Acute changes in mitral valve geometry after percutaneous valve repair with MitraClip XTR by three-dimensional echocardiography.

BACKGROUND: Mitral valve (MV) repair with MitraClip system is a safe treatment option for high-risk patients with significant mitral regurgitation (MR). We aimed to characterize, by three-dimensional echocardiography (3D-E), changes occurring in MV after implantation of third generation MitraClip XTR device, with specific reference to the underlying MR mechanism (functional vs degenerative, FMR vs DMR). METHODS: We prospectively enrolled 59 patients, who underwent intra-procedural 3D-E before and after device deployment. Three-D datasets were analyzed off-line, using a dedicated semiautomatic software, to obtain parametric quantification of mitral anatomy. RESULTS: Post-procedural MR of mild or lesser degree was achieved in 40 patients (68%), with no differences between FMR and DMR (p 0.9). After MitraClip XTR implantation, the FMR group experienced an immediate annular resizing, with reduction of antero-posterior diameter (p 0.024) and sphericity index (p 0.017), next to a recovery of physiological saddle-shape, defined by lower non-planar angle (p ≤0.001) and higher annulus height to commissural width ratio (p ≤0.001). On the opposite, the DMR group revealed a significant decrease of maximum annular velocity (p 0.027), addressing a mechanic effect of the device deployment. Finally, baseline anterior mitral leaflet angle was found as an independent predictor of acute procedural result (OR 6.7, [CI 1.01-44.33], p 0.049). CONCLUSIONS: MitraClip XTR implantation acts in restoring the original mitral geometry, with distinctive effects according to MR mechanism. Three-D parametric quantification of MV sheds new light on changes occurring in the valvular apparatus, and helps identifying possible new predictors of acute procedural success.

Clinical and procedural impact of aortic arch anatomic variants in carotid stenting procedures.

OBJECTIVES: To evaluate the impact of aortic arch variants in patients undergoing carotid artery stenting (CAS). BACKGROUND: CAS is increasingly carried out to treat the patients with internal carotid artery (ICA) stenosis. Aortic arch anatomy may influence its feasibility and affect clinical outcome. METHODS: Aortic arch digital subtraction angiography was systematically performed before CAS. Aortic arch elongation and bovine arch variants were recorded. Catheter manipulation time (CMT) was assessed for each patient. Adverse cardiovascular and cerebral events were assessed at 30 days. RESULTS: A total of 282 consecutive patients undergoing CAS under proximal balloon occlusion (57.8%) or distal filter (42.2%) neuroprotection were enrolled (age, 72 ± 7 years; 72.7% males). Type II and III elongation variants were detected in 23.4% and 10.6% of patients, respectively; in total, 20.5% of the patients had bovine configuration. CMT was significantly influenced by aortic elongation (56.1 ± 16.5 min in patients with type III aortic arch configuration compared to 38.2 ± 11.6 min in patients with type I or type II, P < 0.01) and (in left ICA) by bovine configuration (49.2 ± 11.4 min in bovine variants vs. 37.7 ± 11.5 min in patients with nonbovine anatomy, P < 0.001). CMT, but not aortic arch anatomy, resulted the only independent predictor of 30-day adverse outcome (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.10, P < 0.01). CONCLUSIONS: Adverse aortic arch anatomies are frequently encountered in CAS procedures and are associated to longer procedural times. A longer CMT increases the risk for adverse outcome. These data suggest that a careful procedure planning aimed at a reduction of CMT may be pivotal to improve the safety of CAS procedures.

Whole-Body Cryostimulation in Functional Neurological Disorders: A Case Report.

Functional neurological disorders (FNDs) are complex disabling conditions requiring a multiple rehabilitation intervention. Here, we propose a new use of whole-body cryostimulation (WBC) that was implemented in a multidisciplinary rehabilitation programme in a wheelchair-ridden woman diagnosed with FND and other comorbidities. WBC is a promising adjuvant treatment in various conditions of rehabilitation interest, mainly because of its wide range of rapid effects, from anti-inflammatory to pain and autonomic modulating effects. The 4-week program included physiotherapy, nutritional intervention, psychological support, and WBC (-110 °C for 2 min). Questionnaires to assess disease impact, pain level, fatigue and sleep quality were administered. At discharge, improvements in body composition, haematological biomarkers, physical performance, and questionnaire scores were observed. The patient was able to walk independently with a walker for medium distances and reported unprecedented improvements, particularly in functional parameters and questionnaire scores. Although the extent to which WBC per se contributed to the measured improvements cannot be ascertained, subjective reports and our clinical observations indicate that WBC, the only intervention not previously experienced by the patient, acted as a booster for the rehabilitation interventions. Further research will be necessary to rule out any possible placebo effect and to confirm the effects of WBC on FND.

Usefulness of EuroSCORE systems for risk stratification.

Risk stratification of patients undergoing open-heart surgery or percutaneous interventions may help physicians select the best individual management of patients with advanced heart disease.European System for Cardiac Operative Risk Evaluation (EuroSCORE) is an easy-to-calculate, clinical scoring system which has been developed for coronary surgery and applied in various cardiological settings. Recently, the EuroSCORE II model has been launched with the aim of improving the stratification performance over the first model.In the present study, we review the available scientific data on the use of EuroSCORE systems in patients undergoing surgical or percutaneous procedures.

Comparison of Right and Left Upper Limb Arterial Variants in Patients Undergoing Bilateral Transradial Procedures.

BACKGROUND: Transradial approach (TRA), when compared with transfemoral, improves the safety of percutaneous coronary procedures. Arterial axis variants are known to hinder the performance of transradial approach percutaneous coronary procedures. Data on the occurrence of arterial axis variants in the right and left arm arterial axes of individual patients are lacking. METHODS AND RESULTS: From a single-center prospective registry, we selected all patients in whom bilateral upper limb arterial anatomy was assessed based on the performance of left and right radial catheterization obtained during the same or during repeat coronary diagnostic or interventional procedure(s). The occurrence of upper right and left limb arterial axis variants was classified according to the previously described operative ABC classification. A total of 610 patients were identified. An ABC upper limb arterial axis variant was detected in 156 (25.6%) patients. Variants were right-sided only in 65 (11.0%), left-sided only in 40 (6.6%), and bilateral in 46 (7.5%) patients. Thus, arterial axis variants were significantly more common in the right side (P=0.02). Bilateral arterial variants were significantly associated with age, female sex, and valvulopathy. Both A (radial/brachial) and B (axillary/subclavian/innominate) variants exhibited concordance across the 2 sides (odds ratio, 7.2; 95% confidence interval, 4.1-12.7 and 8.0; 95% confidence interval, 2.1-30.9, respectively). CONCLUSIONS: The occurrence of an anatomic variant potentially hindering transradial approach coronary diagnostic or interventional procedures is bilateral in <8% of cases and is more common in the right arm. Such information may guide, during the clinical practice, the access selection in the case of repeat procedures or need for additional accesses.

Frequency-domain optical coherence tomography findings in patients with bifurcated lesions undergoing provisional stenting.

AIMS: Bifurcations represent challenging lesions which may benefit from improved understanding of stent-related vessel complications. Since optical coherence tomography (OCT) allows us to detect post-stenting vessel injuries, we sought to assess the geographic pattern of stent-related complications occurring during provisional stenting of bifurcated lesions. METHODS AND RESULTS: Fifty-one patients with bifurcated lesions treated by provisional stenting and undergoing intra-procedural OCT assessment were enrolled. OCT images were acquired with the aim of guiding the percutaneous coronary intervention but were re-analysed off-line for the present study. The stented bifurcation was divided into four segments [three in the main vessel (MV) and one in the side branch (SB)]. The following acute post-stenting vessel injuries/complications at the different bifurcation segments were evaluated: (i) stent under-expansion, (ii) stent malapposition, (iii) stent edge dissection, (iv) side-branch ostium dissection, (v) tissue prolapse, (vi) intracoronary thrombus, and (vii) in-stent dissection. A total of 55 bifurcation lesions undergoing provisional stenting were analysed. At least one OCT complication was detectable in all cases. Across different bifurcation sites, significant differences in the occurrence of stent complications were observed. In particular, stent malapposition was more common at the proximal MV segment (P < 0.001), while tissue prolapse was more common at the distal MV segment (P < 0.001). CONCLUSION: In bifurcated interventions, OCT often detects vessel injuries/stent complications, which tend to have a specific geographical distribution. In particular, stent malapposition is more common at the proximal MV and tissue prolapse at the distal MV segment.

Fractional flow reserve or optical coherence tomography guidance to revascularize intermediate coronary stenosis using angioplasty (FORZA) trial: study protocol for a randomized controlled trial.

BACKGROUND: The management of patients with angiographically intermediate coronary lesions is a major clinical issue. Fractional flow reserve provides validated functional insights while optical coherence tomography provides high resolution anatomic imaging. Both techniques may be applied to guide management in case of angiographically intermediate coronary lesions. Moreover, these techniques may be used to optimize the result of percutaneous coronary intervention. We aim to compare the clinical and economic impact of fractional flow reserve versus optical coherence tomography guidance in patients with angiographically intermediate coronary lesions. METHODS/DESIGN: Patients with at least one angiographically intermediate coronary lesion will be randomized (ratio 1:1) to fractional flow reserve or optical coherence tomography guidance. In the fractional flow reserve arm, percutaneous coronary intervention will be performed if fractional flow reserve value is ≤0.80, and will be conducted with the aim of achieving a post-percutaneous coronary intervention fractional flow reserve target value of ≥0.90. In the optical coherence tomography arm, percutaneous coronary intervention will be performed if percentage of area stenosis (AS%) is ≥75% or 50 to 75% with minimal lumen area <2.5 mm2, or if a major plaque ulceration is detected. In case of percutaneous coronary intervention, optical coherence tomography will guide the procedure in order to minimize under-expansion, malapposition, and edge dissections.Cost load and clinical outcome will be prospectively assessed at one and thirteen months. The assessed clinical outcome measures will be: major cardiovascular events and occurrence of significant angina defined as a Seattle Angina Questionnaire score <90 in the angina frequency scale. DISCUSSION: The FORZA trial will provide useful guidance for the management of patients with coronary artery disease by prospectively assessing the use of two techniques representing the gold standard for functional and anatomical definition of coronary plaques. TRIAL REGISTRATION: Clinicaltrials.gov NCT01824030.

Impact of operator experience and wiring technique on procedural efficacy of trans-radial percutaneous chronic total occlusion recanalization performed by dedicated radialists.

BACKGROUND: The efficacy of trans-radial approach (TRA) in chronic total occlusions (CTO) percutaneous coronary interventions (PCI) is not well established. Thus, we sought to review the feasibility and long-term results of TRA for CTO PCI performed by dedicated TRA operatorsof our center. METHODS: CTO PCI performed by dedicated radialists were considered. Primary end-points were "PCI success" (stent implantation with residual stenosis < 20% and TIMI 3) and "patient success" (PCI success in a first or second attempt). Vascular complications and major adverse cardiac events (MACE) were also assessed. Procedures were divided into: Period 1 - no systematic adoption of TRA nor systematic wire selection, and Period 2 - systematic TRA with stepwise wire selection. The starting guidewire was initially an intermediate wire (Period 2a), and, thereafter, a tapered soft polymeric guidewire (Period 2b). RESULTS: Two operators performed 167 TRA PCI on CTO in 158 patients. PCI success rate was 74.3% and patient success rate was 78.5%. Drug-eluting stents were implanted in 95.1% of successful procedures. One (0.6%) patient had a (minor) vascular complication. After a mean follow-up of 580 days, 93.7% of patients were free from MACE. PCI success (57.1% in Period 1 vs. 76.5% in Period 2a vs. 80.5% in Period 2b, p = 0.029) and patient success (62.5% in Period 1 vs. 77.8% in Period 2a vs. 86.1% in Period 2b, p = 0.025) significantly improved during the study. CONCLUSIONS: CTO PCI by TRA is safe and feasible. Its efficacy seems to be strongly dependenton operator experience with CTO techniques and may be influenced by the strategy of guidewire selection.