Background Immune checkpoints inhibitors (ICIs) have emerged as a treatment option for several malignancies. Nivolumab, pembrolizumab, nivolumab plus ipilimumab, and atezolizumab plus bevacizumab have been approved for the management of advanced‐stage hepatocellular carcinoma (HCC). We aimed to systematically review the literature and summarize the characteristics and outcomes on HCC patients treated with ICIs. Methods A systematic literature search of PubMed, the Cochrane Library, and ClinicalTrials.gov was performed according to the PRISMA statement (end‐of‐search date: November 7^th, 2020). Quality of evidence assessment was also performed. Results Sixty‐three articles including 2,402 patients were analyzed, 2,376 of whom received ICIs for unresectable HCC. Response to ICIs could be evaluated in 2,116 patients, and the overall objective response rate (ORR) and disease‐control rate (DCR) were 22.7% and 60.7%, respectively, and the mean overall survival (OS) was 15.8 months. The ORR, DCR and OS for nivolumab (n=846) were 19.7%, 51.1% and 18.7 months, respectively, and for pembrolizumab (n=435) were 20.7%, 64.6% and 13.3 months, respectively. The combination of atezolizumab/bevacizumab (n=460) demonstrated an ORR and DCR of 30% and 77%, respectively. The overall rate of treatment discontinuation due to adverse events was 14.9%. Fifteen patients received ICIs in the liver transplant (LT) setting (one pre‐LT for bridging, 14 for post‐LT recurrence); fatal graft rejection was reported in 40.0% (n=6/15) and mortality in 80.0% (n=12/15). Conclusion ICIs are safe and effective against unresectable HCC, but caution is warranted regarding their use in the LT setting due to the high graft rejection rate. Implications for Practice Our systematic review pooled the outcomes from studies reporting on the use of immune checkpoint inhibitors (ICIs) for the management of 2,402 patients with advanced‐stage hepatocellular carcinoma (HCC), 2,376 of whom had unresectable HCC. The objective response rate and disease‐control rate were 22.7% and 60.7%, respectively, and the mean overall survival was 15.8 months. The overall rate of treatment discontinuation due to adverse events was 14.9%. Fifteen patients received ICIs in the liver transplant (LT) setting (one pre‐LT for bridging, 14 for post‐LT recurrence). Six of the them experienced graft rejection (40.0%).

Despite advancements in algorithms concerning the management of cardiogenic shock, current guidelines still lack the adequate integration of mechanical circulatory support devices. In recent years, more and more devices have been developed to provide circulatory with or without respiratory support, when conservative treatment with inotropic agents and vasopressors has failed. Mechanical circulatory support can be contemplated for patients with severe, refractory, or acute-coronary-syndrome-related cardiogenic shock. Through this narrative review, we delve into the differences among the types of currently used devices by presenting their notable advantages and inconveniences. We address the technical issues emerging while choosing the best possible device, temporarily as a bridge to another treatment plan or as a destination therapy, in the optimal timing for each type of patient. We also highlight the diverse implantation and removal techniques to avoid major complications such as bleeding and limb ischemia. Ultimately, we hope to shed some light in the gaps of evidence and the importance of conducting further organized studies around the topic of mechanical circulatory support when dealing with such a high mortality rate.

We present the case of an asymptomatic 54-year-old male, referred to our department for a follow-up cardiological consultation. Echocardiography assessment showed an unknown cavity adjacent to the lateral wall of the left ventricle. A large left atrial appendage was revealed in further investigations, and the treatment option was proved to be an impasse.