[Transcatheter valve-in-valve implantation in a patient with a degenerative sutureless aortic bioprosthesis: case report and literature review]. / Impianto transcatetere di valvola aortica in paziente con bioprotesi aortica sutureless degenerata: descrizione di un caso e revisione della letteratura.

Sutureless aortic bioprostheses (SAB) provide shorter aortic cross-clamp time and cardiopulmonary bypass duration compared to conventional aortic valve replacement. Similarly to other bioprostheses, reintervention may become necessary in some cases because of long-term structural degeneration of the valve. Valve-in-valve (ViV) transcatheter aortic valve replacement may represent an effective and safe alternative to aortic valve replacement in patients with degenerated bioprostheses who carry a high risk for reintervention. We report the case of a self-expandable transcatheter ViV procedure in a degenerated SAB.

Relationship between early administration of abciximab and TIMI flow in STEMI patients undergoing primary angioplasty: findings from a large regional STEMI network.

AIMS: The aim of this study is to assess whether in S-T Elevation Myocardial Infarction (STEMI) a relationship between early administration of abciximab and Thrombolysis In Myocardial Infarction (TIMI) flow before and after primary percutaneous coronary intervention (PCI) in 960 consecutive patients exists. METHODS: From 1 February 2001 onward, in the Province of Mantua it has been operating a 'Cardiology Network for the Acute Infarction Care' having its Hub in the Central Coronary ICU/Cath Lab of Mantua Hospital and being its Spokes centers represented by the emergency rooms and Central Coronary ICUs of the four territorial hospitals. RESULTS: T1 (time from symptoms onset to first medical contact) and T2 (time from first medical contact to angioplasty) are shorter for patients rescued by first aid units rather than for those presented in emergency rooms as well as Ta (time from symptoms onset to abciximab administration). Furthermore, the patients that received abciximab before hospital arrival had less frequently a coronary occlusion [odds ratio = 0.74, 95% confidence interval (0.57-0.96), P = 0.013]. The patients with T1 less than 4 h are 753/960 (78.4%). For this type of patients, there was a significant Ta difference between the pre-PCI TIMI-flow classes (F = 4.467, df = 3, P = 0.04). Planned contrasts revealed that mean time of TIMI flow 0 (M = 104.2) is statistically different from mean time of TIMI flow 3 (M = 85.7), P = 0.013. CONCLUSION: Our results suggest that the use of abciximab, free from pharmacokinetic limits of oral P2Y12 inhibitors, should be considered in STEMI patients with early presentation before primary PCI.

[Percutaneous coronary revascularization in patients over eighty: acute and long-term results]. / Rivascolarizzazione coronarica percutanea nei pazienti ultraottantenni: risultati immediati e a lungo termine.

BACKGROUND: As a consequence of prolonged life expectancy the number of older patients with symptomatic coronary artery disease is constantly increasing. The aim of the study was to evaluate procedural success, immediate and long-term outcomes and the predictive factors of prognosis in patients aged > 80 years with high-risk coronary artery disease treated with coronary angioplasty. METHODS: In this retrospective study, we report the diagnostic and therapeutic strategies adopted in patients aged > 80 years admitted to our institution for acute coronary syndrome with or without ST-segment elevation or disabling angina (CCS class 3-4) and the immediate and long-term results of patients treated with coronary angioplasty. RESULTS: A conservative approach was adopted in 180 patients (33%, group 1) out of the total number of 545 patients, while 365 patients (67%, group 2) underwent coronary angiography. Among these, 85% underwent revascularization. Relevant comorbidities were significantly higher in group 1 (59 vs 16%, p < 0.001) while a clinical presentation with ST-elevation myocardial infarction was prevalent in group 2 (15 vs 6%, p = 0.007). The in-hospital mortality was 19% in group 1 and 7.9% in group 2 (p = 0.001). Among 198 patients treated with angioplasty, procedural success was achieved in 93% of cases, with 8% in-hospital mortality. Periprocedural myocardial infarction occurred in 3.3% and major bleeding in 5.6% of patients. At multivariate analysis ST-elevation myocardial infarction and cardiogenic shock were significantly related to the in-hospital mortality. At follow-up (mean 25 +/- 13 months) 13 patients died, 9 from cardiac causes and 4 from noncardiac events. Recurrence of ischemia requiring revascularization occurred in 15.9% of cases. Cumulative survival at follow-up was respectively 86% at 1 year and 83% at 5 years, while the event-free survival at 5 years was 59% in the entire group, without any significant difference among patients with multivessel disease in whom a complete vs an incomplete revascularization was performed. The presence of severe comorbidities appeared to be the only predictive factor of unfavorable outcome at long-term follow-up at multivariate analysis. CONCLUSIONS: In patients aged > 80 years with symptomatic ischemic heart disease at high risk, the invasive approach was prevalent. Higher mortality rates were found in patients in whom coronary angiography was not performed. Comorbidities represent an important negative prognostic factor, impairing both the possibility of an invasive approach and conditioning an unfavorable outcome of revascularized patients. Coronary angioplasty can be successfully performed even in elderly patients. The in-hospital mortality turns out significantly higher in the setting of an acute ST-elevation myocardial infarction or in cardiogenic shock patients. For patients overcoming the acute phase, high survival rates can be expected at follow-up.

[The use of the Export Catheter device in a patient with acute myocardial infarction for thrombotic occlusion of the venous graft on the left anterior descending coronary artery: a case report]. / Utilizzo di Export Catheter in paziente con infarto miocardico acuto per occlusione trombotica del graft venoso su discendente anteriore: descrizione di un caso clinico.

Coronary angioplasty, eventually followed by stent implantation, represents the gold standard of acute myocardial infarction (AMI) treatment. Optimal reperfusion implies both patency of the infarct-related artery and a good myocardial microrevascularization with normal tissue reperfusion. The so called no-reflow phenomenon mainly occurs in the presence of highly thrombotic lesions, especially during primary angioplasty and it represents a negative prognostic factor of the outcome of AMI patients treated with angioplasty. A 77-year-old high-risk male patient, previous coronary artery bypass graft with the saphenous vein graft to the left anterior descending coronary artery for post-AMI angina in 1984, aided by 118 ambulance for anterior AMI was admitted to our cath-lab for primary coronary angioplasty. During the transport he was given aspirin i.v. 300 mg, heparin 5000 IU and abciximab (9.4 ml bolus plus infusion for 12 hours). The time of treatment (from symptom onset to first inflation) was about 90 min. Coronary angiography showed a massive thrombus occlusion of the vein graft with TIMI 0 distal flow. We employed the Export Catheter for mechanical aspiration of the occluding thrombus. The procedure was completed with direct stent implantation with good angiographic outcome. The use of thrombus aspiration and protection devices (filters or occlusive balloons) associated or not with the use of glycoprotein IIb/IIIa receptor blockers, has reduced the risk of distal embolization and of no-reflow phenomenon.

[Telecardiology in the management of acute myocardial infarction: the experience of the provincial network of Mantova]. / La telecardiologia nella gestione dell'infarto miocardico acuto: l'esperienza della rete provinciale di Mantova.

BACKGROUND: Since June 2001 we activated a program for the treatment of acute myocardial infarction, based on the early assessment of the patient's risk profile, on telematic connection among care centers and optimization of critical pathways for access to care. The aim of this work was to assess the effectiveness of telemedicine in the reduction of time to treatment. METHODS: Mantova, a province of eastern Lombardy (northern Italy) is provided with one single sanitary district with one (tertiary hospital) referring hospital equipped with a cath lab on call 24/24 hours for primary coronary angioplasty (PTCA) and cardiac surgery and 6 community hospitals: 2 with coronary care units, 2 with a cardiology section, and 2 rehabilitation hospitals. The emergency medical system transport, activated 24/24 hours, consists of 6 advanced life support (ALS) ambulances and 11 basic life support (BLS) ambulances (2 with trained nurse staff). Each ALS ambulance is equipped with a semiautomatic defibrillator LIFEPACK 12 coupled with cellular telephone GSM transmission of the 12-lead ECG. RESULTS: In the first 3-year activity of the project 340 patients with acute myocardial infarction underwent primary PTCA: 248 (73%) referred to first aid of the nearest hospital reached either by BLS ambulance or by their own means of transport and were hence transferred to the referring hospital for primary PTCA (group A), while 92 patients (27%) were aided at their own house by ALS ambulances and, after transmission of the 12-lead ECG to the referring coronary care unit, were directly transferred to the cath lab (group B). Decisional delay was 144 +/- 65 min in group A while 74 +/- 37 min in group B. Mean door-to-balloon time was 76 +/- 26 min in group A and 47 +/- 21 min in group B. High incidence of post-procedural TIMI 3 flow was achieved in both groups. In-hospital mortality was 6.8% in group A e 5.4% in group B. CONCLUSIONS: Our data show that patients referring directly to ALS ambulances had a lower decisional delay. Transmission of the patient's ECG and clinical parameters allows an early and accurate diagnosis and assessment of the individual risk profile with a consistent reduction in time to treatment and positive effects on the mortality rate.

[Network for the treatment of acute myocardial infarction in the province of Mantova: results after 2 years of work]. / Rete provinciale per la terapia deII'infarto miocardico acuto a Mantova: risultati di due anni di attività.

BACKGROUND: Since June 2001, in the province of Mantova, we have been carrying out a program for the management of acute myocardial infarction based on early assessment of the patients' risk profile, on telematic connection among care centers and on optimization of in- and out-of-hospital critical pathways for the access to care. METHODS: Our network provides connection among the following centers: advanced life support ambulances, 7 hospitals, 3 coronary care units, 1 cath lab on call 24 hours a day for primary angioplasty, 1 thoracic surgery division. This program, through its strong telematic platform, allows early assessment of myocardial infarction, and provides primary angioplasty to all high-risk patients, being fibrinolytic treatment reserved only to the low-risk patients admitted in peripheral hospitals. RESULTS: Two hundred and twenty patients with acute myocardial infarction were treated with angioplasty; 179 (81%) patients underwent primary angioplasty, 26 (12%) patients facilitated angioplasty and 15 patients (7%) rescue angioplasty; 121 patients (55%) were first admitted in the Mantova hospital, 65 patients (30%) were referred to Mantova from peripheral hospitals and 34 patients (15%) were directly transported to the cath lab by advanced life support ambulances. Procedural success was obtained in 98% of cases, with 05% intraprocedural mortality. In-hospital mortality was 55%, while mortality of cardiogenic shock patients was 36%. Recurrence of acute myocardial infarction occurred in 1% and major bleeding in 2.2% of patients. One patient with cardiogenic shock died during transport. Mean door-to-balloon time was 73 min with 39% reduction in the second period of recruitment after telematic connection. CONCLUSIONS: This program, developed in the setting of a provincial network for the management of acute myocardial infarction, provided primary angioplasty to all high-risk patients, with a high procedural success rate. Within a few months, time to treatment was minimized by the employment of telematic facilities.

Is heparin still necessary after primary angioplasty in the era of platelet glycoprotein IIb/IIIa receptor inhibitors? A review of the literature.

While there is clear evidence for administering unfractionated heparin after systemic thrombolysis, there are not randomised trials supporting the usefulness of postprocedural heparin in the setting of primary angioplasty, especially in the era of glycoprotein IIb/IIIa inhibitors, and this issue is still a matter of debate. In this review we analysed the 30-day cardiac events of patients treated with primary angioplasty and abciximab, with or without postprocedural unfractionated heparin. We conducted a Medline search and eight studies were selected: in four of them heparin was continued for at least 12 h after the procedure (group 1), in the others heparin was used only during the procedure (group 2). The composite incidence of 30-day major adverse cardiac events was similar in the two groups (5.1 vs. 5.1%; 95% confidence interval 0.66-1.45; P = 0.91), whereas total bleeding occurred in 5.5% of group 1 compared with 3% of group 2 (relative risk 1.82; 95% confidence interval 1.19-2.80; P = 0.005). In conclusion, this review suggests that in the setting of primary angioplasty with concomitant glycoprotein IIb/IIIa inhibitors, postprocedural heparin does not appear to favourably affect cardiac and systemic ischaemic events and turns out to be associated with an increase in haemorrhagic complications.

Coronary flow velocity pattern assessed by transthoracic Doppler echocardiography predicts adverse clinical events and myocardial recovery after successful primary angioplasty.

BACKGROUND: Doppler guidewire studies demonstrated that specific velocity patterns in the left anterior descending coronary artery (LAD) after primary percutaneous coronary intervention (PCI) predict myocardial recovery and clinical outcome. The present study assessed whether similar results can be achieved by transthoracic Doppler echocardiography (TTDE). METHODS: Coronary flow velocities of LAD were evaluated by TTDE in 35 consecutive patients with anterior acute myocardial infarction who were treated with successful primary PCI plus stenting, performed within 6 h after the onset of symptoms or within 6-12 h if there was evidence of continuing ischaemia. Coronary-flow velocity of the LAD was achieved after 12 h and within 48 h after the PCI; TTDE standard examination was repeated after 2 months of follow-up. RESULTS: Three patterns were found: (i) 'pattern A' with good antegrade systolic flow and slow diastolic deceleration rate (63.7%); (ii) 'pattern B' with reduced or absent systolic flow and rapid diastolic deceleration rate (9.1%); and (iii) 'pattern C' with protosystolic retrograde flow and rapid diastolic deceleration rate (27.2%). The clinical characteristics and echocardiographic data were compared: wall-motion-score-index (WMSI), ejection fraction, end-diastolic volume (EDV) after PCI (T1) and after 2 months (T2). Patients with pattern A demonstrated recovery of contractile function (WMSI-T1 1.48 + or - 0.42/WMSI-T2 1.29 + or - 0.29, P < 0.05) and better clinical outcome; patients with patterns B and C ran into ventricular remodelling (EDV-T1 89 + or - 6.3 ml/EDV-T2 123 + or - 25 ml, P = 0.002) and more early and late complications. CONCLUSIONS: TTDE is a reliable method to achieve coronary flow velocities in LAD after an anterior acute myocardial infarction and it could be useful to evaluate no-reflow phenomenon at bedside and thus clinical outcome.