Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI.

BACKGROUND: Coronary revascularization guided by fractional flow reserve (FFR) is associated with better patient outcomes after the procedure than revascularization guided by angiography alone. It is unknown whether the instantaneous wave-free ratio (iFR), an alternative measure that does not require the administration of adenosine, will offer benefits similar to those of FFR. METHODS: We randomly assigned 2492 patients with coronary artery disease, in a 1:1 ratio, to undergo either iFR-guided or FFR-guided coronary revascularization. The primary end point was the 1-year risk of major adverse cardiac events, which were a composite of death from any cause, nonfatal myocardial infarction, or unplanned revascularization. The trial was designed to show the noninferiority of iFR to FFR, with a margin of 3.4 percentage points for the difference in risk. RESULTS: At 1 year, the primary end point had occurred in 78 of 1148 patients (6.8%) in the iFR group and in 83 of 1182 patients (7.0%) in the FFR group (difference in risk, -0.2 percentage points; 95% confidence interval [CI], -2.3 to 1.8; P<0.001 for noninferiority; hazard ratio, 0.95; 95% CI, 0.68 to 1.33; P=0.78). The risk of each component of the primary end point and of death from cardiovascular or noncardiovascular causes did not differ significantly between the groups. The number of patients who had adverse procedural symptoms and clinical signs was significantly lower in the iFR group than in the FFR group (39 patients [3.1%] vs. 385 patients [30.8%], P<0.001), and the median procedural time was significantly shorter (40.5 minutes vs. 45.0 minutes, P=0.001). CONCLUSIONS: Coronary revascularization guided by iFR was noninferior to revascularization guided by FFR with respect to the risk of major adverse cardiac events at 1 year. The rate of adverse procedural signs and symptoms was lower and the procedural time was shorter with iFR than with FFR. (Funded by Philips Volcano; DEFINE-FLAIR ClinicalTrials.gov number, NCT02053038 .).

Initial experience with orbital atherectomy in a non-surgical center in Portugal.

INTRODUCTION AND OBJECTIVES: Percutaneous coronary intervention (PCI) of severely calcified lesions is associated with a higher risk of procedural complications, suboptimal stent expansion, and in-stent restenosis. Lesion preparation with orbital atherectomy (OA) in severely calcified lesions has been shown to increase procedural success and decrease reintervention rates. In this study, we sought to report the procedural safety and efficacy of our initial experience with OA in a non-surgical center in Portugal. METHODS: Patients with severely calcified coronary lesions who were treated with intended intravascular ultrasound (IVUS) guided OA were included in a prospective single-center registry. We evaluated several endpoints, including: debulking success, defined <50% residual stenosis severity after OA; procedural success, defined as stent implantation according to Optimal-IVUS PCI criteria; use of additional calcium debulking strategies; and procedural complications, including coronary no-reflow, dissection, perforation or side branch occlusion. Patients were followed up for 30 days to assess early cardiovascular or procedure-related death, myocardial infarction, myocardial injury and reintervention. RESULTS: Between January 2023 and September 2023, 37 patients and 53 coronary arteries underwent OA. IVUS imaging was used in all cases. Debulking and procedural success were achieved in 90.5% and 97.3% of cases, respectively. In 26 (49.1%) lesions, additional calcium debulking techniques were needed. Procedural complications occurred in three cases and one patient died during hospitalization. CONCLUSION: Our initial experience with OA for heavily calcified coronary lesions demonstrated high procedural success and overall favorable clinical outcomes.

A report on a survey among Portuguese Association of Interventional Cardiology associates regarding ionizing radiation protection practices in national interventional cath-labs.

INTRODUCTION AND OBJECTIVES: Concerns surrounding the consequences of ionizing radiation (IR) have increased in interventional cardiology (IC). Despite this, the ever-growing complexity of diseases as well as procedures can lead to greater exposure to radiation. The aim of this survey, led by Portuguese Association of Interventional Cardiology (APIC), was to evaluate the level of awareness and current practices on IR protection among its members. METHODS: An online survey was emailed to all APIC members, between August and November 2021. The questionnaire consisted of 50 questions focusing on knowledge and measures of IR protection in the catheterization laboratory. Results were analyzed using descriptive statistics. RESULTS: From a response rate of 46.9%, the study obtained a total sample of 159 responses (156 selected for analysis). Most survey respondents (66.0%) were unaware of the radiation exposure category, and only 60.4% reported systematically using a dosimeter. A large majority (90.4%) employed techniques to minimize exposure to radiation. All participants used personal protective equipment, despite eyewear protection only being used frequently by 49.2% of main operators. Ceiling suspended shields and table protectors were often used. Only two-thirds were familiar with the legally established limit on radiation doses for workers or the dose that should trigger patient follow-up. Most of the survey respondents had a non-certified training in IR procedures and only 32.0% had attended their yearly occupational health consultation. CONCLUSIONS: Safety methods and protective equipment are largely adopted among interventional cardiologists, who have shown some IR awareness. Despite this, there is room for improvement, especially concerning the use of eyewear protection, monitoring, and certification.

Clinical results of percutaneous coronary intervention in chronic total occlusions of the right coronary artery.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) of the right coronary artery (RCA) are a relatively common finding in the context of coronary angiography. However, the benefit of revascularization remains controversial. METHODS: A single-center retrospective cohort analysis prospectively collected outcomes of CTO patients undergoing percutaneous coronary intervention (PCI) in 2019 and 2020. Patients were divided into two groups according to the CTO vessel treated (left coronary artery [LCA]-CTO or RCA-CTO). The primary outcome was defined as the recurrence of angina and/or heart failure (HF) symptoms and secondary outcomes were myocardial infarction (MI) and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome occurred in 28 (16.6%) patients and was significantly more frequent in RCA-CTO patients (19, 24.7%, p=0.010) in a mean follow-up of 18 months. This was mainly driven by recurrence of HF symptoms (12, 15.6%, p=0.013). Treated RCA-CTO was an independent predictor of the primary outcome (p=0.019, HR 2.66, 95% CI 1.17-6.05). MI and mortality rates were no different between groups (RCA-CTO with 1.3%, p=0.361 and 2.6%, p=0.673, respectively, on survival analysis). Left ventricular ejection fraction was an independent predictor of mortality (p=0.041, HR 0.93, 95% CI 0.87-0.99). CONCLUSIONS: Revascularization of CTO lesions by PCI was associated with low rates of symptom recurrence, and clinical outcomes showed no differences regardless of which artery was treated. Recanalization of RCA-CTO was less beneficial in reducing the recurrence of HF symptoms.

Ionizing radiation exposure in complex percutaneous coronary intervention: Defining local diagnostic reference levels in the catheterization laboratory.

INTRODUCTION AND OBJECTIVES: Concerns regarding the consequences of ionizing radiation (IR) have been increasing in the field of interventional cardiology (IC). There is little information on reported national and local radiation diagnostic reference levels (DRLs) in catheterization laboratories in Portugal. This study was designed to assess the IR dose exposure during complex percutaneous coronary intervention (PCI), and to set the respective DRLs and future achievable doses (ADs). METHODS: This was a retrospective cohort study which took place between 2019 and 2020, including patients who underwent complex PCI. Complex PCI was defined as all procedures that encompass treatment of chronic total occlusions (CTO) or left main coronary artery. DRLs were defined as the 75th percentile of the distribution of the median values of air kerma area product (PKA) and cumulative air kerma (Ka,r). ADs were set at the 50th percentile of the study dose distribution. Multivariate analysis was performed using linear regression to identify predictors significantly associated with radiation dose (Ka,r). RESULTS: A total of 242 patients were included in the analysis. Most patients underwent a CTO procedure (146, 60.3%). Patients were aged 67.9±11.2 years and mostly male (81.4%). DRLs were set in Ka,r (3012 mGy) and PKA (162 Gy cm2) for complex PCI. ADs were also set in Ka,r (1917 mGy) and PKA (101 Gy cm2). Independent predictors of Ka,r with a positive correlation were PKA (0.893, p<0.001), fluoroscopy time (0.520, p<0.001) and PCI time (0.521, p<0.001). CONCLUSIONS: This study reports the results of IR in complex PCI. DRLs were set for IR dose exposure measured in Ka,r (3012 mGy) and PKA (162 Gy cm2). ADs, values to be achieved in future assessment, were set to Ka,r (1917 mGy) and PKA (101 Gy cm2).

Clinical outcomes of percutaneous coronary intervention in chronic total occlusion in patients with type 2 diabetes mellitus.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) are relatively common findings in patients with type 2 diabetes mellitus (T2DM). However, the indication for percutaneous coronary intervention (PCI) and its clinical benefit in these patients remain controversial. METHODS: A single-center retrospective cohort study with prospectively collected outcomes was carried out with CTO patients undergoing PCI in 2019 and 2020. Patients were divided into two groups according to previous T2DM diagnosis (T2DM and non-T2DM). The primary outcome was recurrence of angina and/or heart failure symptoms and secondary outcomes were myocardial infarction and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome (total symptom recurrence) occurred in 16.6% of the sample, with no difference between groups (non-T2DM 13.6% vs. T2DM 21.2%, p=0.194) in a two-year follow-up. Angina recurrence was significantly more frequent in T2DM patients (15.2%, p=0.043). The presence of T2DM was not an independent predictor of symptom recurrence (p=0.429, HR 1.37, 95% CI 0.62-2.98). Myocardial infarction and all-cause mortality were also not different between groups (T2DM 1.5%, p=0.786 and 4.5%, p=0.352, respectively, on survival analysis). Independent predictors of all-cause mortality were left ventricular function and creatine clearance (p=0.039, HR 0.92, 95% CI 0.85-0.99 and p=0.013, HR 0.96, 95% CI 0.93-0.99, respectively). CONCLUSIONS: T2DM did not influence outcomes in CTO patients undergoing PCI, and its presence should not be a limiting factor in deciding on CTO revascularization.

Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes in contemporaneous clinical practice.

BACKGROUND: Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes (NSTE-ACS) during hospitalization is still a matter of contention within the cardiology community. Our aim was to analyze in-hospital and one-year follow-up outcomes of patients with NSTE-ACS pretreated with dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT). METHODS: A retrospective study was carried out with NSTE-ACS patients planned to undergo an invasive strategy and were included in the Portuguese Registry of ACS between 2018-2021. A composite primary outcome (in-hospital re-infarction, stroke, heart failure, hemorrhage, death) was compared regarding antiplatelet strategy (DAPT versus SAPT). Secondary outcomes were defined as one-year all-cause mortality and one-year cardiovascular rehospitalization. RESULTS: A total of 1469 patients were included, with a mean age of 66±12 years and 73.9% were male. DAPT regime was used in 38.2% and SAPT in 61.8% of patients. NSTE myocardial infarction was the most frequent presentation (88.5%). Revascularization after 24h occurred in 44.8% patients (63% of these after 48h). Enoxaparin was the anticoagulant more frequently used (45.1%). The primary outcome was more frequently observed in the SAPT group (10.4%, p=0.033), mainly driven by more ischemic events. Time until revascularization > 48h and SAPT regime were independent predictors of the primary outcome (OR 1.66, p=0.036 and OR 2.03, p=0.008, respectively). CONCLUSION: NSTE-ACS patients pretreated with SAPT had worse in-hospital outcomes. This difference can be probably explained by a delay in time until revascularization. Pretreatment DAPT strategy and crossover between heparins is still frequently used in clinical practice.

Overlapping versus single long stents in long chronic total occlusions: insights of the Iberian CTO Registry.

BACKGROUND: It is unknown whether the availability of long drug-eluting stents modify the PCI strategy of long CTO. To describe the contemporary PCI strategy of long chronic total occlusions (CTO) using overlapping (OS) or single long stents (SS) and to analyze its results. METHODS: 2842 consecutive CTO PCIs were included. Those with an occlusion length ≥20 mm in which ≥1 drug eluting stent (DES) was implanted were analyzed. We compared procedural characteristics and clinical outcomes of CTO treated with OS or SS. RESULTS: 1088 CTO PCIs were analyzed (79.9% males; 64.7±10.6 years). Mean J-score was 2.8±0.9. A SS was used in 38.5% of cases and OS in 61.5%. Total stent length was 64.1±29.9 mm; it was higher in the OS group (OS: 79.9±25.5 mm vs. SS: 38.3±14.7 mm; P<0.0001). Mean number of stents in the OS group was 2.3±1. Very long stents (≥40 mm) were used in 27.4% of cases, more frequently in the OS group (OS:32.4% vs. SS:19.3%; P<0.0001). After a mean follow-up of 19±15.9 months, the rate of adverse events (MACE) was 2% (cardiac death: 1.6%, myocardial infarction: 1.6%, target lesion revascularization: 1.9% and stent thrombosis: 0.18%) with no significant differences between both groups. Overlapping was not an independent predictor of MACE. CONCLUSIONS: In long CTO PCIs, OS is more frequently used than single stenting, especially in more complex procedures. Clinical outcomes at a mid-term follow-up are favorable. Using newer generation DES, overlapping was not an independent predictor of MACE; however, a trend toward a higher event rate was observed in the OS group.

[Severe coronary vasospasm]. / Grave vasoespasmo coronário.

A 50-year-old man, with chronic kidney disease and on dialysis, underwent coronary angiography in the context of acute coronary syndrome, which revealed focal lesions (type A) in the proximal left anterior descending and mid circumflex arteries. Ad-hoc angioplasty was performed on both lesions with direct stenting. An immediate drop in arterial blood pressure was observed and the angiogram showed new lesions with reduced flow throughout the coronary tree, progressing to cardiogenic shock and electromechanical dissociation. During cardiopulmonary resuscitation maneuvers, intracoronary verapamil was administered and TIMI 3 flow, sinus rhythm and a rise in blood pressure were obtained. Clinical stability was progressively restored. The patient was discharged medicated with calcium channel blockers and nitrates. During follow-up, he was twice readmitted for unstable angina. Coronary angiography revealed findings that could easily have been interpreted as new obstructive lesions, but these resolved after administration of intracoronary nitrates.

Effusive-constrictive pericarditis: the role of noninvasive imaging.

Effusive-constrictive pericarditis is a rare entity in which clinical suspicion is of paramount importance, and although cardiac catheterization remains the gold standard for diagnosis, noninvasive imaging techniques are very useful in consolidating the diagnosis prior to confirmation by invasive means. The authors describe the case of a 52-year-old man, who had undergone heart surgery in the past, with a long history of heart failure refractory to medical therapy and chronic recurrent pericardial effusion, in whom noninvasive imaging techniques were decisive in arriving at the correct diagnosis of effusive-constrictive pericarditis, which was later confirmed by cardiac catheterization, thus enabling the correct therapeutic approach to be adopted and leading to improvement in clinical status.

Epidemiological findings on interventional cardiology procedures during the COVID-19 pandemic: A multi-center study.

BACKGROUND: The rates of in-hospital mortality following percutaneous interventional procedures (PIP) during the COVID-19 pandemic period compared to the non-pandemic period has not been reported so far. METHODS: We retrospectively enrolled all consecutive patients admitted for PIP across five centers from February 2020 to May 2020. RESULTS: A total of 4092 PIP were performed during the reference periods. The total number of procedures dropped from 2380 to 1712 (28.0% reduction). Overall in-hospital mortality increased from 1.1% in 2019, to 2.6% in 2020 (63% relative increase). CONCLUSION: During the COVID-19 pandemic, in-hospital all-cause mortality significantly increased in patients admitted for cardiological PIP.

Five-year clinical results of coronary angioplasty with drug-eluting stents. National initiative in strategic innovation, iNOS.

INTRODUCTION: The use of drug-eluting stents (DES) is beneficial in patients undergoing percutaneous coronary intervention (PCI) and there is particular interest in long-term follow-up. OBJECTIVE: We aimed to assess and characterize early DES use in Portugal during 2003 and patient follow-up over a 5-year period. We developed a web-based database to collect and organize patient and procedural data from PCI performed in ten cardiovascular interventional centers sharing the same database. METHODS: This was a multicenter retrospective study that included 1833 consecutive angiographically successful coronary angioplasties in which a DES was implanted in 2003. A subgroup of patients with 5-year clinical follow-up after the initial procedure was selected for which there was at least a 90% follow-up rate during one quarter of 2003. Demographic, clinical and angiographic characteristics of the entire population were assessed. In the clinical follow-up cohort, the incidence of major adverse cardiac events (MACE)--death, myocardial infarction and surgical or percutaneous target lesion revascularization--was analyzed by survival curves and logistic regression analysis. RESULTS: Of the total population, 23% were female, and mean age was 62 +/- 11 years (25-92). The main risk factors were hypertension (60.5%), dyslipidemia (42.9%), smoking (45.1%) and diabetes (23.9%, of whom 13.2% were on insulin therapy). There was a history of myocardial infarction, PCI or bypass surgery respectively in 23.1%, 25.1%, and 9.7% of the patients. Multivessel disease was present in 59.9% of patients (mean of 1.86 +/- 0.81 vessels). PCI was performed on average in 1.24 +/- 0.48 lesions, and complete revascularization in 58.8%. A total of 2058 stents were used (mean of 1.62 +/- 0.84) in 1271 patients. The longitudinal substudy included only 320 PCIs, for which follow-up was achieved in 319 (99%; median: 1875 days, P25: 1457 days, P75: 2045 days). Thirty-seven deaths (11.6%) and 61 MACE (19.1%) occurred in this group, with no differences between insulin-treated and other diabetic patients. CONCLUSION: This is the first study to analyze the early Portuguese experience with drug-eluting stents. The clinical results compare favorably with the first published international registries. The on-line platform used was successful in collecting data in a standardized format on the clinical experience of multiple centers.

P2Y12 inhibitor loading dose before catheterization in ST-segment elevation myocardial infarction: Is this the best strategy? / Dose de carga do inibidor P2Y12 antes do laboratório de hemodinâmica no enfarte agudo do miocárdio com supradesnivelamento do segmento ST ­ Será mesmo a melhor estratégia?

INTRODUCTION AND OBJECTIVES: In ST-segment elevation myocardial infarction (STEMI) the benefit of dual antiplatelet therapy is unequivocal, but the optimal time to administer the loading dose (LD) of a P2Y12 inhibitor is the subject of debate and disagreement. The main aim of this study was characterize current practice in Portugal and to assess the prognostic impact of P2Y12 inhibitor LD administration strategy, before versus during or after primary percutaneous coronary intervention (PCI). METHODS: This multicenter retrospective study based on the Portuguese National Registry on Acute Coronary Syndromes included patients with STEMI and PCI performed between October 1, 2010 and September 19, 2017. Two groups were established: LD before PCI (LD-PRE) and LD during or after PCI (LD-CATH). RESULTS: A total of 4123 patients were included, 66.3% in the LD-PRE group and 32.4% in the LD-CATH group. Prehospital use of a P2Y12 inhibitor was a predictor of the composite bleeding endpoint (major bleeding, need for transfusion or hemoglobin [Hb] drop >2g/dl), Hb drop >2g/dl and reinfarction. There were no differences between groups in major adverse events (MAE) (in-hospital mortality, reinfarction and stroke) or in-hospital mortality. CONCLUSIONS: Prehospital use of a P2Y12 inhibitor was associated with an increased risk of bleeding, predicting the composite bleeding outcome and Hb drop >2g/dl, with no differences in mortality or MAE, calling into question the benefit of this strategy.

Clinical Events After Deferral of LAD Revascularization Following Physiological Coronary Assessment.

BACKGROUND: Physicians are not always comfortable deferring treatment of a stenosis in the left anterior descending (LAD) artery because of the perception that there is a high risk of major adverse cardiac events (MACE). The authors describe, using the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) trial, MACE rates when LAD lesions are deferred, guided by physiological assessment using fractional flow reserve (FFR) or the instantaneous wave-free ratio (iFR). OBJECTIVES: The purpose of this study was to establish the safety of deferring treatment in the LAD using FFR or iFR within the DEFINE-FLAIR trial. METHODS: MACE rates at 1 year were compared between groups (iFR and FFR) in patients whose physiological assessment led to LAD lesions being deferred. MACE was defined as a composite of cardiovascular death, myocardial infarction (MI), and unplanned revascularization at 1 year. Patients, and staff performing follow-up, were blinded to whether the decision was made with FFR or iFR. Outcomes were adjusted for age and sex. RESULTS: A total of 872 patients had lesions deferred in the LAD (421 guided by FFR, 451 guided by iFR). The event rate with iFR was significantly lower than with FFR (2.44% vs. 5.26%; adjusted HR: 0.46; 95% confidence interval [CI]: 0.22 to 0.95; p = 0.04). This was driven by significantly lower unplanned revascularization with iFR and numerically lower MI (unplanned revascularization: 2.22% iFR vs. 4.99% FFR; adjusted HR: 0.44; 95% CI: 0.21 to 0.93; p = 0.03; MI: 0.44% iFR vs. 2.14% FFR; adjusted HR: 0.23; 95% CI: 0.05 to 1.07; p = 0.06). CONCLUSIONS: iFR-guided deferral appears to be safe for patients with LAD lesions. Patients in whom iFR-guided deferral was performed had statistically significantly lower event rates than those with FFR-guided deferral.

Procedural, Functional and Prognostic Outcomes Following Recanalization of Coronary Chronic Total Occlusions. Results of the Iberian Registry.

INTRODUCTION AND OBJECTIVES: There is current controversy regarding the benefits of percutaneous recanalization (PCI) of chronic total coronary occlusions (CTO). Our aim was to determine acute and follow-up outcomes in our setting. METHODS: Two-year prospective registry of consecutive patients undergoing PCI of CTO in 24 centers. RESULTS: A total of 1000 PCIs of CTO were performed in 952 patients. Most were symptomatic (81.5%), with chronic ischemic heart disease (59.2%). Previous recanalization attempts had been made in 15%. The mean SYNTAX score was 19.5 ± 10.6 and J-score was > 2 in 17.3%. A retrograde procedure was performed in 92 patients (9.2%). The success rate was 74.9% and was higher in patients without previous attempts (82.2% vs 75.2%; P = .001), those with a J-score ≤ 2 (80.5% vs 69.5%; P = .002), and in intravascular ultrasound-guided PCI (89.9% vs 76.2%, P = .001), which was an independent predictor of success. In contrast, severe calcification, length > 20mm, and blunt proximal cap were independent predictors of failed recanalization. The rate of procedural complications was 7.1%, including perforation (3%), myocardial infarction (1.3%), and death (0.5%). At 1-year of follow-up, 88.2% of successfully revascularized patients showed clinical improvement (vs 34.8%, P < .001), which was associated with lower mortality. At 1-year of follow-up, the mortality rate was 1.5%. CONCLUSIONS: Compared with other national registries, patients in the Iberian registry undergoing PCI of a CTO showed similar complexity, success rate, and complications. Successful recanalization was strongly associated with functional improvement, which was related to lower mortality.

Early flow propagation velocity for assessment of diastolic function in myocardial infarction treated with acute reperfusion.

INTRODUCTION: Acute myocardial infarction (MI) causes left ventricular (LV) diastolic dysfunction, which influences prognosis and clinical evolution. Early flow propagation velocity (FPV), evaluated by color M-mode Doppler, has been demonstrated to be a diastolic function parameter with excellent correlation with relaxation constant tau, and is relatively independent of pre- and afterload. OBJECTIVE: The aim of this study was to evaluate left ventricular relaxation in MI patients treated with acute reperfusion therapy. METHODS: Patients with ST-elevation MI treated with reperfusion therapy were evaluated by echocardiagraphy in the first 48 hours and after one week. The parameters studied were: early peak filling velocity (E), late peak filling velocity (A), E/A ratio, E-wave deceleration time (EDT), isovolumic relaxation time (IVRT) and FPV. The values obtained at the first and second evaluation were compared; we evaluated the relation between pain-to-reperfusion time (PRT; < or =3 hours vs. >3 hours) and the presence of single-vessel or multivessel disease with the parameters previously mentioned. RESULTS: 40 patients were studied and 19 included, 15 (80%) male, mean age 57+/-14 The most prevalent risk factors were: hypertension (11 patients - 58%), smoking (14 - 74%), diabetes (6 - 30%), and dyslipidemia (12 - 63%). MI location was anterior in six patients (31%) and inferior in 13 (69%). Five patients (26%) underwent fibrinolysis and 14 (74%) direct percutaneous coronary intervention. Mean pain-to-reperfusion time was 3.7+/-2.8 hours. Four patients (21%) had single-vessel disease and 14 (74%) had multivessel disease. Near significance was found for the difference in the E/A ratio between the two evaluations and a significant difference in the FPV. A significant correlation was also found between PRT and E/A ratio at the two evaluations (p=0.003, p=0.05), and between PRT and IVRT after one week (p=0.011). E/A ratio, IVRT and FPV were normal at the two evaluations in patients who had undergone earlier reperfusion therapy. No significance was found between the number of diseased vessels and the parameters of diastolic function assessed. DISCUSSION AND CONCLUSIONS: In the early phase of M1 treated with acute reperfusion, a delayed relaxation pattern was observed, which evolved to a normal pattern by the second evaluation, as statistically confirmed by FPV. Earlier reperfusion therapy preserves diastolic function. FPV is a sensitive and independent parameter for assessment of diastolic function in MI patients treated with acute reperfusion therapy.

Five cases of transient left ventricular apical ballooning--the experience of a Portuguese center.

Transient left ventricular apical dyskinesia (apical ballooning syndrome, ABS) is characterized by transient alterations in regional wall motion, involving the mid and apical segments of the left ventricle, as well as electrocardiographic alterations, mimicking ST-elevation acute myocardial infarction, in the absence of obstructive disease of the epicardial coronary arteries. In this article, we present a series of five cases of ABS and a theoretical review of the syndrome.

When intravascular ultrasound becomes indispensable in percutaneous coronary intervention of a chronic total occlusion.

Percutaneous coronary intervention of chronic total occlusion is a particular interventional area which requires high level of operator's experience and the support of additional tools based on intracoronary image such as intravascular ultrasound in many cases to clarify difficulties during procedures and to increase success rate. Implantation of long stents in many cases, the presence of stump ambiguity, and the use of specific techniques in this kind of interventions, such as reverse controlled antegrade and retrograde subintimal tracking (CART) and reverse CART make necessary in many cases the use of intravascular ultrasound for a better understanding of the situation, for reducing eventual complications and increasing procedural success rate. We made a review of literature related to most challenging situations in which the use of intravascular ultrasound during chronic total occlusion percutaneous coronary intervention becomes rather indispensable to safely continue and finish the procedure. Besides, two complex percutaneous coronary interventions of chronic total occlusion with unfavourable anatomic features in which intravascular ultrasound was crucial for the procedural success are presented in this manuscript along with support of the literature.

Evaluation of systolic and systo-diastolic function: the Tei index in acute myocardial infarction treated with acute reperfusion therapy--early and late evaluation.

INTRODUCTION: Evaluation of systolic and diastolic function by non-invasive methods in the acute phase of myocardial infarction (MI) is of great importance for risk stratification and prognosis. Ejection fraction (EF), as determined by echocardiography using the Simpson method, is the main parameter for assessing left ventricular (LV) function. The Tei index (TI), a Doppler-derived index that reflects systolic and diastolic function in MI, has an excellent correlation with prognosis. OBJECTIVE: The purpose of this study was to evaluate systolic and systo-diastolic function in the acute and late phase of ST-elevation MI treated with acute reperfusion therapy. METHODS: Patients with ST-elevation MI who underwent acute reperfusion therapy were evaluated by echocardiography in the first 48 hours and after one week. The parameters studied were: EF, wall motion score index (WMSI), and TI. The values obtained at the first and second evaluation were compared and correlated with pain to reperfusion time (PRT) (<3 vs. > or =3 hours), presence of single or multivessel disease, ejection fraction, total CK (<1500 or > or =1500 UI/l), and MI location (anterior vs. other). RESULTS: 40 patients were studied and 19 were included, of whom 15 (80%) were male, mean age 57 +/- 14 years. Risk factors included hypertension (11 patients, 58%), smoking (14, 74%), diabetes (6, 30%), and dyslipidemia (12, 63%). MI location was anterior in 6 patients (32%) and inferior in 13 (68%). Five patients (26%) underwent fibrinolysis and 14 (74%) direct percutaneous coronary intervention. Mean pain to reperfusion time was 3.7 +/- 2.8 hours. Four patients (21%) had single vessel disease and 14 (74%) multivessel disease. Significant differences were found: (a) in mean EF and WMSI between the two evaluations (p < 0.0001 and p = 0.002 respectively); (b) between PRT and EF (p = 0.001) and WMSI (p = 0.020) at 48 hours; (c) between PRT and EF (p = 0.01) and TI (p = 0.033), and MI location and EF (p = 0.005) after one week. DISCUSSION AND CONCLUSIONS: Early systolic function and LV remodeling one week after MI were accurately evaluated by EF and WMSI. Early reperfusion therapy positively influences early and late systolic and systo-diastolic function.

Percutaneous intervention in chronic total coronary occlusions caused by in-stent restenosis: procedural results and long-term clinical outcomes in the TORO (Spanish registry of chronic TOtal occlusion secondary to an occlusive in-stent RestenOsis) multicentre registry.

AIMS: Limited data exist on the treatment and outcomes of patients with chronic total occlusions due to in-stent restenosis (CTO-ISR). We sought to evaluate results and clinical outcomes in percutaneous interventions over CTO-ISR. METHODS AND RESULTS: We conducted a registry in 16 centres involving consecutive patients undergoing attempted percutaneous intervention over CTO-ISR. A total of 233 patients were included, 192 (82.4%) with a successful acute result. The success rate was significantly lower in patients with: lesion in the circumflex artery, ostial lesions, J score >3 and no femoral access. The presence of tandem lesions (OR 0.19, 95% CI: 0.06-0.68; p=0.01) was identified as an independent predictor for outcome. After a median follow-up of 20 months, cardiac death in the successful vs. failed groups was 3% and 8.3%, respectively (p=0.09). Independent predictors for mortality were previous CABG (HR 8, 95% CI: 1.3-50; p=0.02) and multivessel disease (HR 2.3, 95% CI: 1.2-4.3; p=0.01). In the successful group, TLR was 15%, re-occlusion 6% and definite/probable stent thrombosis 1.8%. CONCLUSIONS: Percutaneous treatment of CTO due to ISR in contemporary practice shows a high success rate, resulting in good long-term results. The angiographic and procedural predictors identified may contribute to improving procedural outcome through better patient selection.