To date, billions of vaccine doses have been administered to restrain the current COVID-19 pandemic worldwide. Rare side effects, including intravascular blood clots, were reported in the general population after vaccination. Among these, cerebral venous sinus thrombosis (CVST) has been considered the most serious one. To shed further light on such an event, we conducted a literature search for case descriptions of CVST in vaccinated people. Findings were analyzed with emphasis on demographic characteristics, type of vaccine, site of thrombosis, clinical and histopathological findings. From 258 potential articles published till September 2021, 41 studies were retrieved for a total of 552 patients. Of these, 492 patients (89.1%) had received AZD1222/Vaxzevria, 45 (8.2%) BNT162b2/CX-024414 Spikevax, 15 (2.7%) JNJ-78436735, and 2 (0.3%) Covishield vaccine. CVST occurred in 382 women and 170 men (mean aged 44 years), and the median timing from the shot was 9 days (range 2–45). Thrombi were predominantly seen in transverse (84%), sigmoid (66%), and/or superior sagittal (56%) sinuses. Brain injury (chiefly intracranial bleeding) occurred in 32% of cases. Of 426 patients with detailed clinical course, 63% were discharged in good clinical conditions, at times with variable neurological sequelae, whereas 37% deceased, largely due to brain injury. This narrative review confirmed CVST as a rare event after (adenoviral vector) COVID-19 vaccination, with a women/men rate ratio of 2.25. Though the pathogenesis of thrombosis is still under discussion, currently available histopathological findings likely indicate an underlying immune vasculitis.

Aim: Mutated transthyretin (TTRv) cardiac amyloidosis (CA) represents an uncommon form of CA. Our study aimed to assess the best echocardiographic prognostic parameter in the early stage of TTRv amyloidosis with cardiomyopathy. Methods: In total, 99 patients with TTRv in New York Heart Association class I or II and with no clinical history of previous cardiac disease were studied. Assessment with 99mTc-DPD whole-body scan showed CA in 46 patients. At the first medical contact, an echocardiographic examination was performed. In addition to conventional left ventricular (LV), echocardiographic measurements [ejection fraction (EF), dimensions and diastolic function, global longitudinal strain (GLS), longitudinal strain of the 4 apical segments, longitudinal strain of the 12 mid-basal segments (MBLS)] and their ratio [relative regional strain ratio (RRSR)] were obtained. Patient outcome was evaluated during a follow-up with an average duration of six years. Cardiac death and appropriate implantable cardiac defibrillator (ICD) shock were considered major events. Results: A higher value of LV thickness, E/E’, and RRSR and lower LV volumes, EF, GLS, MBLS were observed in patients with CA than the ones with only TTRv. During follow-up (median of 7.7 years), 25 major events (23 cardiac death and 2 appropriate ICD shocks) occurred. The logistic univariate analyses showed that LV EF, LV septal thickness, E/E’, GLS, and MBLS were all predictors of cardiovascular death. In multivariate analysis, MBLS was the only independent predictor of major events. A cut off of -14 of MBLS was selected as the best value to discriminate a worse prognosis on Kaplan-Meyer analysis. Conclusion: Longitudinal dysfunction is observed in the early stages of ATTRv amyloidosis with cardiomyopathy. Medio-basal LV longitudinal dysfunction is a strong independent echocardiographic predictor of cardiac death.

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Methods and results A 87 years old woman, with history of dyslipidemia and permanent Atrial Fibrillation, already undergone full SARS-CoV2 vaccination few months before, referred to our E.R. with complain of dyspnoea and chest pain. COVID-19 molecular test resulted positive and CT Scan of the chest confirmed the presence of several areas of ground-glass opacity and consolidation together with bilateral pleural effusion (right 6 cm with pulmonary atelectasis; left 2 cm), not requiring drainage. Moreover, it showed severe calcification of both the aortic valve and root. Transthoracic echocardiogram showed eccentric LV hypertrophy with diffuse hypokinesia (EF 20–25%), ectatic ascending aorta (45 mm) with severe LF-LG aortic stenosis (AVAi 0.19 cm2) and moderate regurgitation, moderate-severe mitral regurgitation. During hospitalization in the COVID-19 Unit, despite O2 therapy she experienced worsening of the respiratory status with concomitant pulmonary oedema, hypotension and acute kidney injury, requiring administration of i.v. dobutamine and high dose diuretics. After gradual stabilization and COVID-19 negativization on 10th molecular test, she was transferred to our Coronary Care Unit. Coronary angiography showed absence of significant stenoses in the main vessels. In the following days the patient underwent a new clinical deterioration with dyspnoea, hypotension (BP 85/50 mmHg), oliguria and ankle swelling, requiring Ventimask O2 therapy and Dobutamine infusion. Transtoracic echocardiogram confirmed EF of 25% with PASP 30 mmHg. We decided to perform a ‘Rescue’ TAVI procedure, facilitated by extra-corporeal cardiac and respiratory support. CT Angiography of the chest, performed with low-dose contrast injection under amines infusion, showed severly calcific aortic valve with large sizes of the ring (Virtual Basal Ring area 620 mm2, perimeter 91 mm), measures compatible with the largest sizes of TAVI prostheses. After Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) cannulation, we performed the implantation of a 34 mm Evolut R (Medtronic) TAVI prosthesis, post-dilated with 24 mm balloon for under-expansion due to massive calcification. During both self-expandable TAVI delivery and balloon inflation the patient underwent two phases of cardiac arrest, during which the ECMO flow provided a proper circulatory support. Conclusions Since percutaneous valve replacement the patient’s recovery was fast with rapid ECMO removal and discontinuation of inotropic therapy. Few weeks after discharge, at first follow-up examination, the patient appeared asymptomatic, in excellent clinical conditions. 701 Figure

Background Management of asymptomatic severe aortic stenosis is controversial and the decision to intervene requires careful assessment of the benefits and risks in an individual patient. Multimodality imaging approach is becoming an important tool to evaluate the severity and outcome of aortic stenosis (AS). Aim To assess the outcome of asymptomatic AS and the usefulness of aortic calcium score (CS) by computed tomography (CT) for solving the dilemma of low-flow, low-gradients (LFLG) severe AS. Methods 70 (81.4±8.4yrs) prospective asymptomatic patients with AS were followed for 2.77±2.01yrs with a trans-thoracic echo (TTE) every 6 months. End-points were all cause mortality, aortic valve replacement (AVR or TAVR), aortic velocity and gradients progression and symptoms occurrence. Prevalence of LFLG-AS was investigated and these patients underwent CT for CS calculation at the end of follow-up (FU), Figure 1. Results Baseline TTE results from the 70 pts were: peak velocity 3.1±0.8m/sec; peak gradient 44±21mmHg; mean gradient 26±14 mmHg; AVA 1±0.3 cm2; DVI 0.31 ±0.1; Svi 33.8±18 ml/m2; EF: 55±9% with an AS being mild in 32.9%, moderate in 28.4%, severe in 27.1%; 36.8% of severe AS were LFLG. During FU, 23 (32.8%) pts died (5.7% LFLG) and 13(18.5%) underwent AVR/TAVR. Predictors of mortality were aortic gradients (p=0.03), AVA (p=0.008), DVI (p<0.001), pulse pressure (p=0.005) and dilated ascending aorta (p<0001). Predictors of AVR/TAVR were: gradients (p=0.003), peak aortic velocity (p=0.02) and dilated ascendent aorta (p=0.01). The best cut-off to predict survival was AVA =1cm2 (100% sensitivity and 80% specificity). In 34 pts ending FU we found an overall progression of AS severity (peak velocity 3.6±0.9m/sec; peak gradient 50±24mmHg; mean gradient 33±15 mmHg; AVA 0.7±0.3 cm2; DVI 0.25±0.08; Svi 36±10 ml/m2; EF 54±10%; p<0.05 for all vs baseline) with 24 (70.5%) pts with severe AS and 10 (29.5%) with not severe AS. 18 (75%) of progressive severe AS were LFLG, 12 asymptomatic and 6 symptomatic and all underwent CS revealing that AS was not severe in 6 (1233±1123 AU; 622±55AU/m2) and true severe in 12 (3388±1188 AU;1858 ±795 AU/m2; p=0.005 and p=0.002, respectively). Symptomatic severe LFLG AS were all true severe according to CS (Figure 1). Table 1 shows the main CS correlations. Conclusions Asymptomatic AS in elderly people is associated with high mortality risk and rapid progression. AVA remains the best predictor of outcome. In severe LFLG AS, calcium score correlates with symptoms occurrence, progression of valve disease, LV hypertrophy and function and also with RV function.

Introduction The Impella Heart Pump device (Abiomed, Danvers, MA, USA) is commonly used to provide mechanical circulatory support during high-risk percutaneous coronary intervention (PCI) and has demonstrated both efficacy and safety in patients with cardiogenic shock. Left ventricular assist devices (LVADs) alter the pathophysiological impact of ventricular arrhythmias in advanced heart failure; for example, life-threatening arrhythmias such as ventricular fibrillation (VF). We present a case of sustained VF tolerance in a patient with IMPELLA CP® support. Methods and results A 64-year-old man was admitted with typical chest pain that began 3 days earlier and an anterior myocardial infarction with ST-segment elevation. Urgent coronary angiogram showed a left anterior descending artery treated with angioplasty and stent implantation (TIMI 3). An initial echocardiogram, performed after PCI, showed a reduced left ventricular ejection fraction (LVEF) of approximately 35% with good right ventricular function. Two days later, the ECG tracing showed persistence of the ST elevation, and the patient developed recurrent ventricular tachycardia and an episode of acute pulmonary oedema; the echocardiogram showed a significant worsening of LVEF (15%). A percutaneous mechanical circulatory support device (Impella CP; Abiomed) was inserted through the right common femoral artery in order to preserve adequate systemic perfusion (Figure 1A). Twelve hours later, the patient developed rapid VT degenerating into VF without loss of consciousness (Figure 1C). During the arrhythmia, the patient was alert and his mental status was normal, Impella flow was 2.4–3.0 l/min, and invasive blood pressure (IBP) was 80/65 mmHg (Figure 1D). Intravenous lidocaine was administered without effect. After approximately 10 min of incessant VF, the patient received sedation with propofol from the anesthesiologist. A single unsynchronized DC shock of 200 J converted the patient to sinus rhythm. A bedside transthoracic echocardiogram was performed to check the optimal position of the Impella device (Figure 1B). In the following days, the patient had two new episodes of asymptomatic VF treated with DC-shock after sedation and was transferred to the cardiac surgery department to undergo urgent LVAD implantation. Conclusions Impella CP was helpful in the management of this patient with severe heart failure and malignant ventricular tachyarrhythmias, reducing the hemodynamic and neurological impact of this latter catastrophic arrhythmic event.

Aims The myocardial work (MW) is a new echocardiographic method, based on the pressure–strain loop, which allows to quantify the cardiac performance. On the other hand, the pulse wave velocity (PWV) evaluates arterial stiffness, knowing that as the stiffness of an artery increases, the transmission velocity of the anterograde and the retrograde sphygmic wave increase. The aim of the study is to evaluate the correlation between MW and PWV parameters. Methods and results We enrolled 32 healthy patients (mean age: 39 ± 17 years), who underwent transthoracic Doppler echocardiography (TTE). The MW parameters was derived from the strain–pressure loop, including in its calculation the measurement non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. The PWV measurement was obtained by tonometry at the level of the common carotid artery and the common femoral artery. None of the parameters measured was pathological according to the normality studies considered. It was found a linear correlation between PWV and global wasted work (GWW) (linear R2: 0.603; P = 0.001) and an inverse linear correlation between PWC and global work efficiency (GWE) (linear R2: −0.307; P = 0.032). Conclusions The study highlights the possibility of PWV to predict pre-clinical myocardial changes, given the correlation with GWW and the linear inverse correlation with GWE.