Pulmonary thromboembolism (PTE) is a life-threatening condition with a high early mortality rate caused by acute right ventricular failure and cardiogenic shock. We report a series of three patients who presented with acute and subacute submassive PTE. They were suc-cessfully treated by simple catheter-based mechanical thrombectomy and intrapulmonary arterial thrombolysis. Mechanical fragmentation and aspiration of thrombus was performed by commonly used J-wire, multi-purpose and Judkin Right guiding catheters and this obviated the need of specific thrombectomy devices.

Background Evaluation of patient outcomes following transcatheter aortic valve implantation (TAVI) has usually been based on sur-vival and clinical improvement. Studies on quality of life are limited, and data from comprehensive assessments after the procedure are lack-ing. Methods Sixty patients referred for cardiac rehabilitation after TAVI underwent in-hospital and after-discharge multidimensional as-sessments to evaluate clinical, functional, and nutritional statuses, degree of autonomy, cognitive impairment, depression and quality of life. Results On admission to rehabilitation, approximately half of the patients had severe functional impairment and dependence for basic ac-tivities of daily living. During their hospital stay, one-third of the patients suffered significant clinical complications and two had to be trans-ferred to the implantation center. Despite this, the overall outcome was very good. All of the remaining patients were clinically stable at dis-charge and functional status, autonomy and quality of life were improved in most. During a mean follow-up of 540 days (range:192–738 days), five patients died from noncardiac causes, three were hospitalized for cardiac events, and nine for non cardiac reasons. Functional status and autonomy remained satisfactory in the majority of patients and most continued to live independently. Conclusions Patients re-ferred for rehabilitation after TAVI are often very frail, with a high grade of functional impairment, dependence on others and high risk of clinical complications. During a rehabilitation programme, based on a multidimensional assessment and intervention, most patients showed significant improvement in functional status, quality of life, and autonomy, which remained stable in the majority of subjects during mid-term follow-up.

Objective To investigate the effects ofamiodarone (AMD) on simvastatin (SV) in human liver microsomes and the possible underlying mechanisms. Methods Time-, NADPH- and concentration-dependent inhibitions were tested in HLM. The logarithm of relative inhibition values was plotted versus preincubation time (0, 5, 10, 15, 20min) for a series concentration of AMD used (0, 2, 5,25, 50 μ mol/L), and the slopes determined by linear regression. These slope values represente the observed inactivation rate constants (kobs). A double-reciprocal plot was then constructed using the reciprocal of the ko～ (y-axis) and the reciprocal of the associated inhibitor concentration (x-axis) to estimate the values ofkinact and K, which were two principal kinetic constants that were specific for mechanism-based inhibition (MBI).drug-drug interactions (DDI) potential was predicted based on in vitro data and by using the in vitro-in vivo extrapolation. Results The time-, concentration- and NADPH-dependent charactga'istics confirmed that when SV was the substrate of CYP3A4, the inhibition of AMD to CYP3A4 is MBI. Kj and kinact value were calculated to be 5.1 μ mol/L and 0.018min-1 The Clint of SV was reduced 2.96-5.63 fold when it was administrated with AMD. Conclusion Based on the results, AMD would inhibit SV metabolism via the mechanism-based manner, which would lead to DDI when they are taken together. Careful clinical observation is recommended when AMD and SV have to be simultaneously prescribed.

We report a modified technique to perform iliac artery stenting through the brachial artery access. A 6F Brite tip sheath (Cordis, Jonhson & Jonhson Medical, Miami Lakes, FL, USA) is inserted into either brachial artery and a standard 4F Judkins Right diagnostic catheter was inserted over a 260 cm 0.038 Terumo Stiff wire (Terumo Corp, Tokyo, Japan) through the sheath. The catheter is navigated down to the aortic bifurcation, and after selecting the common iliac artery ostium, the wire is navigated through the lesion and advanced to the ipsilateral superficial femoral arteries. The catheter should be then moved forward over the wires beyond the lesion and the Terumo guidewire is replaced by two 0.038 260 cm Supracor wires (Boston Scientific Corporation, San Jose, CA, USA). In order to facilitate advancement of the stent without risk of dislodgement as well as to check the position with low contrast dose injection, a 6 F (or 7F if large stent is selected) 90cm Shuttle Flexor introducer long sheath (Cook Group, Bloomington, IN, USA) should be advanced over the Supracor wire until it reaches the common iliac artery ostium. A road-map technique can be used to check the ostium position in order to properly deploy the selected stent. This technique promises to be safe and effective offering more support than guiding catheter technique; moreover it reduces the stress on the arterial vessel at the subclavian site and enables a stiff balloon or stent catheter to be advanced even through a very elongated and calcified aorta without the risk of stent dislodgement.

Heart failure (HF) is a common disease associated with increasing age. B-type natriuretic peptide (BNP), is a cardiac neurohormone, and is released as prepro BNP and then enzyrnatically cleaved to the Ntenninal-proBNP (NT-proBNP) and BNP upon ventricular myocyte stretch. Blood measurements of BNP have been used to identify patients with I-IF. The BNP assay is currently used as a diagnostic and prognostic aid in HF. In general, a BNP level below 100 pg/mL excludes acutely decompensated HF and levels ＞ 500 pg/ml indicate decompensation. Recombinant human BNP (hBNP, nesiritide) is an approved intravenous treatment for acute,decompensated -HF. Nesiritide given in supraphysiologic doses causes vasodilation, natriuresis, diuresis, and improved symptoms over the course of a 48-hour infusion. This paper will sort out the literature concerning the use of this peptide both as a diagnostic test and as an intravenous therapy.

Approximately 50% of all heart failure patients in the US are above 75 years of age, which is almost similar to most European countries and the Middle and the Far East. Even though aging is an independent molecular process with a multitude of genetic predetermination and biochemical mediations, aging itself does not automatically result in cardiac insufficiency. On the other hand, with increasing age, cardioprotective mechanisms in response to stress are lost, and progressive cardiomyocyte degeneration with replacement fibrosis is often seen in older hearts, even though the exact triggers are not completely understood. Older patients with heart failure have distinct features that require special attention in diagnosis as well as therapy. The elderly more frequently suffer from multiple co-morbidities and might have atypical clinical presentations. Several precautions are essential in the treatment of heart failure in the elderly due to co-existing morbidities and the pharmacokinetic and pharmacodynamic changes related to increased age. Also, treatment expectations, compliance, mental status and cognitive function might play a major role regarding optimized treatment and monitoring options in the elderly suffering from heart failure. This review summarizes current issues of heart failure management in the elderly.

To describe the successful endovascular treatment in a nonagenarian with symptomatic internal carotid artery stenosis using direct carotid artery access. An independent 98 year-old man was admitted to our hospital for symptoms of progressive weakness with disorientation and dysphasia. Carotid Duplex ultrasonography was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery by velocities of 608/240 cm/sec. The patient refused surgical endarterectomy and thus he was referred for carotid artery stenting. Using the femoral artery approach and multiple catheter techniques, access to the common carotid artery could not be accomplished safely. The procedure was aborted and he was therefore brought back to the catheterization laboratory the following day for direct carotid access. Carotid artery stenting was accomplished by using of a 6F sheath percutaneously in the left common carotid, cerebral protection device (CPD) and a Nitinol stent. The patient was discharged the following day without complications. At 14 months follow-up the patient is functional and independent without recurrence of symptoms. Carotid artery stenting via direct access can be accomplished in patients when the femoral artery approach is anatomically prohibitive. In this case of advanced age and the patient's refusal for surgery, direct carotid access was his only option.

The daily practice of cardiopulmonary resuscitation (CPR) in elderly patients has brought up the attention of outcome research and resource allocation. Determinants to predict survival have been well identified. There has been empirical evidence that CPR is of doubtful utility in the geriatric population, more studies have showed controversial data. Sometimes situations in which CPR needs to be given in the elderly, causes stress to healthcare providers, due to lack of communication of the patient's wishes and the belief that it will not be successful. It is of importance to state that we have the duty to identify on time the patients that will most likely benefit from CPR, and find out the preferences of the same. Whenever it is possible to institute these guidelines, we will avoid patient suffering.

Elderly patients with acute myocardial infarction have not been specifically studied in the context of a large randomized clinical trial. Estimates of the efficacy of available treatments are gleaned from subset analyses of clinical trials, retrospective analysis and singlecenter experiences. In western countries the population is aging and a disproportionate number of myocardial infarctions occur in the elderly. Usage of appropriate therapy in this age group is becoming increasingly important given the potential for benefit but also the potential for harm. Recent publications have found steady improvement in outcomes in the elderly population utilizing contemporary interventions.

The increase in life expectance makes the diagnosis of PFO a possible and not easily manageable event in patients ＞ 60-years-old due to the presence of different comorbidities and in particular of diastolic dysfunction which is considered as a contraindication to PFO closure. The literature review suggests that aged patients with PFO cannot be excluded a priori from PFO closure that should evaluated as therapeutic options in presence of anatomical and functional indications. Moreover in the elderly many other syndromes than paradoxical stroke mediated by PFO required full assessment and, if needed, transcather PFO closure: deoxygenating in obstructive sleeping apnoea, unexplained increased dyspnoea associated with hypoxemia after lung surgery, paralysis of the hemidiaphragm, and platypnea orthodeoxia. Differently from in the young and middle age, the management of PFO in aged patients should obligatory include the careful evaluation of potential comorbidities and eventual contraindications, such as severe diastolic dysfunction due to for example to hypertensive cardiomyopathy and coronary heart disease, the main causes of diastolic dysfunction.