Subclavian angioplasty during coronary interventions using radial approach.

BACKGROUND: In the past years, the percentage of percutaneous coronary angiography and coronary interventions using radial access had significantly increased due to its higher safety, lower risk of major bleeding, and hence lower cardiovascular mortality. Subclavian artery stenosis is one of the challenges that may be met during transradial coronary interventions, which may necessitate femoral access crossover or conversion. AIMS: To evaluate the feasibility and safety of performing subclavian angioplasty via radial access during complex coronary interventions using the forearm approach. METHODS: A series of patients with complex radial approach due to subclavian stenosis received subclavian angioplasty during the procedure. We included 48 patients out of 22 500 procedures performed from February 2009 to February 2020. All patients did not have alternative vascular access due to extensive peripheral arterial disease (previous history of iliac stenting or distal aortic occlusion, which makes femoral access crossover difficult; also the contralateral radial/ulnar artery was very faint or not detectable at all). RESULTS: Mean age was 72 (10) years and 67% of patients were males. Subclavian angioplasty was successfully done in all patients via ipsilateral radial access; 44 patients (91.7%) required subclavian stenting, and 4 patients were treated by subclavian angioplasty without stenting. Coronary angiography or intervention was perfectly achieved through the revascularized subclavian artery; coronary stenting was successfully done in 36 patients as indicated. CONCLUSIONS: It can be concluded that percutaneous subclavian artery angioplasty can be done safely and effectively to facilitate complex transradial coronary procedures with an acceptable immediate technical success, especially in patients without alternative vascular access. Also, we may conclude that subclavian angioplasty may be successfully performed in patients with symptomatic upper limb ischemia, via the radial approach.

Prognostic Implication of Non-Obstructive Coronary Lesions: A New Classification in Different Settings.

The clinical significance of non-obstructive coronary artery disease is the subject of debate. Our objective was to evaluate the long-term cardiovascular prognosis associated with non-obstructive coronary artery disease in patients undergoing coronary angiography, and to conduct a stratification by sex, diabetes, and clinical indication. We designed a multi-centre retrospective longitudinal observational study of 3265 patients that were classified into three groups: normal coronary arteries (lesion <20%, 1426 patients), non-obstructive coronary artery disease (20-50%, 643 patients), and obstructive coronary artery disease (>70%, 1196 patients). During a mean follow-up of 43 months, we evaluated a combined cardiovascular event: acute myocardial infarction, stroke, hospitalization for heart failure, or cardiovascular death. Multivariable-adjusted Cox proportional hazard models showed a worse prognosis in patients with non-obstructive coronary artery disease, in comparison with patients of normal coronary arteries group, in the total population (hazard ratio 1.72, 95% confidence interval 1.23-2.39; p for trend <0.001), in non-diabetics (hazard ratio 2.12, 95% confidence interval: 1.40-3.22), in women (hazard ratio 1.75, 95% confidence interval 1.10-2.77), and after acute coronary syndrome (hazard ratio 2.07, 95% confidence interval 1.25-3.44). In conclusion, non-obstructive coronary artery disease is associated with an impaired long-term cardiovascular prognosis. This association held for non-diabetics, women, and after acute coronary syndrome.

Transcatheter Mitral Valve Repair in Cardiogenic Shock and Mitral Regurgitation: A Patient-Level, Multicenter Analysis.

OBJECTIVES: The aim of this study was to evaluate the outcome of transcatheter mitral valve repair (TMVr) in patients with cardiogenic shock and significant mitral regurgitation (MR). BACKGROUND: Patients in cardiogenic shock with severe MR have a poor prognosis in the setting of conventional medical therapy. Because of its favorable safety profile, TMVr is being increasingly used as an acute therapy in this population, though its efficacy remains unknown. METHODS: A multicenter, collaborative, patient-level analysis was conducted. Patients with cardiogenic shock and moderate to severe (3+) or severe (4+) MR who were not surgical candidates were treated with TMVr. The primary outcome was in-hospital mortality. Secondary outcomes included 90-day mortality, heart failure (HF) hospitalization, and the combined event rate of 90-day mortality and HF hospitalization following dichotomization by TMVr device success. RESULTS: Between January 2011 and February 2019, 141 patients across 14 institutions met the inclusion criteria. In-hospital mortality occurred in 22 patients (15.6%), at 90 days in 38 patients (29.5%), and at one year in 55 patients (42.6%). Median length of hospital stay following TMVr was 10 days (interquartile range: 6 to 20 days). HF hospitalization occurred in 26 patients (18.4%) at a median of 73 days (interquartile range: 26 to 546 days). When stratified by TMVr procedural results, successful TMVr reduced rates of in-hospital mortality (hazard ratio [HR]: 0.36; 95% confidence interval [CI]: 0.13 to 0.98; p = 0.04), 90-day mortality (HR: 0.36; 95% CI: 0.16 to 0.78; p = 0.01), and the composite of 90-day mortality and HF hospitalization (HR: 0.41; 95% CI: 0.19 to 0.90; p = 0.03). CONCLUSIONS: TMVr may improve short- and intermediate-term mortality in high-risk patients with cardiogenic shock and moderate to severe MR. Randomized studies are needed to definitively establish MR as a therapeutic target in patients with cardiogenic shock.

Spontaneous Coronary Artery Dissection and Hypothyroidism.

INTRODUCTION AND OBJECTIVES: Thyroid hormone affects the metabolism of all tissues in the body. The aim of this study was to analyze the prevalence and implications of thyroid disorders in a cohort of consecutive patients with spontaneous coronary artery dissection (SCAD). METHODS: A total of 73 patients with SCAD were analyzed. Baseline characteristics and clinical outcomes were compared between euthyroid and hypothyroid patients. Subsequently, the prevalence of thyroid function abnormalities and the clinical characteristics of SCAD patients were compared with those in 73 patients with acute coronary syndrome but without SCAD, matched by age, sex, and presentation. RESULTS: Mean age was 55 ± 12 years and 26% had hypothyroidism. Compared with patients with normal thyroid function, patients with SCAD and hypothyroidism were all women (100% vs 69%, P = .01), more frequently had dissection in distal (74% vs 41%, P = .03) and tortuous coronary segments (68% vs 41%, p = .03), and more frequently received conservative medical management (79% vs 41%, P = .007). During a mean clinical follow-up of 4.1 ± 3.8 years, 23% of the patients had adverse cardiac events irrespective of thyroid function status. The prevalence of hypothyroidism was higher in patients with SCAD than in matched patients with acute coronary syndrome without SCAD (26% vs 8%, P = .004). CONCLUSIONS: There is a high prevalence of hypothyroidism in patients with SCAD. Patients with SCAD and hypothyroidism are more frequently women, more frequently have distal dissections in tortuous vessels, and are more frequently managed with a conservative medical strategy.

Abluminal Neointimal Healing by Optical Coherence Tomography Assessment After Drug-Eluting Stent Implantation on Organized Recanalized Thrombus.

Six-month PCI follow-up results of left anterior descending (LAD) and circumflex (CX) drug-eluting stent implantation are presented. Angiography showed patent LAD and CX stents. However, OCT revealed almost all abluminal cavities were completely filled, which the authors surmise was due to a neointimal healing process.

Radial/Ulnar angioplasty in selected patients undergoing elective angiography or PCI using complex forearm approach.

BACKGROUND: Angioplasty on the radial artery have been performed with good success rates in patients with critical hand ischemia. We sought to assess the feasibility and safety of radial angioplasty on complex radial access in patients undergoing coronary angiography. METHODS/MATERIAL: A prospective series of procedures with complex radial/ulnar access to which radial-ulnar angioplasty (RU-A) was performed. We set goals of efficacy and safety that included the success rate of the procedure (need for ¨Crossover femoral¨) and the existence of radial pulse at one month. RESULTS: 18 cases of RU-A out of 11,500 procedures from March 2010 to July 2016 (0.15%) were included. The majority of the patients were men with a variety of cardiovascular risk factors (age 71±9; 94% Hypertensive, 56% Diabetic, 18% chronic kidney disease). The most common indication for radial/ulnar angioplasty was severe arteriosclerotic stenosis. Angioplasty was performed with different types of over the wire peripheral balloons (Mean diameter 4,3±1 and mean length 42±15mm), in one case a stent implantation was needed. The success rate was 100% without vascular complications at 1-month clinical and vascular doppler follow-up. CONCLUSIONS: Radial/ulnar artery angioplasty is feasible and safe in selected patients undergoing elective angiography or percutaneous coronary intervention using complex forearm approach.

Detection of spontaneous coronary artery spasm with optical coherence tomography in a patient with acute coronary syndrome.

We present 2 illustrative cases of acute coronary syndrome and spontaneous coronary artery spasm evaluated by optical coherence tomography. Different spasm patterns were showed by optical coherence tomography (OCT), according to whether there were underlying atherosclerotic plaques or not.

Bioresorbable Scaffolds in Spontaneous Coronary Artery Dissection: Long-Term Follow-Up in 4 Patients.

Spontaneous coronary artery dissection is a rare condition, and diagnosis and treatment are challenging among patients who present with acute coronary syndrome. Typically, the condition affects young females who have no underlying atherosclerotic disease. To date, few cases of bioresorbable scaffold implantation for the treatment of spontaneous coronary artery dissection have been reported. Therefore, we describe the cases of 4 patients whom we treated with scaffolds. We evaluated the long-term results by using intravascular ultrasound and optical coherence tomographic scanning.

Utility of 3D-OCT Imaging With Angiographic Co-Registration in Acute Coronary Syndrome With Normal or Near-Normal Coronary Arteries.

The OPTIS integrated system (St. Jude Medical) is a new technology allowing the online co-registration of optical coherence tomography (OCT) images with the angiogram in the catheterization laboratory. Additionally, 3D navigation can be performed. This integration of OCT information on an angiographic roadmap could find broad application in the characterization of substrates causing acute coronary syndromes with normal or near-normal coronary arteries. The utility of OCT with co-registration for the guidance of percutaneous coronary intervention could be considerable in the management of patients with acute coronary syndromes.

The Absorb Limits.

A patient presented with an inferior non-ST segment elevation myocardial infarction and a tight lesion on the distal right coronary artery. After stent implantation, a large scaffold malapposition was observed by optical coherence tomography. This case emphasizes the importance of not expanding a bioresorbable vascular scaffold more than 0.5 mm over its nominal size.

[Spontaneous dissection of the left main coronary artery treated by multiple stent implantation]. / Disección espontánea del tronco coronario izquierdo tratada mediante implantación de multiples stents.

We report a case of spontaneous dissection of the left main coronary artery in a 32-year-old healthy woman that was unrelated with childbirth or other known risk factors. The clinical presentation was an extensive acute anterior myocardial infarction. She was treated by thrombolysis, but did not meet reperfusion criteria. Coronary angiography revealed dissection of the left main coronary artery that extended into the anterior descending and circumflex coronary arteries. Rescue angioplasty with stenting was performed. The clinical, diagnostic, and therapeutic features of this rare entity are discussed.

[Patterns of clinical presentation of atrial fibrillation in hospitalized patients]. / Patrones clínicos de presentación de la fibrilación auricular en los pacientes hospitalizados.

INTRODUCTION AND OBJECTIVES: The ACC/AHA/ESC 2001 guidelines for the management of atrial fibrillation (AF) establish 4 categories: first episode, paroxysmal, persistent and permanent. The aim of this study was to analyze the frequency of the different clinical patterns of presentation of AF in hospitalized patients. PATIENTS AND METHOD: We analyzed the pattern of AF in 300 hospitalized patients, 200 of whom were admitted to the cardiology and 100 to the internal medicine department. We determined the clinical profile and evaluated the factors influencing therapeutic management. RESULTS: The permanent form was present in 30% of the patients admitted to the cardiology department and in 51% if those admitted to the internal medicine department. The first episode pattern was the most frequent in cardiology department patients (41%). In patients hospitalized the in cardiology the percentage use of anticoagulants (57.9% vs. 41%; p < 0.01) and beta blockers was greater than in internal medicine patients, and digitalis use was lower. In the multivariate analysis, admission to the cardiology department was an independent predictor of treatment with beta blockers (OR = 3.8; 95% CI, 1.3-11.1; p < 0.05), and discharge from the hospital with AF was a predictor of anticoagulant prescription (OR = 4.8; 95% CI, 2.5-9.2; p < 0.001). CONCLUSIONS: a) Atrial fibrillation is an arrhythmia with a heterogeneous clinical pattern that varies depending on the type of care provided; b) on admission to cardiology, only 30% of the patients present with permanent arrhythmia, and the most frequent clinical pattern is first episode; and c) discharge from the hospital with AF was the principal determinant of therapeutic management.