Aortic aneurysms are associated with substantial morbidity and mortalitbecause of the risk of progressive dilation, rupture, and related acute aortic complications. Although diabetes mellitus (DM) is a major cardiovascular risk factor, epidemiological studies have consistently reported an inverse association between DM and the prevalence and progression of abdominal aortic aneurysm (AAA). More limited evidence suggests an inverse association between diabetes and thoracic aortic aneurysm. Accordingly, this review focuses primarily on AAA; where available, evidence concerning TAA and aortic dissection is discussed separately. This review examines the pathophysiological mechanisms underlying the inverse association between DM and aortic aneurysm development. Key mechanisms include the effects of hyperglycemia on extracellular matrix remodeling, particularly through modulation of matrix metalloproteinase (MMP-2 and MMP-9) activity, increased formation of advanced glycation end products (AGEs), and enhanced collagen cross-linking. Experimental and translational evidence suggests that diabetes may influence inflammatory cell states and mural neoangiogenesis, although these effects appear to be context- and model-dependent. Antidiabetic therapies, including metformin, DPP-4 inhibitors, GLP-1 receptor agonists, thiazolidinediones, sulfonylureas, and SGLT2 inhibitors, may also contribute to the observed association through glucose-lowering and/or pleiotropic vascular effects. Furthermore, diabetes-related changes in aortic wall biomechanics, including increased wall thickness and potentially altered wall stress, may contribute to aneurysm stabilization. Overall, DM is associated with a lower prevalence and slower progression of AAA, potentially through a combination of metabolic, inflammatory, structural, and treatment-related mechanisms. These observations should not be interpreted as evidence that diabetes or chronic hyperglycemia is clinically beneficial; rather, they may help identify biological pathways relevant to aneurysm development and progression.

Transthoracic and transoesophageal echocardiogram (TTE, TOE) are central imaging techniques for the diagnosis of endocarditis and its complications. Mitral leaflet aneurysms and perforation are rare and usually late complications of endocarditis requiring surgery. However, when the endocarditic process is significant, complications may instead be precocious. We report here two cases of aneurysm and perforation of the mitral valve (MV) leaflets. These cases are examples of a late and an early complication of endocarditis respectively. The former is about a 78-year-old woman with previous infective endocarditis of the MV due to methicillin-resistant Staphylococcus aureus successfully treated with antibiotic therapy, who presented after 5 months with acute pulmonary oedema. TTE and TOE showed aneurysm and perforation of the P3 leaflet with severe mitral regurgitation (MR). The patient underwent successful cardiac surgery for MV replacement with biological prosthesis (Panels A–C, Supplementary material online , Videos S1 and S2). Both blood cultures and microbiological tests on the valve resulted negative. The second case is related to a 76-year-old man presenting with lumbosciatica. MRI and CT showed spondylodiscitis with abscesses localized in the psoas and glutaeus muscles and the brain. Blood cultures were positive for Streptococcus anginosus. TTE and TOE showed a large, perforated aneurysm of the MV (A2 scallop) causing a severe MR. In addition, a small vegetation was detected on MV and the non-coronary aortic cusp. The patient underwent successful surgical replacement of both the aortic and the MV with biological prosthesis (Panels D–F, Supplementary material online , Videos S3 – S5) due to multiple systemic abscesses. Both patients underwent cardiovascular rehabilitation with full recovery. The MV aneurysms usually occur in association with infective endocarditis of the aortic valve (AV). The suggested mechanism of involvement is either the direct extension of the infective process from the AV or the infected jet of aortic regurgitation striking the anterior leaflet of the MV, creating a secondary site of infection. Perforation of the aneurysm carries potentially catastrophic consequences leading to significant MR, pulmonary oedema, or embolism. Echocardiography reveals a mobile saccular bulge arising from mitral leaflets, protruding to the left atrium during systole and collapsing during diastole. The differential diagnosis includes congenital diverticulum, mitral prolapse, and blood cysts. Although a saccular shape and narrow neck are common features, the diverticulum bulges in the opposite direction into the left ventricle with the mouth facing the left atrium. Instead, neither mitral prolapse nor blood cysts has an almost round structure and a distinct narrow neck. Mitral aneurysm can cause MR by malcoaptation of the mitral leaflets or due to its perforation (as in these two cases).

Early and late outcomes after Cardioband procedure in patients with atrial and non-atrial functional tricuspid regurgitation

Aim: To compare the accuracy of 2D and 3D tricuspid valve reconstructions of TTE versus TEE for screening patients with TR who are candidates for surgical or transcatheter interventions. Methods: Consecutive 42 patients with diagnosis of symptomatic and significant TR were enrolled. Each patient underwent a 2D/3D TTE and a 2D/3D TEE on the same day. Parameters for RV dimension and function evaluation were acquired on a 2D examination from the RV focused apical window for TTE and 4 mid‐esophageal chambers for TEE. 3D reconstructions were made to visualize the structures and parameters to be studied (tricuspid annulus, leaflets, annulus area, annulus perimeter, valve area). The leaflets gap was obtained from the transgastric view (for TEE) and from 3D reconstructions (for TTE). The GLIDE score (Gap, jet Location, Image quality, chordal structure Density, En‐Face TR jet morphology), a simple, five‐component score that can predict a successful T‐TEER, was calculated for TTE and TEE. Results: TR grade, function and dimension of RV, tricuspid annulus parameters, coaptation gap and total GLIDE‐score analyzed at TTE and TEE did not show any statistically difference ( p > 0.05) except for the number of leaflets that were better determined by TEE instead of TTE ( P < 0,001). Conclusions: TTE is an excellent initial screening tool for evaluating patients who are candidates for transcatheter repair or surgical intervention for significant TR. However, TEE provides superior visualization of the valve leaflets and should be performed in patients with favorable anatomical characteristics identified on TTE.

Piera Ciaramella, MD, Lucrezia Netti, MD, Domenico Laviola, MD, Marco Totaro, MD, PhD, Viviana Maestrini, MD, PhD; A rare case of endocarditis vegetation i