Rotational atherectomy as endovascular haute couture: a road map of tools and techniques for the interventional management of burr entrapment.

OBJECTIVES AND BACKGROUND: Rotational atherectomy (RA) is used as a debulking technique prior to stenting in some specialized cardiac centers for calcified coronary lesions amenable to percutaneous coronary intervention (PCI). A specific possible complication, burr entrapment, is unusual but carries serious risks and may sometimes necessitate surgery as a rescue procedure. However, different modalities using a percutaneous approach were proposed as a bail-out. We aim to propose a framework for possible management for trapped RA burr. METHODS AND RESULTS: A literature review of the most relevant cases of entrapped burr during PCI was performed. Twelve cases were reported and different solutions were discussed. Surgery was needed in only 1 patient to retrieve the trapped burr, and in all the other cases, different percutaneous solutions were successful to retract the trapped device. CONCLUSIONS: These cases illustrate that burr entrapment during RA, albeit rare, may occur and may transform a relatively simple PCI to a procedure failure. Although prevention is better than treatment, the operators should be aware of such serious complication and they should keep in mind that various possible percutaneous solutions may be successful to retrieve the burr and to avoid surgery.

Perspectives on the value of biomarkers in acute cardiac care and implications for strategic management.

Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management.

Rotational atherectomy for left main coronary artery disease in octogenarians: transradial approach in a tertiary center and literature review.

OBJECTIVES: The aim of this study was to appreciate the safety and effectiveness of transradial percutaneous coronary intervention (PCI) with rotational atherectomy for highly calcified left main coronary artery (LMCA) disease in octogenarians. BACKGROUND: Conventional surgery is still considered the preferred management for LMCA disease; but, when the lesion is severely calcified, and the patient is unsuitable for surgery, the interventional cardiologist faces a complex PCI traditionally approached by femoral access. METHODS: Between June 2004 and December 2010, octogenarians with calcified LMCA disease who were primary denied for surgical revascularization were enrolled. Procedural success and major adverse cerebral and cardiovascular events (MACCE) including death, nonfatal myocardial infarction, target lesion revascularization (TLR), or stroke during long-term follow-up were evaluated. RESULTS: Forty-two consecutive patients ≥80 years had undergone stenting for calcified LMCA disease (13 with rotational atherectomy, the "Rota" group, and 29 without rotational atherectomy, the "without Rota" group). Procedural success was good (92.3% vs. 96.6%, respectively, p = NS). Mean follow-up time was 25.7 ± 21.4 and 28 ± 32.3 months, respectively. There was a TLR in 25% and 11.1%, respectively; p = NS. No difference was detected in terms of overall in-hospital or long-term mortality or MACCE. CONCLUSION: Rotational atherectomy followed by stent implantation by transradial approach, when applied to heavily calcified lesions, appeared to be a safe and effective strategy for the treatment of LMCA disease in octogenarians who were refused for surgery.

Spontaneous coronary artery dissection: one entity with several therapeutic options.

Spontaneous coronary artery dissection is an unusual and a rare cause of acute coronary syndrome and sudden death with multiple predisposing factors. Prompt recognition is crucial for appropriate patient management, but specific guidelines for optimal treatment are lacking. We report four cases of women with spontaneous coronary artery dissection revealed by ST-segment elevation, three in women during postpartum and one case associated with a Marfan syndrome. Our cases span the different therapeutic options from medical treatment, stenting, to coronary artery bypass graft surgery.

Left main coronary stenting in a non surgical octogenarian population: a possible approach.

Coronary artery bypass grafting is conventionally considered the standard treatment for significant left main coronary artery (LMCA) disease. The management of LMCA disease in octogenarians is however still debated. The aim of this study was to appreciate the safety and effectiveness of percutaneous coronary intervention (PCI) for LMCA disease in octogenarians who were denied for surgical revascularization. The study included 70 consecutive patients ≥80 years of age who had undergone PCI for the treatment of LMCA and who were primary denied by our center's heart team for surgical revascularization. Mean age was 83.4±2.6 years. Mean Euroscore was 21.1±16.7 and mean Syntax score was 28.6±8.7. Overall in-hospital mortality was 11%. Mean follow-up time was 30.5±24.2 months. Overall mortality at the end of follow-up was 28%. Cardiac death was found in 18 patients and 2 patients died from terminal renal insufficiency. One patient (2%) presented with a new STEMI, 7 (11.3%) with a new non-STEMI, 13 (21%) with heart failure, and 2 (3.2%) had minor hemorrhage. There was a percutaneous target vessel revascularization in 6 (10%) patients. During follow-up, the total major adverse cerebral and cardiovascular event (MACCE including death, non-fatal acute myocardial infarction (AMI), target lesion revascularization (TLR), or stroke) was 27.4%. Stent implantation was relatively safely applied for the treatment of LMCA disease in octogenarians who were refused for surgery and who represented a high risk population. Despite a non-negligible rate of MACCE, the clinical long term outcome seems correct for this specific population with heavy basal status.

Myocardial strain assessment in cystic fibrosis.

BACKGROUND: The aim of this work was to evaluate myocardial strain analysis as a tool for the early detection of left ventricular functional changes in patients with cystic fibrosis. METHODS: A total of 42 consecutive patients (mean age, 24 ± 7.5 years; 52% men) diagnosed with cystic fibrosis and referred for echocardiographic cardiac function assessment were prospectively enrolled. A group of healthy age-matched and gender-matched volunteers (n = 42) formed the reference population for echocardiographic comparisons. RESULTS: Left ventricular ejection fraction was conserved in both groups but was significantly lower in the cystic fibrosis group. Cardiac function assessment using Doppler tissue imaging parameters revealed that both systolic and diastolic measurements differed between the two groups: mitral peak systolic and diastolic velocities, as well as septal and lateral wall strain rates, were decreased in patients with cystic fibrosis, as was longitudinal strain of both the septal and lateral walls. CONCLUSIONS: Using strain measurements, subclinical changes in left ventricular function were found in patients with cystic fibrosis. These parameters were correlated with the degree of pulmonary involvement severity. These findings have potentially significant clinical implications for the outcomes and follow-up of patients with cystic fibrosis, meriting further studies.

Thrombus in normal coronary arteries: retrospective study and review of case reports.

BACKGROUND: Myocardial infarction is rarely caused by non-occlusive thrombus in angiographically normal coronary arteries. The cases reported in the literature are scarce and follow-up was usually short. The efficacy and tolerability of the exclusively medical treatment strategy used in most cases remain unknown. AIMS: To evaluate efficacy of medical treatment and long-term prognosis in these patients. METHODS: We retrospectively selected and analysed patients hospitalized in our centre between 1998 and 2008 for myocardial infarction caused by non-occlusive thrombus in angiographically normal coronary arteries (defined as stenosis<30%), who were exclusively medically treated. A long-term follow-up was performed. A review of the literature regarding such cases was carried out. RESULTS: Sixteen patients were identified; apart from smoking, they had few conventional cardiovascular risk factors. Two patients died in hospital. The 14 survivors were followed up for an average of 4.9 years and only one death (non-cardiac cause) and one stroke (related to supraventricular arrhythmia) occurred in this period. Medical treatment included the use of glycoprotein IIb/IIIa inhibitors in 75% of cases. The literature review revealed 36 similar cases due to multiple aetiologies-particularly coronary artery spasm and prothrombotic coagulopathies. CONCLUSION: Patients with myocardial infarction secondary to non-occlusive thrombus in angiographically normal coronary arteries seem to have a good long-term prognosis after the acute phase when treated with an exclusively medical strategy. However, initial clinical presentation was often severe, leading to early in-hospital death.

Clinical and angiographic analysis with a cobalt alloy coronary stent (driver) in stable and unstable angina pectoris.

The Clinical and Angiographic analysis with a Cobalt Alloy Coronary Stent (Driver) (CLASS) study was a prospective, nonrandomized, multicenter study designed to assess the safety and efficacy of a cobalt-chromium alloy-based stent in patients with stable or unstable angina pectoris. A total of 203 lesions were treated in 202 enrolled patients. The percentage of major adverse cardiac event-free patients was 87.6% (177 of 202) at 6 months (primary safety end point; major adverse cardiac events were defined as death, myocardial infarction, emergency bypass surgery, or target lesion revascularization [percutaneous transluminal coronary angioplasty or coronary artery bypass grafting]). The angiographic success rate (primary efficacy end point) was 100%, and the procedural success rate was 98%. The binary in-stent restenosis rate at 6 months was 12.6%. Our results have demonstrated that the Driver cobalt-chromium alloy stent can be used with a low 6-month incidence of major adverse cardiac events, a low 6-month binary restenosis rate, and high angiographic and procedural success rates.

Back from irreversibility: extracorporeal life support for prolonged cardiac arrest.

BACKGROUND: The survival of patients after prolonged cardiac arrest is still inadequate. Extracorporeal life support (ECLS) represents an alternative therapeutic method for patients who do not respond to conventional cardiopulmonary cerebral resuscitation. This technology is used to support the circulation of a patient with severe cardiac failure. METHODS: Between June 1997 and January 2003, 40 ECLS procedures were performed in patients who presented with refractory cardiac arrest. During external cardiac massage, the patient was connected to an extracorporeal circuit by the insertion of an arterial and venous cannula through the femoral vessels. The extracorporeal circuit included a centrifugal pump and an oxygenator. Mean age was 42 +/- 15 years; the average time of external cardiac massage was 105 +/- 44 minutes. RESULTS: Once the circulation was restored, 22 patients were disconnected from the extracorporeal circulation because of brain death or multiorgan failure; after 24 hours, among the 18 survivors, 6 were weaned off the pump, 9 were bridged to a ventricular assist device, and 2 patients were directly bridged to cardiac transplantation. Eight patients are alive and without any sequelae at 18 month's follow-up. CONCLUSIONS: In prolonged cardiac arrest with failing conventional measures, rescue by extracorporeal support provides an ultimate therapeutic option with a good outcome in survivors. Our results encourage the wider application of ECLS for refractory cardiocirculatory arrest in selected patients. The high rate of neurologic death needs further improvements in the early phase of resuscitation maneuvers.

Initial and follow-up results of the European Seaquence coronary stent registry.

The primary objective of the present study was to assess the feasibility and the safety of the Seaquence stent (CathNet-Science) deployment for the treatment of coronary artery disease and the event-free survival of patients treated with this coronary stent. The study was conducted as a multicenter, prospective, observational registry. Patients with stable or unstable angina pectoris who were candidates for percutaneous coronary intervention with elective stenting of one single de novo lesion in a native coronary artery > or =3 mm in diameter were included in the study. Clinical follow-up was performed at 1 month and 9 months. Major adverse coronary events (MACE), that is, cardiac death, myocardial infarction, and target vessel revascularization (re-PTCA or CABG), were recorded over a period of 9 months. Using this stent, a 99% in-hospital success rate was achieved. A total of 17 patients presented MACE (8.7%) during the whole follow-up period and target lesion revascularization was needed for 14 (7.1%) patients. Using multivariate analysis only some clinical parameters (patients treated for unstable angina, with a history of CABG or of female gender) were found as independent predictors of MACE after coronary stenting. Procedural related factors, angiographic characteristics, or reference diameter were not found to influence clinical outcome. Because the study was performed in patients with a high proportion of complex lesions (relative high-risk nonselected population with nearly one third calcified lesions, many long and type B2 and C lesions) we can conclude that the coronary Seaquence stent can be considered as a stent of reference in routine practice.

Mini-invasive strategy in acute coronary syndromes: direct coronary stenting using 5 Fr guiding catheters and transradial approach.

The purpose of this study was to assess the feasibility and safety of direct coronary stenting in acute coronary syndromes using 5 Fr guiding catheters by transradial approach. A series of 119 patients with an acute coronary syndrome (unstable angina, n = 55; acute myocardial infarction, n = 45; recent acute myocardial infarction, n = 19) explored by transradial approach and eligible for direct stenting were included. A large proportion of patients (52%) was treated during the procedure by platelet IIb/IIIa receptor blockade. Only Medtronic 5 Fr guiding catheters were used in this study. Direct coronary stenting was attempted in all 119 highly selected patients. Failure of direct stenting was observed in only five cases (3.9%) and the stent successfully retrieved in each case in the 5 Fr guiding catheter. In these five cases, balloon predilation was performed and then the stent implanted successfully. Different stents were used: ACS stent (54%), AVE stent (33%), Velocity stent (10%), Nir stent (3%), with diameter ranging from 2.5 to 4 mm. In four cases, the dilation was finally performed using 6 Fr guiding catheters because the backup of the 5 Fr catheter was considered to be too low (3%). No vascular access site complications occurred in this series of patients. We conclude that direct coronary stenting using transradial approach and 5 Fr guiding catheters yields excellent procedural success rate. In the setting of acute coronary syndromes requiring platelet IIb/IIIa receptor blockade or after failure of thrombolysis, this mini-invasive strategy is very attractive because of the low risk of access site complications.