Rationale and study design of the RESERVOIR trial: a randomized trial comparing reservoir-based polymer-free amphilimus-eluting stents versus everolimus-eluting stents with durable polymer in patients with diabetes mellitus.

BACKGROUND: Patients with diabetes mellitus (DM) remain at high risk for stent restenosis and adverse cardiovascular events in the drug-eluting stent era. The amphilimus-eluting stent (AES) is a third generation reservoir-based polymer-free drug-eluting stent that has shown promising preliminary results in patients with DM. It has been suggested that the formulation of the drug with fatty acids could not only modulate the drug release in a timely manner but also achieve convenient levels of drug concentration in diabetic cardiac cells. The aim of this trial is to assess the efficacy of the AES in patients with DM compared with the cobalt chromium everolimus-eluting stent with non-erodible polymer (EES). STUDY DESIGN: This is an investigator-initiated, multicenter, randomized clinical trial, performed in patients with DM. A total of 112 diabetic patients receiving glucose-lowering agents and requiring percutaneous revascularization of a de novo lesion will be randomized in a 1:1 fashion to receive AES or EES. The primary endpoint is the neointimal volume obstruction at 9 months, evaluated by optical coherence tomography. Secondary endpoints will include strut coverage, angiographic in-stent late loss and clinical endpoints such as target vessel revascularization or probable/definite stent thrombosis. This study completed the inclusion in October 2013. CONCLUSIONS: The RESERVOIR trial is an investigator-initiated trial that will evaluate whether the polymer-free AES is not inferior to the EES inhibiting the neointimal hyperplasia in patients with DM. These results are also expected to improve our knowledge of the neointimal healing process in this population (Clinicaltrials.gov number NCT01710748).

Secondary revascularization after coronary surgery.

World population is aging day after day and coronary atherosclerosis disease is becoming a worldwide pandemic disease. Whereas the number of patients with surgical or percutaneous coronary revascularization is increasing, a new revascularization procedure in a previously revascularized patient is a situation that is already being common in cath labs all over the world. Such patients present some special considerations, with a higher risk and worse prognosis than the usual patients and they require to take specific attitudes regarding prognosis, treatment and revascularization technique. At present, much has been achieved in this field, with new devices developed and many randomized clinical trials, but there is still sparse knowledge about this subject and some confusing points. The following article will discuss about the present-day knowledge of secondary coronary revascularization in patients previously operated, focusing in its indications and which are the technical considerations to keep in mind. Special attention will be paid to the percutaneous revascularization of saphenous vein grafts, the most complex and specific situation that we can find in such patients due to its special histopathology and behavior. Moreover, a mention will be made of the new advances that have been made in recent years, about all kind of devices, coronary stents, pharmacological treatment and new emerging revascularization strategies.

Risk-adjusted early invasive strategy in patients with non-ST-segment elevation acute coronary syndrome in Intensive Cardiac Care Units. / Estrategia invasiva precoz ajustada al riesgo en pacientes con síndrome coronario agudo sin elevación de segmento ST en Unidades de Cuidados Intensivos Cardiológicos.

OBJECTIVE: Current guidelines recommend a risk-adjusted early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). The present study assesses the application if this strategy, the conditioning factors and prognostic impact upon patients with NSTEACS admitted to Intensive Cardiac Care Units (ICCU). DESIGN: A prospective cohort study was carried out. SETTING: The ICCUs of 8 hospitals in Catalonia (Spain). PATIENTS: Consecutive patients with NSTEACS between October 2017 and March 2018. The risk profile was defined by the European Society of Cardiology criteria. INTERVENTIONS: EIS was defined as the performance of coronary angiography within the first 6hours in patients at very high-risk or within 24hours in high-risk patients. OUTCOME VARIABLES: Mortality or readmission at 6 months. RESULTS: A total of 629 patients were included (mean age 66.6 years), of whom 225 (35.9%) were at very high risk, and 392 (62.6%) at high risk. Most patients (96.2%) underwent an invasive strategy. EIS was performed in 284 patients (45.6%), especially younger patients with fewer comorbidities. These patients had a shorter ICCU and hospital stay, as well as a lesser incidence of ACS, revascularization and death or readmission at 6 months. After adjusting for confounders, the association between EIS and death or readmission at 6 months remained significant (hazard ratio: .66, 95% confidence interval .45-.97; P=.035). CONCLUSIONS: The EIS was performed in a minority of NSTEACS admitted to ICCU, being associated with better outcomes.

Preserved endothelium-dependent vasodilation in coronary segments previously treated with balloon angioplasty and intracoronary irradiation.

BACKGROUND: Abnormal endothelium-dependent coronary vasomotion has been reported after balloon angioplasty (BA), as well as after intracoronary radiation. However, the long-term effect on coronary vasomotion is not known. The aim of this study was to evaluate the long-term vasomotion of coronary segments treated with BA and brachytherapy. METHODS AND RESULTS: Patients with single de novo lesions treated either with BA followed by intracoronary beta-irradiation (according to the Beta Energy Restenosis Trial-1.5) or with BA alone were eligible. Of these groups, those patients in stable condition who returned for 6-month angiographic follow-up formed the study population (n=19, irradiated group and n=11, control group). Endothelium-dependent coronary vasomotion was assessed by selective infusion of serial doses of acetylcholine (ACh) proximally to the treated area. Mean luminal diameter was calculated by quantitative coronary angiography both in the treated area and in distal segments. Endothelial dysfunction was defined as a vasoconstriction after the maximal dose of ACh (10(-6) mol/L). Seventeen irradiated segments (89.5%) demonstrated normal endothelial function. In contrast, 10 distal nonirradiated segments (53%) and 5 control segments (45%) demonstrated endothelium-dependent vasoconstriction (-19+/-17% and -9.0+/-5%, respectively). Mean percentage of change in mean luminal diameter after ACh was significantly higher in irradiated segments (P=0.01). CONCLUSIONS: Endothelium-dependent vasomotion of coronary segments treated with BA followed by beta-radiation is restored in the majority of stable patients at 6-month follow-up. This functional response appeared to be better than those documented both in the distal segments and in segments treated with BA alone.

Restenosis and progression of coronary atherosclerosis after coronary angioplasty.

The relation between restenosis and progression of atherosclerosis in other coronary segments after angioplasty was studied in 98 consecutive patients with 110 coronary stenoses successfully treated with angioplasty. At early angiographic restudy (5 +/- 2 months after angioplasty) 37 patients (38%) had restenosis (defined as a stenosis greater than or equal to 50% of the luminal diameter or loss of greater than or equal to 50% of the gain achieved by angioplasty); progression of atherosclerosis was observed in 4 patients with and 7 without restenosis (13 versus 11%, p = NS). Ninety of the 98 patients underwent a late angiographic restudy a mean of 34 +/- 11 months after angioplasty. Late restenosis was found in one patient. Progression of coronary artery disease (defined as a greater than or equal to 20% decrease in the diameter of a vessel initially narrowed by greater than or equal to 50% or a greater than or equal to 30% decrease when the initial stenosis was less than 50%) was examined in relation to restenosis in 85 of the 90 patients. It occurred in 9 of 27 patients with and 22 of 58 patients without restenosis (33 versus 38%, p = NS). Restenosis developed more rapidly than did progression of disease. Diameter stenosis increased from 35 +/- 8 to 73 +/- 11% at the early restudy in lesions with restenosis; in lesions with disease progression it increased from 9 +/- 18 to 20 +/- 28% (p less than 0.001) at the early restudy to 53 +/- 21% (p less than 0.001) at the late restudy.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk of thrombosis during coronary angioplasty with low osmolality contrast media.

Studies in vitro have suggested that nonionic low osmolar contrast agents produce an increase in thrombogenicity. To determine the incidence of thrombi related to the use of nonionic low osmolar contrast media during coronary angioplasty, a double-blind randomized study was performed in 100 patients. Medication before angioplasty included oral aspirin (250 mg/day) in all cases. At the beginning of the procedure, aspirin (250 mg) and heparin (10,000 U) were intravenously administered. During the procedure patients were randomly assigned to receive either an ionic low osmolar contrast agent ioxaglate (n = 50), or a nonionic low osmolar contrast media iohexol (n = 50). The presence of thrombus was evaluated on the angiogram and on the guidewire immediately after its retrieval from the patients. Clinical, angiographic and procedural variables were similar in the 2 randomized groups. Angiographic evidence of thrombus was observed in 1 patient (2%) assigned to ioxaglate and in 11 patients (22%) assigned to iohexol (p less than 0.005). One patient (2%) from the ioxaglate group and 6 patients (12%) from the iohexol group showed thrombotic residues on the guidewire (p = not significant). Three patients had acute myocardial infarction, 1 patient (2%) receiving ioxaglate and 2 patients (4%) iohexol (p = not significant). There were no deaths. Thus, compared with an ionic low osmolar contrast media ioxaglate, the nonionic low osmolar contrast agent iohexol increases the incidence of thrombus during coronary angioplasty.

Stenting the stent: initial results and long-term clinical and angiographic outcome of coronary stenting for patients with in-stent restenosis.

Stent restenosis constitutes a therapeutic challenge affecting an increasing number of patients. Conventional angioplasty and debulking techniques are currently used in these patients. However, the potential role of a second stent implantation in this setting (stenting the stent) remains unknown. Therefore, 65 consecutive patients (12 women, aged 62 +/- 11 years) undergoing stent implantation (42 elective and 23 unplanned) for the treatment of in-stent restenosis (diffuse [> 10 mm] in 39 [60%]) were studied. Angiographic success was obtained in all patients. Three patients developed hospital complications: 1 died from refractory heart failure and 2 suffered non-Q-wave myocardial infarctions. During follow-up (mean 17 +/- 11 months) 1 patient died (noncardiac cause) and only 9 (14%) required target vessel revascularization. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and target vessel revascularization) at 1 year was 84%. Using Cox analysis, patients with unstable symptoms, a short time to stent restenosis, nonelective stenting, and B2-C lesions tended to have poorer prognosis. After adjustment, nonelective stenting was associated (adjusted RR 2.9, 95% confidence interval [CI] 0.82 to 10.3, p = 0.09) with an adverse clinical outcome. On quantitative angiography (core lab) restenosis was found in 13 of 43 patients (30%) (75% of those eligible). Logistic regression analysis identify restenosis length (adjusted RR 1.43, 95% CI 1.04 to 2.14, p = 0.04), and time to restenosis (adjusted RR 0.67, 95% CI 0.47 to 0.94, p = 0.01) as the only independent predictors of recurrent restenosis. Thus, repeat coronary stenting is a safe and efficacious strategy for the treatment of patients with in-stent restenosis. Both elective and nonelective stenting provide excellent initial results. The long-term clinical and angiographic outcome of these patients is also favorable.

Partial improvement in pulmonary function after successful percutaneous balloon mitral valvotomy.

STUDY OBJECTIVES: This study was performed to assess the changes in pulmonary function after a successful percutaneous balloon mitral valvotomy (PBMV) in 23 consecutive patients with symptomatic mitral stenosis. METHODS AND RESULTS: Lung function preprocedure and postprocedure were evaluated by spirometric flow, static pulmonary volumes, and diffusion capacity of the lung for carbon monoxide (DLCO). At baseline, a reduction in small airways flow (maximal expiratory flow at 50% of vital capacity, 70 +/- 29% of predicted value; maximal expiratory flow at 25% of vital capacity, 55 +/- 26% of predicted value) and an increase in DLCO (118 +/- 29%) and Krough Index (KCO; 123 +/- 29% of predicted value) were observed. PBMV caused an improvement in hemodynamic parameters with an increase in mitral valve area (from 1.0 +/- 0.3 to 1.9 +/- 0.5 cm(2); p < 0.001) and a decrease in left atrial pressure (from 17 +/- 3 to 12 +/- 5 mm Hg; p < 0.001). These changes were associated with a significant increase in FVC (from 2.8 +/- 0.84 to 2.9 +/- 0.80 L; p < 0.05) and in FEV(1) (from 2.2 +/- 0.72 to 2.3 +/- 0.68 L; p < 0.05). A decrease in DLCO was observed after PBMV (from 26.7 +/- 7 to 22.5 +/- 5.4 mL/min/mm Hg; p < 0.001; and KCO, from 6.2 +/- 1.4 to 5.2 +/- 1.2 mL/min/mm Hg/L; p < 0.001). No significant changes in small airways flow were detected, suggesting only a partial improvement in pulmonary congestion. CONCLUSION: We conclude that the initial impairment of lung function in patients with symptomatic mitral stenosis is only partially ameliorated by PBMV.

Predictive factors and long-term evolution of early endothelial dysfunction after cardiac transplantation.

BACKGROUND: Abnormal coronary vasomotion appears to be a common finding after heart transplantation (HTx). However, the pathophysiology and outcome of this functional disturbance remains poorly understood. Aims of the study were to determine the prevalence, predictive factors and long-term evolution of endothelial dysfunction after cardiac transplantation. METHODS: The endothelium-dependent coronary vasomotion of 50 patients, who showed angiographically normal coronary arteries, were studied early (at 3 +/- 1 months) and at follow-up (16 +/- 5 months) after HTx. Endothelial function was studied by selective infusion of serial doses of acetylcholine (ACh) (10(-8), 10(-7)and 10(-6) mol/l) in the left anterior descending coronary artery. Changes in mean luminal diameter after the infusion of each dose were evaluated by quantitative coronary angiography (QCA). RESULTS: At early study, 17 patients (34%) showed a vasoconstriction after maximal dose of ACh (-13.3 +/- 13%) indicative of endothelial dysfunction. Logistic regression analysis identified the following variables as independent predictors of early endothelial dysfunction: donor inotropic support (p = 0.004), female donor (p = 0.04) and rejection at the time of the study (p = 0.01). Forty-one patients were re-studied at follow-up. Nine of them (22%) presented endothelial dysfunction. Early endothelial dysfunction was restored in 6 patients (43%) at follow-up. The number of episodes of rejection was the only variable associated to late endothelial dysfunction. CONCLUSIONS: Endothelial dysfunction is a common finding after cardiac transplantation. The pathogenesis of this functional disturbance appears to be donor-related and immune-mediated. The reversibility of this phenomenon observed at follow-up suggests the episodic nature of the immunologic injury.

[Registry of activities of the Section of Hemodynamics and Interventional Cardiology in 1997]. / Registro de actividad de la Sección de Hemodinámica y Cardiología Intervencionista del año 1997.

The results of the Spanish Registry of Hemodynamic and Interventional Cardiology in 1997 are presented. The Registry collects the activity of 83 centers which constitute all the cardiac catheterization laboratories in Spain. The main activity was adult cardiac catheterization in 75 centers and exclusively pediatric cardiac catheterization in 8. A total of 72,370 diagnostic catheterization procedures, 80% coronary angiographies (57,960; 1,462 per million inhabitants), were performed which represents a 13% total increase compared to 1996. Coronary intervention increased by 23% compared to 1996, for a total number of 18,545 procedures. The ratio of coronary interventions per million inhabitants was 468. Success rates of coronary interventions (91.3%) and complications (3.7%) were similar to those registered in previous years. In the specific field of revascularization devices, there has been a dramatic increase in the use of stents. In 1997, coronary stents were employed in 11,417 cases (a 61% increase compared to 1996) which represents 61.5% of all coronary revascularizations procedures. A total of 14,170 prosthesis were implanted, 72% in a elective way, with a low rate of complications (0.95% subacute closure; 1.45% myocardial infarction and 0.75% mortality). Compared to 1996, directional coronary atherectomy (92 procedures) showed a slight decrease, whereas rotational atherectomy (554 procedures) increased by 49% with double the number of centers performing this technique. As in previous years, a slight decrease (7% compared to 1996) in adult valvuloplasties (559 vs 599) was noted. Pediatric interventional procedures decreased by 17% (465 vs 558 procedures) compared to the 1996 Registry.

[The Registry of the Activities of the Hemodynamics and Interventional Cardiology Section in 1998]. / Registro de Actividad de la Sección de Hemodinámica y Cardiología Intervencionista del año 1998.

The results of the Spanish Registry of Hemodynamic and Interventional Cardiology of the Spanish Society of Cardiology in 1998 are hereby presented. The Registry collects the activity of 82 centers, which constitutes all the cardiac catheterization laboratories in Spain. The main activity was adult cardiac catheterization in 75 centers, and exclusively pediatric cardiac catheterization in 7. A total of 74,364 diagnostic catheterization procedures, 80% coronary angiographies (59,321; 1,498 per million inhabitants), were performed, which represents a 2.8% total increase compared to 1997. Coronary intervention increased by 8.6% compared to 1997, for a total number of 20,146 procedures. The ratio of coronary interventions per million inhabitants was 509. Success rates of coronary interventions (94%) and complications (2.3%) are similar to those registered in previous years, and in 9.7% of the cases, IIb-IIIa glicoprotein inhibitors were used. A 8.6% of the procedures were performed in order to treat an acute myocardial infarction. Coronary stenting is, continues to be the main device for coronary intervention. In 1998, coronary stents were employed in 14,497 cases (a 27% increase compared to 1997) which represents the 72% of all coronary revascularizations procedures. A total of 19,378 prosthesis were implanted, 83% in a elective way and 12.9% primary stenting, with a low rate of complications (1.5% subacute closure, 1.5% myocardial infarction and 0.94% mortality). Compared to 1997, directional coronary atherectomy (83 procedures) showed a slight decrease, whereas rotational atherectomy (549 procedures) has stabilized the number of procedures and centers performing this technique. As in previous years, a slight decrease (9% compared to 1997) in adult valvuloplasties (505 vs 559) were noted. Pediatric interventional procedures increased by 20% (557 vs 465 procedures) compared to the 1997 Registry.

[Comparative study of iohexol and iopamidol as cardioangiographic contrast media]. / Estudio comparativo entre iohexol e iopamidol como contraste cardioangiográfico.

We have done a double-blind randomized study to compare the cardiac effects of 2 nonionic low osmolality contrast agents, iohexol (n = 25) and iopamidol (n = 25), for left ventriculography and coronary arteriography. No statistical differences were detected between both groups in quality of image, clinical (absence of nausea; intense warmth [8% vs 8%, p = NS]) and electrocardiography (repolarization changes [24% vs 12%, p = NS], absence of severe bradycardia and ventricular arrhythmia) effects. Ventriculography induced no change in systolic left ventricular pressure (iohexol: 128.6 +/- 18 vs 127 +/- 19 mmHg, p = NS; iopamidol: 133 +/- 24 vs 131.8 +/- 23 mmHg, p = NS), and a little but significant rise in left ventricular end-diastolic pressure (iohexol: pre = 11.6 +/- 7 vs post = 13.9 +/- 7 mmHg, p less than 0.01; iopamidol: 11.7 +/- 4 vs post = 15.5 +/- 5 mmHg, p less than 0.001). Our results suggest that iohexol and iopamidol are comparable and qualified for angiocardiography.

[Angioplasty versus surgery in proximal stenosis of the anterior descending artery]. / Angioplastia frente a cirugía en estenosis proximales de la arteria descendente anterior.

The points of view of the cardiac surgeon and the interventional cardiologist on their personal approach to the treatment of the significant lesions of the proximal left anterior descending coronary artery are still a matter of controversy. Two randomized studies have compared the efficacy of PTCA vs CABG in the treatment of patients with isolated proximal left anterior descending (LAD) coronary artery stenosis. After a mean follow-up of 3 years these studies concluded that the incidence of events was significantly reduced in the CABG group. However, this conclusion requires a cautious interpretation because of methodological limitations of these studies. On the other hand, a recent randomized study has shown a reduction in the restenosis rate when an intracoronary stent is electively implanted after PTCA in proximal LAD stenosis. Similarly, surgical modifications in material and in technical aspects will probably result in a reduction of the morbidity sometimes associated with surgical procedures. Presented with favourable anatomy, PTCA with elective stent implantation may be the initial option in the treatment of proximal LAD stenosis, especially if another revascularization procedure is contemplated in the future. However, CABG is preferred when the LAD lesion suggests a complicated anatomy (chronic obstructions, ostial lesions or proximal bifurcations with a significant diagonal). Depending on the particular results for both procedures in each Institution, an individual evaluation seems to be mandatory in the vast majority of patients.

[Penetrating aortic ulcer: clinical and angiographic characteristics]. / Ulcera penetrante de aorta: características clínicas y angiográficas.

BACKGROUND: "Penetrating aortic ulcer", an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows haematoma formation within the aortic wall, is rarely considered in the differential diagnosis of patients with sudden onset of severe chest or back pain. It has been suggested that it is a pathologic process that involves elderly hypertensive patients with severe atherosclerosis and rarely has been observed in the ascending aorta. METHODS: To determine the characteristics of this process, 11 clinical, 2 hemodynamic, 3 angiographic and 4 surgical variables were compared between 10 consecutive patients with penetrating aortic ulcers and 20 matched patients with classic acute aortic dissection. RESULTS: Clinical and hemodynamic variables were similar in both compared groups. In the group of patients with penetrating ulcer mean age was 58 +/- 6 years, previous hypertension was observed in 6 patients and the penetrating ulcer was located in the ascending aorta in 6 cases. In comparison to patients with aortic dissection, more angiographic projections were necessary to obtain the diagnosis in the group of patients with penetrating ulcer (2.4 +/- 0.8 vs 1.7 +/- 0.6; p < 0.05). In addition, the presence of angiographic aortic valve regurgitation was only observed in the group of patients with acute dissection (60% vs 0%; p < 0.001). Severe atherosclerosis was not present angiographically in any patient with penetrating ulcer. CONCLUSIONS: Penetrating aortic ulcer can also affect middle age patients without severe atherosclerosis and is frequently observed in the ascending aorta. Its form of presentation and clinical characteristics are similar to classic aortic dissection. The lack of angiographic confirmatory evidence of dissection with suggestive clinical history, should raise the possibility of penetrating aortic ulcer.

[Percutaneous mitral valvuloplasty. An analysis of the immediate results]. / Valvuloplastia mitral percutánea. Análisis de los resultados inmediatos.

Percutaneous mitral valvuloplasty (PMV) was performed by the anterograde transseptal approach in 113 patients with symptomatic mitral stenosis. Mean age was 53 +/- 14 years and 89% were female. PMV resulted in a marked decrease in mitral gradient from 16 +/- 5 to 6 +/- 3 mmHg (p less than 0.0001) and a significant increase in mitral valve area from 1.09 +/- 0.36 to 2.12 +/- 0.83 cm2 (p less than 0.0001). An optimal hemodynamic result (gain in valve area greater than or equal to 25% and post-PMV valve area greater than or equal to 1.5 cm2) was obtained in 82 patients (73%). Multivariate statistical analysis selected as independent predictors of an optimal result: normal cardiac index (p = 0.0001), NYHA functional class less than 3 (p = 0.002), smaller left atrial diameter (p = 0.005), and echocardiographic score less than or equal to 8 (p = 0.01). The lowest frequency of optimal results was observed in patients with echocardiographic scores greater than or equal to 11 (20%). Three patients died (2.6%). All deaths occurred among the first 34 patients and none in the last 79 (p less than 0.05). Morbidity was also influenced by a learning curve effect. Mitral regurgitation developed or increased in severity in 38% of patients. This increase was mild (1 degree) in 85% of cases. Although the incidence of atrial shunting was high (76% by indicator dilution curve and 33% by oximetry), their magnitude was usually small (mean Qp/Qs 1.23 +/- 0.23) and lacked clinical significance. In conclusion, PMV provides excellent immediate hemodynamic results with low mortality and morbidity risks, specially once experience has been gained with this technique. Patients with echocardiographic scores less than or equal to 8 and smaller left atrial diameters, usually younger and less symptomatic, are the best candidates for PMV.

[Intracoronary stents in the treatment of angioplasty complications]. / Stent intracoronario en el tratamiento de las complicaciones de la angioplastia.

Acute or subacute occlusion of the dilated artery is the main cause of complication after percutaneous transluminal coronary angioplasty. The occlusion incidence ranges between 2 and 10% of the procedures and the mechanisms include dissection, subintimal hemorrhage, thrombosis, vasospasm and elastic recoil. Intracoronary stent is a metallic support which may seal dissection due to angioplasty, resists elastic recoil and geometric remodeling and prevents other occlusion mechanisms. Data from recent studies demonstrate the benefit of stenting acute occlusive coronary dissection in a large artery with extensive myocardium at risk. The election of the type of stent in the treatment of the acute coronary occlusion depends on the clinical status, the coronary anatomy and the stent characteristics. The major limitation of stent is the apparition of subacute thrombosis. The mechanisms of stent thrombosis are not well known. However, some factors related to complicated angioplasty, such as the presence of important dissection, intracoronary thrombus and vessels of small diameter have been involved. For this reason, the major incidence of subacute thrombosis is observed in bail-out situations. New techniques using intravascular ultrasound and high pressure dilatation after stent placement and new approaches in antiplatelet treatment have been recently described in order to reduce the incidence of subacute occlusion and the hemorrhagic events associated to previous anticoagulant therapy.

[Right ventricular outflow obstruction due to a giant pseudoaneurysm of the anterior descending coronary artery in a patient with Behçet's disease]. / Obstrucción del tracto de salida del ventrículo derecho por un seudoaneurisma gigante de la arteria coronaria descendente anterior en un paciente con enfermedad de Behçet.

Giant pseudoaneurysms of coronary arteries in patients with Behçet's disease is a uncommon finding. It has been described exceptionally in the literature. We present a case of giant pseudoaneurysm of the left anterior descending coronary artery with obstruction of the right ventricular outflow in a patient with Behçet's disease. He improved after surgical resection and steroid treatment.

[The mechanism producing nausea during ventriculography performed with ioxaglate: the implications of a randomized study]. / Mecanismo de producción de las náuseas durante la ventriculografía realizada con ioxaglato: implicaciones de un estudio randomizado.

INTRODUCTION: The mechanism of ioxaglate-induced nausea has not been fully elucidated. Recent studies have demonstrated that serotonin is one of the principal neurotransmitters of emesis in humans. On the other hand, the greater capacity of ioxaglate to stimulate vomiting has been ascribed to its great ability to inhibit cholinesterase. METHODS: To determine if oral metoclopramide (a serotonin receptor-blocker) is effective in the prophylaxis of ioxaglate-induced nausea during left ventriculography, 637 of 711 consecutive eligible patients were included in a prospective study. Patients were randomized to receive, 60-90 minutes before the procedure, either diazepam 10 mg p.o. (control group [n = 315]) or diazepam 10 mg p.o. plus metoclopramide 10 mg p.o. (metoclopramide group [n = 322]). RESULTS: The two randomized groups were similar in relation to baseline clinical and hemodynamic characteristics. Nausea was documented in 103 patients (16.1%) with similar incidence in the two groups (control group: 16.8%, metoclopramide group: 15.5%; p = NS). Nausea duration was also similar (56 +/- 63 s vs 52 +/- 63 s; p = NS). When patients with and without nausea were compared, the following variables showed a significant difference between the two groups: male gender (86% vs 76%; p < 0.05), age (53 +/- 10 yrs vs 56 +/- 9 yrs; p < 0.05) and body surface area (1.84 +/- 0.2 m2 vs 1.78 +/- 0.1 m2; p < 0.01). Stepwise multiple regression analysis identified low age (p = 0.02) and male gender (p = 0.06) as independent predictors of nausea. The incidence of nausea was 24% in males < or = 45 yrs vs 9% in females > 45 yrs (p < 0.05). CONCLUSIONS: Prophylaxis with oral metoclopramide did not reduce the incidence of ioxaglate-induced nausea during left ventriculography. This data do not support a role of serotonin in the production of nausea by ioxaglate. Low age an male gender are independent predictors of nausea apparition during left ventriculography. A cholinergic mechanism is probably involved in the capacity of ioxaglate to stimulate vomiting.