In this writing, I propose pathophysiological mechanisms that could be altering the regulatory control of blood pressure and heart rate of patients hospitalized in ICU for COVID-19, through clinical observation, monitoring, and measurements of non-invasive hemodynamic variables, in a series of patients.

Context Elevated lipoprotein (a) [Lp(a)] levels is an often-ignored risk factor for major adverse cardiac events (MACEs) in humans. Even after accounting for established risk factors (discussed in the text), some residual risk can still be independently attributed to elevated Lp(a) levels. Current guidelines dictating normal and elevated Lp(a) levels and subsequent treatment have proven haphazard due to unstandardized studies. Many studies offer cutoff values in units mg/dL, which do not account for the heterogeneity of Lp(a). Interpretation of elevated Lp(a) necessitates consideration of ethnicity necessary for proper predictions. Numerous studies detail the effects of elevated Lp(a) in relation to myocardial infarction, aortic valve stenosis, and atherosclerosis, among other conditions. This article aims to clarify the numerous cutoffs and guidelines presented. Methods Searches were primarily conducted through Google, PubMed.gov, and cochrane.org. Results Elevated Lp(a) seems to correlate with the incidence of MACEs and should be considered when assessing risk. Specific cutoff values remain quite unclear. Conclusions We urge for further detailed investigation on the effects of elevated Lp(a) on cardiac outcomes with the use of isoform independent assays. Particular attention should be given to ethnicity when assigning risk cutoffs for cardiac conditions. Proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors can lower Lp(a) levels significantly and should be investigated.

Background - Complex higher-risk and indicated patients (CHIP) percutaneous coronary interventions (PCI) still challenge interventionalists. Coexistence of coronary atherosclerotic ectasia, narrowings and chronic total occlusion (CTO), represents a unique complex scenario where no evidence could support a standard treatment. Case summary - A 67-year-old man, hypertensive, diabetic, and with recent kidney transplantation with ongoing anti-rejection therapies, presented a complex three-vessel disease, in which the triad of ectasia, stenosis and chronical total occlusion became linked in a continuous pathological arterial remodelling process. The patient was successfully treated with CHIP-PCI integrating endovascular devices, drugs and imaging modalities. Discussion - If revascularization is clinically warranted, procedural challenges and thrombotic issues could be overcome with advanced devices and effective antithrombotic therapies. Moreover, coronary computed tomography angiography (CCTA) represents one of the most promising procedures to predict the likelihood of success during CTOs recanalization and to overcome the absence of some objective means on invasive angiography. If narrowings, CTO and lesion-containing thrombus coexist, coronary imaging combined with modern technical devices and new antithrombotic drugs need to be combined in a tailored complex procedure.

Background: Unligated vertical vein in repaired obstructive totally anomalous pulmonary venous connection (TAPVC) with pulmonary hypertension reduces perioperative pulmonary artery pressure, pulmonary hypertensive crises and improves survival. Our aim was to assess the long-term results of delayed ligation of the vertical vein using an adjustable ligature on survival and reoperations. Method: A series of 99 consecutive patients (62 males), aged 24.8±55.3 months (range 1 day-25 years; median 4 months) underwent rechanneling of isolated, obstructive and non-obstructive TAPVC with left atrial augmentation, atrial septal fenestration and an unligated vertical vein. An adjustable vertical vein ligature was employed in all patients for later interruption. Results: Hospital mortality was 5.0% (n=5) with 2 (2%) late deaths. At a mean follow-up of 218.8 (sE± 209.9) months, the actuarial survival was 93.7% (SE± 0.02%; 95% CI: 86.5, 97.1). Postoperatively, all ligatures were tightened gradually over a period of 24-144 hours. Computed-tomographic angiograms during follow-up revealed absence of flow through the vertical vein and ruled out distortion of the left superior pulmonary vein and left brachiocephalic vein. Conclusions: A patent vertical vein, augmented left atrium and atrial septal fenestration in repaired obstructive and non-obstructive TAPVC with pulmonary hypertension decreased postoperative pulmonary hypertensive crises and improved survival by providing superior hemodynamics. Percutaneously adjustable vertical vein ligature is an expedient, safe and effective technique in these patients in a setting where transcatheter solutions are not available. Use of a percutaneously adjustable ligature around the vertical vein allows gradual tightening of the ligature under optimal physiological conditions, without multiple reoperations

Introduction Most chronic heart failure (HF) patients receive therapy with non-potassium-sparing diuretics (loop diuretics), which are fundamental drugs used to prevent multi-organ failure and improve symptoms. The use of diuretics in HF is also associated with neuroendocrine activation, organ damage and increased mortality. However, there is a lack of studies in the very elderly over the age of eighty. Methods The study included 99 elderly patients with HF, mean age 81 years, which represented a cohort of patients gathered during recent years. They had been admitted to the internal medicine ward at Lund University Hospital and had been given the primary diagnosis of HF. The patients were divided into two groups based upon the dose of furosemide they had at discharge. Patients receiving less than 80 mg daily were allocated to the low-dose furosemide group (LD-group), 65 patients, and patients receiving 80 mg or more of furosemide, 34 patients, were allocated to the high-dose furosemide group (HD-group). Results The HD-group received a mean of 118 mg/day of furosemide and the LD-group received a mean of 39 mg/day of furosemide (p < 0.01). The main finding was that the HD-group had an increased 6 month mortality compared to the LD-group (p = 0.03). Also, both groups demonstrated significant decreases in mean NT-proBNP values from enrollment into the hospital compared to follow up (p < 0.01). Conclusions Elderly patients (>80 years of age) were enrolled into the hospital with the diagnosis of severe HF. During treatment they showed higher 6-month mortality when therapy was focused on high doses of furosemide as compared to low doses combined with neuroendocrine therapy. The use of non-potassium-sparing diuretics in the elderly is not unproblematic and this group of patients respond favourable to neuroendocrine treatment.