Update on the TURBO BOOSTER spectranetics laser for lower extremity occlusive disease.

In the last two decades the endovascular treatment of peripheral arterial occlusive disease (PAOD) has gained a widespread and predominant role. New technologies have developed in the last years as atherectomy devices, self expandible nitinol stents, drug eluting devices (stent and balloons), absorbable stents. In recent years, growing interest has been dedicated to laser technology due to device improvements and literature data reporting safety and efficacy of excimer laser. The role of this new endovascular technique for the treatment of atherosclerotic arterial diseases should be considered with regard to two fields of interest: the claudicatio intermittens (CI) and the critical limb ischemia (CLI). A 20-year history with medical lasers has proven that not all lasers are equal. Lasers used and studied in the late 1980s and 1990s had poor outcomes due to inappropriate laser selection and undefined laser techniques. Over the last 10 years, multicenter studies with the excimer laser confirm that case selection, appropriate utilization of equipment, application of safe lasing techniques, and knowledge of indications and contraindications, all contribute to the successful application of laser-assisted angioplasty in complex coronary and peripheral artery disease. If applied properly, the Excimer Laser is a useful technique to transform complex obstructive arterial disease into more treatable lesions, improving the results of endovascular treatment and lowering the threshold of intervention for ''untreatable'' patients. New larger studies are requested to assess the definitive role of this technique in PAD treatment and limb salvage. This review will discuss the Laser Phisics and application in PAD along with the clinical data available to support the Excimer Laser as a reliable technology for endovascular intervention.

[Thrombo-embolic risk evaluation in patients with atrial fibrillation. Role of echocardiography]. / Stratificazione del rischio tromboembolico nel paziente con fibrillazione atriale. Ruolo dell'ecocardiografia.

Atrial fibrillation (AF) is the most common observed cardiac arrhythmia and is the most frequent condition associated with thromboembolic events in patients with or without mitral valve disease. The source of cardiac emboli is the left atrium, the left atrial appendage or, less frequently, the left ventricle. Emboli may also originate from aortic atherosclerotic plaques. It is important to identify patients at risk in order to perform the appropriate therapy. Risk stratification is multiparametric, being based on clinical, laboratory, and echocardiographic data. Several trials have pointed out the role of echocardiography in the evaluation of anatomic and functional parameters associated with thromboembolic risk. Transthoracic echocardiography (TTE) does not provide sufficient information regarding posterior cardiac structures, being its sensitivity in detecting thrombi relatively low (33-72%). Transesophageal echocardiography (TEE) in contrast, has an almost 100% sensitivity; this technique is, therefore, mandatory in patients with AF for an adequate prevention of thromboembolism. The echocardiographic information joined with clinical features allow to stratify, in a proper way, the risk of every single patient.

Post-ischaemic myocardial dysfunction (stunning) results from myofibrillar oedema.

OBJECTIVE: To test the hypothesis that myocardial stunning is due to myofibrillar oedema. METHODS: Experiments were performed in anaesthetised closed-chest pigs. In 15 pigs (group 1), myocardial stunning was produced by repetitive ischaemia and reperfusion; 5 pigs each were studied at 2 hours, 2 days, and 5 days later. Circumferential left ventricular (LV) mid-wall myocardial strain (E(cc)) was estimated in vivo using tagged magnetic resonance imaging. Myocardial water content (MWC) was measured post mortem, from which interfilament lattice distance (d) was calculated. In 6 pigs (group 2), myocardial dysfunction was produced by intracoronary administration of a mast cell degranulator. Animals were euthanised immediately upon induction of regional LV dysfunction to avoid development of inflammation. In 4 pigs (group 3), transmission electron microscopy (EM) was performed to quantify d in stunned versus normal myocardium. RESULTS: In group 1 pigs, MWC was raised in the stunned compared with normal myocardium (p<0.02) and decreased over time. An inverse relation was found between E(cc) and MWC in the stunned myocardium (r = -0.81) and between E(cc) and d (r = -0.90). A similar relation was noted between wall thickening and increase in MWC in group 2 (r = -0.84) pigs. In group 3 pigs, d on EM was significantly lower (40 (3) nmol/l) in normal myocardium than in stunned myocardium (46.4 (4) nmol/l), p<0.001. CONCLUSIONS: Ischaemia-reperfusion results in myocardial oedema, with consequent myocyte swelling and myofibrillar oedema. The latter leads to an increase in d, causing myosin heads to either fail to latch, or to latch improperly, onto the actin filament with poor force generation, leading to myocardial dysfunction. As the myocardial oedema abates, myocyte function improves.

Acute myocardial infarction and rescue percutaneous transluminal coronary angioplasty in a young HIV-infected patient.

We report a case of acute myocardial infarction in an HIV-infected patient without significant coronary artery disease (CAD) risk factors. The patient underwent rescue percutaneous transluminal coronary angioplasty (PTCA), with a successful outcome. We presume a possible pathogenetic role of anti-retroviral therapy and/or direct viral action on ischaemic heart disease progression. We propose that the current approach to management of AIDS-affected patients needs close monitoring for CAD risk factors and symptoms, to improve prognosis and life expectancy.

Double subepicardial aneurysm after myocardial infarction.

The echocardiogram of 68-year old man, admitted with an acute myocardial re-infarction revealed the presence, in the middle-apical region of the lateral wall, of two little and contiguous subepicardial aneurysms.