722; e-mail: apignatelli@hotmail.it Received 4 February, 2018 Revised 4 April, 2019 Accepted 11 September, 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.

Hypertrophic cardiomyopathy, long QT interval and coronary perforator disease in the Noonan syndrome The current article deals with original electrocardiographic and echocardiographic findings from a young adult patient with Noonan syndrome. Massive hypertrophic cardiomyopathy, long QT interval and abnormal intramural coronary blood flow velocity were simultaneously demonstrated. Correspondence to Cesare de Gregorio, MD, Dipartimento di Medicina Clinica e Sperimentale, Resp. Outpatient Heart Failure and Cardiomyopathy Lab, AOU Policlinico ‘G. Martino’, Via Consolare Valeria, 98125 Messina, Italy Tel: +39 090 221 3531; fax: +39 090 221 3531; e-mail: cdegregorio@unime.it Received 24 January, 2019 Revised 5 July, 2019 Accepted 10 September, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Hypertrophic cardiomyopathy and membranous subaortic stenosis: a rare, but possible association A 69-year-old male was admitted to our hospital with exertional angina and dyspnea. Transthoracic echocardiography showed asymmetric left ventricular (LV) hypertrophy and an elevated subaortic pressure gradient, in absence of dynamic LV outflow tract obstruction. Transesophageal echocardiography and cardiac computed tomography scan revealed the presence of a subvalvular membrane causing a fixed subaortic obstruction. Cardiac magnetic resonance showed typical findings of hypertrophic cardiomyopathy. A final diagnosis of subaortic stenosis associated with hypertrophic cardiomyopathy was made. This case highlights the key role of multimodality imaging in morphological assessment, risk stratification and differential diagnosis of these complex cases of cardiomyopathy, as it may help in identifying concealed concomitant causes of LV outflow tract obstruction. Correspondence to Angelica B. Delogu, MD, Department of Woman and Child Health and Public Health, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy Tel: +39 0630154187; e-mail: angelicabibiana.delogu@policlinicogemelli.it Received 22 March, 2019 Revised 21 May, 2019 Accepted 11 September, 2019 © 2019 Italian Federation of Cardiology. All rights reserved.

Life-saving transcatheter aortic valve implantation for acute severe aortic regurgitation due to rheumatoid arthritis and complicated by cardiogenic shock No abstract available