[Grey zones on diabetes in cardiovascular disease. Expert opinion]. / Grey zones sul diabete mellito in ambito cardiologico. Opinioni degli esperti.

Clinical guidelines, while representing an objective reference to perform correct therapeutic choices, contain grey zones, where recommendations are not supported by solid evidence. In a conference held in Bergamo in October 2018, an attempt was made to highlight some of the main grey zones in Cardiology and, through a comparison between experts, to draw shared conclusions that can illuminate our clinical practice. This manuscript contains the statements of the symposium concerning the controversies in diabetes mellitus and cardiovascular disease. The first topic concerns the appropriateness of second level cardiovascular screening of the entire population of diabetic patients. The second gap in evidence concerns the validity of a target of glycated hemoglobin considering the last trials. The work has also been implemented with the evidences deriving from important randomized studies published after the date of the Conference.

Renal artery side branches patency protection during endovascular exclusion of giant renal artery aneurysm with covered stent: Well done is better than well said.

RATIONALE: Endovascular treatment of renal artery aneurysms has offered a viable alternative with a high success rate and low procedure-related morbidity and mortality. PATIENT CONCERNS: A 60-year-old man, having a right renal artery aneurysm involving the main vessel with two arteries (supplying the inferior and superior lobes of the kidney) originating from the aneurysm sac as well. INTERVENTIONS: A 6 × 28 mm covered stent was inflated in vitro and a side hole was made with a femoral needle in the polytetrafluoroethylene (PTFE) layer, through which a wire was placed in an outside/inside direction in to be inserted in the inferior pole branch. The other wire was inserted inside the main lumen of the stent (to be inserted in the main artery) and the latter, carefully re-crimped on the balloon. This way, the authors guaranteed continuous access to both arteries during aneurysm exclusion and if needed, a second stent could be advanced at the level of the bifurcation to preserve side branch patency. CONCLUSION: Perforating the PTFE of the stent before its introduction into the vessel and keeping a wire into the side branch could be a good strategy to protect any vessel arising from aneurysmal sac that needs to be excluded..

Biventricular implantable cardiac defibrillator in dextrocardia with situs viscerum inversus.

A case of dextrocardia in situs viscerum inversus, prior myocardial infarction, dilated cardiomyopathy with severe left ventricular systolic dysfunction, ventricular tachyarrhythmias and recurrent episodes of heart failure is described. Coronary artery bypass grafting for multivessel coronary artery disease had been previously performed; coronary and graft anatomy evaluation excluded the possibility of any further revascularization procedure. Electrocardiography showed left bundle branch block and echocardiography revealed significant interventricular mechanical dyssynchrony. After a complete vascular and cardiac anatomy evaluation, the patient was submitted to biventricular cardiac defibrillator implantation via a right approach and using conventional fluoroscopic equipment.

Time course changes of cystatin C and inflammatory and biochemical markers in non-ST-elevation acute coronary syndromes.

BACKGROUND: Serum cystatin C (Cys-C), a good marker of renal function, predicts prognosis in non-ST-elevation acute coronary syndromes (NSTE-ACS). However, no data are available on the time course of Cys-C values after discharge. In this study, Cys-C was measured during admission (ACS sample) and 6 weeks after discharge, and was correlated with troponin (c-TNT), high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6) and the N-terminal portion of the pro-brain natriuretic peptide (proBNP) peptide (NT-proBNP) in a highly selected homogeneous group of NSTE-ACS patients. METHODS: In this prospective, multicentre study, patients with a first NSTE-ACS, single-vessel disease and successful percutaneous coronary interventions (PCIs) had their sera collected, aliquoted and stored at the enrolling site and then shipped for analysis to the clinical chemistry core laboratory. RESULTS: Cys-C values slightly, but significantly, increased from the ACS samples to the 6-week samples. In contrast, hsCRP, NT-proBNP and IL-6 values significantly decreased from the ACS to the 6-week sample. Patients with elevated c-TNT levels had higher hsCRP, NT-proBNP and IL-6 values than patients with normal c-TNT levels in the ACS sample, whereas Cys-C levels were similar in patients with and without elevated c-TNT. Cys-C was highly correlated with estimated glomerular filtration rate in both the ACS and 6-week samples. CONCLUSIONS: In contrast to inflammatory and biochemical stress markers, Cys-C is not affected by the occurrence of myocardial necrosis or by acute left-ventricular impairment, being a reliable marker of renal function during NSTE-ACS.

Effect of prolonged Bivalirudin infusion on ST-segment resolution following primary percutaneous coronary intervention (from the PROBI VIRI 2 study).

Bivalirudin is widely used as an anticoagulant during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction. However, an increase in acute stent thrombosis rates has been found in the HORIZONS-AMI trial. A prolonged infusion after PCI has been shown to be a safe and effective tool in patients undergoing urgent or elective PCI in the PROBI VIRI study. We examined the effects of prolonged drug infusion after primary PCI. From databases of 5 high-volume centers we compared a group of patients treated with a 4-hour prolonged infusion after PCI to 2 groups treated with a peri-PCI infusion and heparin plus abciximab. The primary study end point was >70% ST-segment resolution within 90 minutes after PCI; secondary end points were partial (>50%) ST-segment resolution within 90 minutes and intrahospital major and minor bleedings on the Acuity scale. The study population consisted of 264 patients undergoing primary PCI who were pretreated with aspirin and clopidogrel. The 3 study groups did not differ significantly by baseline characteristics. The primary end point was achieved in 69.8%, 48.8%, and 69.6% of patients in the prolonged bivalirudin, bivalirudin, and heparin/abciximab groups, respectively (p = 0.048 for prolonged vs standard infusion, p = 0.98 for prolonged infusion vs abciximab). Major bleedings and other secondary study end points were not significantly different among study groups. In conclusion, a strategy of prolonged bivalirudin infusion after primary PCI seems equivalent to a strategy with heparin plus abciximab, with an improvement in standard infusion in obtaining early microvascular reperfusion.