Left bundle branch area pacing versus conventional pacing in patients with advanced atrioventricular conduction abnormalities: a prospective cohort study.

BACKGROUND: Left bundle branch area pacing (LBBAP) is an emerging pacing method that may prevent the deleterious effects of right ventricular pacing. The aim of this study is to compare the effects of LBBAP with right ventricular septal pacing (RVSP) in patients with advanced atrioventricular conduction abnormalities and preserved left ventricular ejection fraction. METHODS: The effect of pacing was evaluated by echocardiographic indices of dyssynchrony, including global myocardial work efficiency (GWE) and peak systolic dispersion (PSD). The primary endpoint was GWE postprocedural, at 3, 6, and 12 months after the procedure. RESULTS: Twenty patients received LBBAP and 18 RVSP. Complete follow-up was accomplished in 37 patients (97.4%) due to the death of a patient (RVSP arm) from nonrelated cause. GWE was significantly increased in the group of LBBAP compared to RVSP at all time points (90.8% in LBBAP versus 85.8% in RVSP group at 12 months, p = 0.01). PSD was numerically lower in the LBBAP arm at all time points, yet not statistically significant (56.4 msec in LBBP versus 65.1 msec in RVSP arm at 12 months, p = 0.178). The implantation time was increased (median 93 min in LBBAP versus 45 min in RVSP group, p < 0.01), along with fluoroscopy time and dose area product (DAP), in the arm of LBBAP. There were no severe perioperative acute complications in either group. CONCLUSIONS: LBBAP is an emerging and safe technique for patients with a pacing indication. Despite the longer procedural and fluoroscopy time, as well as higher DAP, LBBAP seems to offer better left ventricular synchrony compared to RVSP, according to GWE measurements.

Spontaneous Coronary Artery Dissection as a Cause of Acute Myocardial Infarction in COVID-19 Patients: A Case Report and Review of the Literature.

Patients with COVID-19 often experience significant cardiovascular complications, including heart failure, myocarditis, and acute coronary syndrome. We present the case of a male patient with severe COVID-19 pneumonia, complicated with inferior ST-segment elevation myocardial infarction (STEMI), which was attributed to spontaneous coronary artery dissection (SCAD). We also make a review of the literature on case reports of patients with COVID-19 and acute myocardial infarction due to SCAD. Through these clinical cases, a potential correlation between SCAD and COVID-19 infection is implied. Endothelial dysfunction, thrombotic complications, and disturbance of the vascular tone are established COVID-19 sequelae, triggered either by direct viral injury or mediated by the cytokines' storm. These abnormalities in the coronary vasculature and the vasa vasorum could result in SCAD. Moreover, disturbances of the vascular tone can cause coronary vasospasm, a reported precipitant of SCAD. Thus, SCAD should be considered in COVID-19 patients with acute coronary syndrome (ACS), and in the case of STEMI, an early angiographic evaluation, if feasible, should be performed rather than thrombolysis to avoid potential adverse events of the latter in the setting of SCAD.

Randomized comparison of Glidesheath Slender with conventional 5Fr arterial sheaths for coronary angiography through the distal radial artery.

BACKGROUND: The potential benefits of the thin-walled 5F Glidesheath Slender sheath in the distal transradial access (dTRA) have not been investigated. This study aimed to compare the Glidesheath Slender versus conventional 5Fr arterial sheaths in patients undergoing diagnostic coronary angiography (CAG) through the dTRA. METHODS: A total of 352 consecutive patients with an indication for CAG were randomized (1:1) to Glidesheath Slender 5Fr versus a conventional 5Fr arterial sheath for dTRA. The primary endpoint was the rate of successful hemostasis at 30 minutes after sheath removal. Follow-up ultrasound of the right radial and distal radial artery was performed 7-10 days after the procedure. RESULTS: After exclusion of patients where a 6Fr sheath or crossover of access site was required, 108 patients in the Glidesheath Slender and 105 patients in the conventional 5Fr arterial sheath group were included in the analysis. The crossover rate to conventional radial access and the rate of successful hemostasis at 30 minutes after sheath removal were similar between the two groups (18.9% in the Glidesheath slender vs. 22% in the control group; P=0.460, and 62% vs. 51.4%; P=0.118, respectively). The level of pain associated with the procedure was significantly lower in the Glidesheath Slender group (2.69 vs. 3.29 in the control group; P=0.02). No significant difference was recorded between the two groups in the rate of access-related complications. CONCLUSIONS: Use of Glidesheath Slender for dTRA did not increase the rate of early hemostasis compared with conventional arterial sheath.

Ultrasound-guided femoral approach for coronary angiography and interventions in the porcine model.

Coronary angiography and percutaneous coronary intervention (PCI) procedural details in swine are similar to those performed to humans, since their heart and coronary anatomy closely resembles. However, only a few detailed descriptions of the procedure are available, containing notable differences. We present a feasible and reproducible protocol for percutaneous coronary interventions in porcine experimental models, utilizing ultrasound-guided femoral approach. Nine female pigs were studied to explore the feasibility of superficial femoral arterial (SFA) access for coronary angiography and provisional PCI, as well as the most suitable guiding coronary catheters and angiographic projections for the above interventions. Experiments were performed under general anesthesia, using ultrasound-guided puncture of the SFA to gain arterial access. The Amplatzer AR1® catheter, and the Right Coronary Bypass® catheter were used for the selective engagement of the right and the left coronary artery, respectively. Successful arterial access and subsequent cardiac catheterization were performed in all pigs. Only one animal required a second puncture for femoral artery access. None of the 9 animals presented any significant tachycardia or hypotensive episode. One animal developed an access site-related complication following the first catheterization procedure. During follow-up, 100% success of SFA catheterization was achieved using the same ultrasound-guided technique. The ultrasound-guided superficial femoral artery access for coronary angiography and provisional interventions in porcine models is a quick and safe alternative to the carotid artery approach. The RCB and AR1 catheters may be the best choice for the quick and easy selective coronary engagement of the right and left ostia, respectively.

Distal or Traditional Transradial Access Site for Coronary Procedures: A Single-Center, Randomized Study.

OBJECTIVES: This study aimed to compare the efficacy and safety of the distal transradial approach (dTRA) versus the conventional transradial approach (TRA) for coronary angiography and percutaneous coronary interventions. BACKGROUND: The recommended approach for coronary procedures is TRA. However, it is associated with radial artery occlusion (RAO). The dTRA could potentially decrease the incidence of RAO. METHODS: One thousand forty-two consecutive patients were randomized (1:1) to right dTRA or TRA. The primary endpoint was the rate of RAO, which was evaluated by Doppler ultrasound at 60 days after randomization. RESULTS: Five hundred eighteen and 524 patients were randomized to dTRA and TRA, respectively. Follow-up Doppler evaluation of the radial artery was accomplished in 404 (78.0%) patients in the dTRA group and 392 (74.8%) in the TRA group. The rate of RAO was significantly reduced in the dTRA group compared with TRA group (3.7% vs 7.9%, respectively; P = 0.014). The rate of successful sheath insertion was lower in the dTRA group compared with the TRA group (78.7% vs 94.8%, respectively; P < 0.001). More punctures (median = 2 [IQR: 1-3] vs median = 1 [IQR: 1-2]; P < 0.001) and a longer time (120 vs 75 seconds; P < 0.001) were required for sheath insertion in the dTRA group compared with the TRA group. The hemostasis time was shorter in the dTRA group compared with the TRA group (60 vs 120 minutes; P < 0.001). The dose area product was higher in the dTRA group (median = 32,729 in the dTRA vs 28,909 cGy/cm2 in the TRA group; P = 0.02). No significant differences were observed in the secondary safety endpoints (bleeding [Bleeding Academic Research Consortium ≥2] and severe radial artery spasm). CONCLUSIONS: According to our study, dTRA was associated with a lower rate of forearm RAO, a shorter time of hemostasis, a higher crossover rate and dose area product, and a longer procedural time compared with TRA.

Joint ESH excellence centers' national meeting on renal sympathetic denervation: A Greek experts' survey.

OBJECTIVE: The efficacy of renal sympathetic denervation (RDN) has been affirmed by a number of recent clinical studies, despite controversies in this field over the last five years. Therefore, it is of paramount importance that hypertension experts debate the merits of RDN by revealing and expressing their personal beliefs and perspectives regarding this procedure. METHODS: A cross-sectional survey was conducted among Greek leaders of the Hypertension Excellence Centers with the use of a closed-type questionnaire specifically designed to elicit information and evaluate the respondent's views and perspectives about RDN efficacy, safety and ideal target patient population. RESULTS: A total of 36 participants completed the survey. Based on the results, RDN was considered efficient (91.7%) and safe (94.5%), while the overwhelming majority of the participants felt confident in the long-term efficacy (88.9%) of the intervention and that it lacks reliable predictors of blood pressure response (94.5%). Patients with resistant (91.7%), ultra-resistant (94.4%), and uncontrolled hypertension (80.6%) were suggested as ideal candidates for RDN. Establishing a close co-operation between interventionalists and hypertension experts was considered essential to ensure the efficacy (97.2%) as well as the safety (97.3%) of the procedure. CONCLUSION: The vast majority of Greek hypertension experts surveyed were convinced of the efficacy and safety of RDN based on the preponderance of available scientific and clinical data. Identification of the ideal patient group remains controversial. Respondents generally agreed on the necessity of building close collaborative relationships between interventionalists and hypertension experts in order to improve RDN clinical outcome.

Potential Relationship Between Lifestyle Changes and Incidence of Hospital Admissions for Acute Coronary Syndrome During the COVID-19 Lockdown.

Aims: To evaluate the impact of lockdown during the COVID-19 pandemic on lifestyle changes of the general population, and on admissions for acute coronary syndrome (ACS). Methods and Results: All ACS admissions during the COVID-19 lockdown (10 March to 4 May, 2020), in 3 municipalities (3 spoke, and 1 hub hospital), in Southwestern Greece (411,576 inhabitants), were prospectively recorded and compared to the equivalent periods during 2018, and 2019. A telephone survey of 1014 participants was conducted to explore the lifestyle habits of citizens aged ≥35-years-old before and during lockdown. The median ACS incidence rate decreased from 19.0 cases per week in 2018 and 21.5 in 2019 down to 13.0 in 2020 (RR: 0.66 during the Covid-19 lockdown; 95%CI: 0.53-0.82; P = 0.0002). This was driven by a significant reduction of admissions for Non-ST elevation myocardial infarction (NSTEMI) (RR: 0.68; 95%CI: 0.52-0.88; P = 0.0037), mainly in patients with a lower burden of cardiovascular risk factors, as we noticed an inverse association between the reduction of the incidence of ACS during the Covid-19 lockdown period and the number of registered patient risk factors. There was no difference in the rates of STEMI and population-based all-cause mortality across the examined time periods. The telephone survey demonstrated reduction of passive smoking, working hours, alcohol, junk food and salt consumption, and an increase in sleeping hours, mainly in participants with a lower burden of cardiovascular risk factors. Conclusions: A significant decline in ACS admissions during the COVID-19 lockdown was noted, affecting mainly NSTEMI patients with a lower burden of cardiovascular risk factors. This was accompanied by significant lifestyle changes. Thus, it is tempting to speculate that to some extend the latter might be associated with the observed decline in ACS admissions.

Transradial access through the anatomical snuffbox: Results of a feasibility study.

BACKGROUND: Distal transradial access (dTRA), through the anatomical snuffbox (AS) of the hand, is a novel, potentially beneficial, vascular access for patients undergoing coronary procedures. METHOD: Consecutive patients with an indication for coronary angiography and/or percutaneous coronary intervention (PCI) were enrolled in our tertiary center, from November 2018 to March 2019. The success rate of the procedure, the incidence of local complications, the time required for hemostasis, and the incidence of radial artery occlusion (RAO) were evaluated. RESULTS: Α total of 167 patients were catheterized through the dTRA (79.6% men, 20.4% women), with a median age of 64 years. The indication for catheterization was ACS in 80 (47.9%) patients, stable coronary artery disease in 51 (30.5%) patients, and other reasons in 36 (21.6%) patients. Fifty patients (32.9%) underwent PCI. Successful sheath insertion was recorded in 152 (91.0%) patients. The mean time to hemostasis after sheath removal was 52 ± 11 min. Vascular access site complications were evaluated with ultrasound in 62 (40.8%) of the enrolled patients, 40 ± 15 days after the procedure. Among them, 2 (3.2%) patients presented with arteriovenous fistula, and 2 (3.2%) patients with local occlusion at the puncture site within the AS and distal to the transverse ligament, with preservation of the patency of the radial artery proximal to the radial styloid process. CONCLUSION: The dTRA may be a feasible and safe access site for diagnostic and interventional coronary procedures, with decreased incidence of RAO and time required for hemostasis compared to classical radial artery access.

Escherichia coli Endocarditis Presenting With Septic Shock in an Immunocompetent Female Patient.

Escherichia coli (E. coli) is a rare cause of infective endocarditis, despite being a common cause of bacteremia. E. coli endocarditis affects most frequently immunocompromised elderly women, especially those with diabetes mellitus. We present a case of a 78-year-old female immunocompetent patient, presenting with septic shock and multiple organ dysfunction syndrome. E. coli was isolated in all sets of blood cultures and in urine culture and a contrast-enhanced abdominal computed tomography (CT) scan revealed spleen and left kidney infracts. Transthoracic echocardiography revealed a large (> 15 mm) mobile mass on the atrial side of the posterior mitral valve leaflet. The patient was initially treated with intravenous ceftriaxone and ciprofloxacin for 2 weeks with successful clinical response and clearance of bacteremia, was then subjected to valve replacement (with isolation of E. coli from replaced valve cultures) and continued antibiotic therapy for additional 4 weeks postoperatively. E. coli has emerged in recent years as an important cause of bacteremia, especially in the elderly. In selected patients, as those with persistent Gram-negative bacteremia or severe sepsis/septic shock, echocardiography is of paramount importance for the diagnosis of Gram-negative endocarditis and should be included in our diagnostic algorithm of patient's evaluation.

Does Ticagrelor Improve Endothelial Function?

Ticagrelor is a P2Y12 receptor antagonist with proven clinical benefit in patients with acute coronary syndrome. Apart from its principal antiplatelet action, pleiotropic effects have been implicated in the clinical profile of ticagrelor, including a potentially beneficial impact on endothelial function. In light of the common presence and prognostic value of endothelial dysfunction in patients with coronary artery disease, several clinical studies have investigated the postulated effect of ticagrelor on endothelial function, yielding conflicting results. Limitations of the relevant studies as well as substantial differences in patient population, study design, and methods may account for these controversial findings. Most of these studies, however, support a beneficial impact of ticagrelor on endothelial function, which seems to be significant in the higher risk patients. In order to elucidate this effect, further research efforts should aim to clarify how quickly does endothelial function respond to ticagrelor, how sustained this response is during the dosing intervals and in the long term, which mechanisms are implicated, and whether this pleiotropic action is clinically significant. Future studies should include larger and diverse populations of patients, assess endothelial function at several time points after treatment initiation, and use multiple methods of endothelial function measurement, while implementing strict methodology. Nevertheless, the extent of the clinical benefit of ticagrelor attributable to actions beyond its potent and consistent antiplatelet effect remains uncertain.

Absence of differential effect of ticagrelor versus prasugrel maintenance dose on endothelial function in patients with stable coronary artery disease.

BACKGROUND: Endothelial function may be improved by ticagrelor through adenosine-mediated mechanisms. We aimed to assess the effect of ticagrelor versus prasugrel on endothelial function in patients with stable coronary artery disease (CAD). METHODS: In a prospective, randomized, crossover study, 22 stable CAD patients under prasugrel 10 mg once daily maintenance dose (MD) for at least 3 months were randomized to either ticagrelor 90 mg twice daily or prasugrel 10 mg once daily for 15 days with a direct treatment-crossover for another 15 days. Endothelial function was assessed by peripheral arterial tonometry (EndoPAT 2000 system, Itamar Medical, Caesarea, Israel) at Day 0 (randomization), Day 15, and Day 30. Reactive Hyperemia Index (RHI) was calculated by using an automated software, and endothelial dysfunction (ED) was defined as RHI <1.67. RHI at the end of the two treatment periods did not differ between ticagrelor and prasugrel MD treatments. Least squares estimates (95% confidence interval) were 1.78 (1.58-1.99) versus 1.88 (1.67-2.08), with a fixed estimate of -0.099 (95% CI: -0.45 to 0.25) for the difference between them (p = 0.5). ED rate did not differ significantly between ticagrelor and prasugrel (45.5% vs 45.5%, p = 0.6). CONCLUSIONS: In CAD patients, we have failed to find evidence of alteration of endothelial function following ticagrelor compared to prasugrel MD treatment, as assessed by peripheral arterial tonometry. CLINICALTRIALS. GOV UNIQUE IDENTIFIER: NCT01957540.

Randomised comparison of JUDkins vs. tiGEr catheter in coronary angiography via the right radial artery: the JUDGE study.

AIMS: The aim of this study was to compare the performance of the Tiger-II with Judkins 3.5L/4R catheters in coronary angiography (CAG) via the transradial approach (TRA). METHODS AND RESULTS: Consecutive patients undergoing non-urgent CAG via the right TRA were randomised to either the Tiger-II (Terumo) or Judkins (3.5L/4R; Medtronic) 5 Fr catheters; 320 patients in each group were randomised. Catheter or access site change was required in 57 (17.8%) vs. 68 (21.3%) patients allocated to the Tiger-II and Judkins group, respectively (p=0.3). The study's primary endpoint of contrast volume (ml) used until completion of CAG was lower for Tiger-II vs. Judkins group: 66.8 (54.0-82.0) vs. 73.4 (60.0-94.1), p<0.001. Angiography, fluoroscopy time (min) and severe spasm rate were also significantly lower for Tiger-II vs. Judkins group: 5.52 (4.17-7.32) vs. 6.85 (5.15-9.63), p<0.00, 2.01 (1.32-3.13) vs. 2.24 (1.50-3.50), p=0.01 and 6 (2.8%) vs. 39 (12.2%), p<0.001, respectively. The Tiger-II catheter obtained better opacification grade for the right coronary artery (RCA): 4.0 (4.0-4.0) vs. 4.0 (3.0-4.0), p=0.02, but slightly compromised opacification of the left anterior descending (LAD) and left circumflex (LCX) arteries compared with the Judkins group: 3.75 (3.0-4.0) vs. 4.0 (3.5-4.0), p<0.001, and 3.78 (3.6-4.0) vs. 4.0 (3.6-4.0), p<0.001, respectively. CONCLUSIONS: The Tiger-II was found superior to the Judkins 3.5L/4R regarding contrast volume use, procedural and fluoroscopy time, spasm rate and RCA imaging, and inferior regarding LAD and LCX imaging.

Effect of High (200 µg/kg per Minute) Adenosine Dose Infusion on Fractional Flow Reserve Variability.

BACKGROUND: Variations in distal coronary pressure (Pd)/aortic pressure (Pa) ratio during steady-state hyperemia with standard (140 µg/kg per minute) adenosine dose may hamper accurate fractional flow reserve assessment. This study investigated to what extent an increased adenosine dose can overcome Pd/Pa variation. METHODS AND RESULTS: In a prospective, single-arm study, out of 95 prospectively screened patients, 38 (40.0%) exhibited significant (≥0.05 difference of max Pd/Pa minus min Pd/Pa) variations in Pd/Pa from 15 s post Pd/Pa dip and until the end of a 3-minute adenosine (140 µg/kg per minute) infusion. Thirty patients agreed to participate in a post 5-minute repeat fractional flow reserve assessment using 200 µg/kg per minute 3-minute adenosine infusion. The study's co-primary end point of Pd/Pa coefficient of dispersion was lower for the high versus standard adenosine dose: 1.31 (1.13-2.72) versus 2.76 (2.38-5.60), P=0.002. The study's co-primary end point of ΔPd/Pa was also lower for the high versus standard adenosine dose: 0.065 (0.038-0.10) versus 0.08 (0.06-0.11), P=0.002. This difference was mainly driven by the lowering effect of the high adenosine dose on the maximum Pd/Pa compared to the standard dose: 0.84 (0.81-0.93) versus 0.90 (0.83-0.95), P=0.007, while minimum Pd/Pa remained unaffected. High adenosine dose was adequately tolerated by all patients, without requiring infusion discontinuation in any case. CONCLUSIONS: Pd/Pa variability is frequently observed during standard adenosine infusion and is significantly decreased following a high (200 µg/kg per minute) adenosine dose. This is achieved without a significant difference in the minimum Pd/Pa. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02350439.

Long-Term P2Y12-Receptor Antagonists in Post-Myocardial Infarction Patients: Facing a New Trilemma?

Physicians considering prescription of P2Y12-receptor antagonist for long-term (>1 year) protection of patients post-myocardial infarction face the trilemma of selecting between clopidogrel, prasugrel, or ticagrelor. Differential ischemic benefits derived from relevant trials may assist in tailoring treatment, although the different bleeding definitions applied make any meaningful comparison of each agent's bleeding potential very difficult. Considering the available data and recognizing the significant limitation of observations obtained thus far from subgroup analyses, prasugrel appears to provide higher anti-ischemic protection than clopidogrel. Ticagrelor seems to be an attractive option for patients with renal dysfunction, peripheral arterial disease, or following a brief P2Y12-receptor antagonist interruption, whereas clopidogrel may be advised in the presence of cost and availability issues. As head-to-head comparative trials between P2Y12-receptor antagonists are lacking, selection of a specific agent by the clinician should be made on the basis of critical appraisal of available large clinical datasets.

Pre-hospital ticagrelor in ST-segment elevation myocardial infarction: Ready for prime time?

In ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) peri-procedural P2Y12 antagonism - although of great importance - is often suboptimal, even with the novel oral antiplatelet agents prasugrel and ticagrelor. The concept of pre-hospital ticagrelor loading, investigated in the recently published Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST Elevation Myocardial Infarction to Open the Coronary Artery (ATLANTIC) trial, appears quite a promising strategy to optimize peri-procedural platelet inhibition and potentially clinical outcome. Implementation of such an approach when treating low risk STEMI patients in 'real life' practice might prove even more beneficial than expected from the ATLANTIC results, given the reported delays from first medical contact to primary PCI performance.