APpropriAteness of percutaneous Coronary interventions in patients with ischaemic HEart disease in Italy: the APACHE pilot study.

OBJECTIVES: To first explore in Italy appropriateness of indication, adherence to guideline recommendations and mode of selection for coronary revascularisation. DESIGN: Retrospective, pilot study. SETTING: 22 percutaneous coronary intervention (PCI)-performing hospitals (20 patients per site), 13 (59%) with on-site cardiac surgery. PARTICIPANTS: 440 patients who received PCI for stable coronary artery disease (CAD) or non-ST elevation acute coronary syndrome were independently selected in a 4:1 ratio with half diabetics. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of patients who received appropriate PCI using validated appropriate use scores (ie, AUS≥7). Also, in patients with stable CAD, we examined adherence to the following European Society of Cardiology recommendations: (A) per cent of patients with complex coronary anatomy treated after heart team discussion; (B) per cent of fractional flow reserve-guided PCI for borderline stenoses in patients without documented ischaemia; (C) per cent of patients receiving guideline-directed medical therapy at the time of PCI as well as use of provocative test of ischaemia according to pretest probability (PTP) of CAD. RESULTS: Of the 401 mappable PCIs (91%), 38.7% (95% CI 33.9 to 43.6) were classified as appropriate, 47.6% (95% CI 42.7 to 52.6) as uncertain and 13.7% (95% CI 10.5% to 17.5%) as inappropriate. Median PTP in patients with stable CAD without known coronary anatomy was 69% (78% intermediate PTP, 22% high PTP). Ischaemia testing use was similar (p=0.71) in patients with intermediate (n=140, 63%) and with high PTP (n=40, 66%). In patients with stable CAD (n=352) guideline adherence to the three recommendations explored was: (A) 11%; (B) 25%; (C) 23%. AUS was higher in patients evaluated by the heart team as compared with patients who were not (7 (6.8) vs 5 (4.7); p=0.001). CONCLUSIONS: Use of heart team approaches and adherence to guideline recommendations on coronary revascularisation in a real-world setting is limited. This pilot study documents the feasibility of measuring appropriateness and guideline adherence in clinical practice and identifies substantial opportunities for quality improvement. TRIAL REGISTRATION NUMBER: NCT02748603.

Long-Term Outcomes and Complications of Intracardiac Echocardiography-Assisted Patent Foramen Ovale Closure in 1,000 Consecutive Patients.

BACKGROUNDS: Long-term fate of patients submitted to patent foramen ovale (PFO) closure is still unclear. The aim of the study was to evaluate the incidence of atrial fibrillation (AF), aortic or atrial free wall erosion, device thrombosis (DT), new onset or worsening of mitral valve regurgitation (MVR), and recurrent cerebral ischemic events in the long-term follow up after intracardiac echocardiography (ICE)-aided PFO closure in a large population. METHODS: We reviewed the medical and instrumental data of 1,000 consecutive patients (mean age 47.3 ± 17.1 years, females) prospectively enrolled in 2 centres over a 13 years period (February 1999-February 2012) for R-to-L shunt ICE-aided catheter-based closure using different devices. RESULTS: Immediate success was 99.8%. Implanted devices were Amplatzer PFO Occluder in 463 patients (46.3%), Amplatzer ASD Cribriform Occluder in 420 patients (42.0%), Premere Occlusion System in 95 patients (9.5%), and Biostar Occluder in 22 patients (2.2%). On a mean follow-up of 12.3 ± 0.6 years (minimum 4- maximum 17 years), permanent AF occurred in 0.5%, DT was apparent in 0.5%, new onset or worsening of MVR was observed in 0.2%, whereas recurrent cerebral ischemic events were 0.8%. Occlusion rate was 93.8%. No aortic or atrial free wall erosion has been observed. CONCLUSION: ICE-aided closure of PFO using different devices, appeared very safe and effective on very long-term follow up with low incidence of erosion, DT, recurrent ischemic events, MVR new onset or worsening, and permanent AF.

A new management for limb graft occlusion after endovascular aneurysm repair adding a vollmar ring stripper: the unclogging technique.

BACKGROUND: Lower extremity ischemia for limb thrombosis is a well-known adverse event after endovascular abdominal aortic aneurysm repair (EVAR), ranging from 2.6-7.4%. We report our experience in the management of graft limb occlusion that occurred in patients who underwent EVAR in our institution. In cases in which balloon catheter thrombectomy is not useful or is risky, it is important to take into consideration the use of a Vollmar ring stripper (Aesculap, San Jose, CA) to avoid dislodging or disrupting the sealing zones. This technique has taken from thromboendarterectomy the principle of detaching plaque from adventitia and transformed it in a less traumatic way for dissecting thromboses from endografts. METHODS: Between September 1999 and December 2011, 608 patients underwent EVAR in our institution. In cases of severe claudication or critical ischemia, we tried to remove the thrombus using mild Fogarty balloon traction; in cases of progressive and old stratification, we added the Vollmar ring stripper. After recanalization, if there was a stenosis, an angioplasty was performed and in most patients an adequately size Cheatham platinum stent was positioned. If the endovascular approach failed, bypass procedures were considered. RESULTS: In 608 patients over a mean follow-up time of 72 months, there were 23 cases of limb thrombosis. Fifteen of the 23 limb occlusions were identified within 6 months after aneurysm repair. The mean time to occlusion was 8.2 ± 4.3 months (range: 20 days-25 months). Presenting symptoms were mild to moderate claudication (Rutherford classification I) in 3 patients (13%), medium severe claudication (Rutherford classification IIA) in 18 patients (78.3%), and paresthesia and rest pain (Rutherford classification IIB) in 2 patients (8.7%; 1 of those patients had a loss of motor function). Four (17.4%) were stable during follow-up, and in 1 of these cases we tried thrombolysis without thrombosis resolution. In 13 (56.5%) cases, we performed balloon catheter thrombectomy with a LeMaitre over the wire embolectomy catheter (LeMaitre Vascular, Burlington, MA). In 8 of 13 (61.5%) patients with certain thrombosis characteristics, we decided to add to the balloon catheter a Vollmar ring stripper for mechanical catheter thrombectomy. In all 13 thrombectomy cases, blood flow was restored through the limb with the endograft itself. There were no episodes of graft dislocation, disruption of the sealing zones, or recurrences. In 5 (21.7%) cases, a femorofemoral crossover was performed, and in 1 (4.3%) case, an axillofemoral bypass was performed. During the follow-up period, 2 of the 5 femorofemoral crossovers closed after 6 and 8 months, respectively. CONCLUSIONS: This unclogging technique, alone or associated with Vollmar ring stripper, proves to be simple, safe, and effective in the treatment of graft limb occlusion. Additional research will help confirm the role of Vollmar ring stripper.

Hyperhomocysteinemia is inversely related with left ventricular ejection fraction and predicts cardiovascular mortality in high-risk coronary artery disease hypertensives.

OBJECTIVE: The purpose of this study was to investigate the relationship of plasma homocysteine (tHcy) levels with coronary artery disease (CAD) and left ventricular ejection fraction (LVEF) in high-risk patients undergoing coronary angiography for suspected CAD. METHODS AND RESULTS: In 936 consecutive patients, we measured LVEF, tHcy, folate levels, and quantified CAD with a modified Duke Index score. We also genotyped patients at the methylen-tetrahydrofolate-reductase 677C-->T polymorphism. Hyperhomocysteinemia (HHcy) was defined as tHcy levels > or =15.46 micromol/L; total and cardiovascular mortality was assessed at follow-up that lasted 43 months (median). CAD was confirmed in 75% of patients and ruled out in the rest (non-CAD group). No relationship of HHcy with either arterial hypertension or the CAD score was found. In contrast, there was a significant inverse relationship of tHcy with LVEF in arterial hypertensive but not in normotensive patients, regardless of previous myocardial infarction. At logistic regression, HHcy was the strongest predictor (P=0.001) of a low (<40%) LVEF, followed by type 2 diabetes mellitus and cigarette smoking. At follow-up, HHcy significantly predicted cardiovascular mortality but only in the arterial hypertension subgroup. CONCLUSIONS: In arterial hypertensive but not in normotensive patients, HHcy predicts cardiovascular mortality and a low LVEF, independent of CAD and history of myocardial infarction.

Pseudo-lesion of internal mammary artery graft and left anterior descending artery during percutaneous transluminal angioplasty--a case report.

New lesions appearing during coronary angioplasty may be due to spasms, dissection, and thrombosis. Straightening of the tortuous vessels by guidewire may produce transient angiographic pseudo-lesions, which mimic severe artery damage. An additional case is reported, in which simultaneous artifactual lesions involved the internal mammary artery and the left anterior descending coronary artery, mimicking thrombosis and dissection. Recognition of this entity is essential to avoid unnecessary interventions and potentially harmful complications.

Role of intracardiac echocardiography in atrial septal abnormalities.

The purpose of this review is to outline the feasibility of performing a comprehensive atrial septal examination from the internal confine of the right atrium and to evaluate the advantages resulting by intracardiac echocardiography (ICE) evaluation of atrial septal morphology as well as pathophysiology. In this setting, ICE indications have not yet been established because ICE is a relatively new technique that is still evolving. Notwithstanding, during catheter-based secundum atrial septal defect and patent foramen ovale closure, ICE seems useful for diagnosing cardiac abnormalities instantly, guiding and monitoring all stages of the procedures, and assessing proper selection and optimal device placement. Moreover, ICE provides solid anatomical criteria to diagnose fenestrated atrial septal aneurysm, interatrial communications such as ostium primum and sinus venosus defects, partial anomalous pulmonary venous connection, and lipomatous hypertrophy of atrial septum.

The T-786C endothelial nitric oxide synthase genotype is a novel risk factor for coronary artery disease in Caucasian patients of the GENICA study.

OBJECTIVES: We investigated the association of polymorphisms in the promoter region and exon 7 endothelial nitric oxide synthase (eNOS) gene with coronary artery disease (CAD). BACKGROUND: Endothelial dysfunction foretells cardiovascular events and can be genetically determined. METHODS: We genotyped for the promoter (T(-786)C) and exon 7 (Glu298Asp, G(894)T) polymorphisms in 1,225 subjects; 1,106 were consecutive patients undergoing coronary angiography and 119 control subjects without any cardiovascular risk factors. Genotyping was performed with melting curve analysis of polymerase chain reaction products from allele-specific acceptor and donor probes that were 5'- and 3'-end labeled with LCRed640 and fluorescein, respectively; CAD was assessed by quantitative coronary angiography. We performed multiple logistic regression analysis for the effect of the T(-786)C, the missense Glu298Asp variant, and other coronary risk factors on two- and three-vessel CAD. RESULTS: The overall genotype distribution of T(-786)C (CC = 17.7%, CT = 40.4%, and TT = 41.9%) and Glu298Asp (GG = 43.3%, GT = 37.0%, and TT = 19.7%) was consistent with the Hardy-Weinberg equilibrium. The regression analysis showed that the T(-786)C, but not the missense Glu298Asp variant, significantly predicted CAD, independent of other risk factors. Compared with TT homozygous, subjects carrying the C allele had a significant (p = 0.002) increase in the odds ratio of harboring two- or three-vessel CAD of 1.672 (95% confidence interval, 1.062 to 2.527). A subgroup analysis confirmed this effect of the T(-786)C polymorphism in men (p = 0.007), cigarette smokers (p = 0.001), subjects older than 60 years of age (p = 0.007), with hypercholesterolemia (p = 0.011), low high-density lipoprotein cholesterol (p = 0.006), and overweight or with obesity (p = 0.041). CONCLUSIONS: The C allele at the T(-786)C endothelial nitric oxide synthase polymorphism is associated with a higher risk of multivessel CAD in Caucasians.