Long-term follow-up of medically treated patients with spontaneous coronary artery dissection: a prospective, Swiss single-centre cohort study.

AIMS OF THE STUDY: Spontaneous coronary artery dissection (SCAD) is an increasingly diagnosed cause of acute myocardial infarction. However, there is still a limited number of larger cohorts with long-term follow-up. We report on the largest Swiss single-centre cohort to date, with follow-up of up to 22 years. METHODS: We prospectively collected SCAD cases from June 1998 until December 2020. A strategy of systematic follow-up angiography was applied. Information on long-term follow-up was collected up to the end of 2020. Major cardiovascular events (MACE) were defined as all-cause death, non-fatal MI, and non-fatal cardiac arrest. RESULTS: We identified 105 SCAD patients (mean age 53 ± 11 years, 98 female, 5 peripartum). Presentation was myocardial infarction in all patients. In 102 patients, there was one contiguous dissection. Three patients had two (n = 2) or three (n = 1) non-contiguous dissections. In the majority of patients (n = 97), the primary treatment approach was conservative (dual antiplatelet therapy for 12 months in 90% of patients, statins in 91%). Seven patients were treated with percutaneous coronary intervention (PCI) and one patient underwent bypass surgery. Elective follow-up angiograms were performed in 73 asymptomatic patients after a median follow-up of 6.0 months (interquartile range [IQR] 5.5-6.5). These showed healing of the dissection (n = 65) or a good result after PCI (n = 5) in 70 patients. Three patients had a persistent dissection but conservative treatment was continued. After a median follow-up of 7.5 years (IQR 3.6-12.5) (longest follow-up: 22.5 years) there were 15 MACE. Five MACE occurred within 30 days of the index event: death following catastrophic peripartum left main SCAD (n = 1), out-of-hospital cardiac arrest with successful resuscitation 16 days after SCAD (n = 1), ST-segment elevation myocardial infarction due to occlusion of the dissected artery 10 hours after the index angiogram with subsequent PCI (n = 1), SCAD of a second vessel 8 days after the index SCAD (n = 1), and non-ST-segment elevation myocardial infarction with persistent, multisite SCAD 10 days after the index event (n = 1). There were 10 late MACE, including myocardial infarction and recurrent SCAD (different vessel/lesion) a median of 7.6 years (IQR 3.9-9.6) after the index event in eight patients and death with unclear cause in two patients. CONCLUSION: This SCAD series highlights its highly variable clinical course during the acute phase and in the long term. Although most SCAD patients can be treated conservatively with subsequent healing of the dissection and good clinical outcome, there are also patients with dramatic acute presentation or MACE several years after the initial presentation.

Impact of a volume challenge on haemodynamics and prognosis in patients with severe aortic stenosis.

AIMS: A volume challenge can unmask pulmonary hypertension (PH) and its mechanism. We evaluated the impact of a volume challenge on mean pulmonary artery pressure (mPAP) and mean pulmonary artery wedge pressure (mPAWP) and its prognostic implications in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). METHODS AND RESULTS: In 285 patients with severe AS (indexed aortic valve area 0.41 ± 0.13 cm2 /m2 ), mPAP and mPAWP were measured before and after administration of 150 ± 58 mL of low-osmolal or iso-osmolal contrast. Following contrast, mPAP and mPAWP rose from 25 ± 10 and 16 ± 8 mmHg by 5 ± 4 and 4 ± 4 mmHg to 30 ± 11 and 20 ± 8 mmHg. There were 112 (39%) patients with pre-contrast PH and 70 (40% of those without pre-contrast PH) patients with post-contrast PH only. Post-contrast PH patients were intermediate between pre-contrast PH and no PH in terms of AS severity, cardiac dysfunction, and haemodynamics. After a median follow-up of 43 months post-AVR, pre-contrast PH patients had numerically the highest mortality driven by those with pre-contrast combined pre-capillary and post-capillary PH (n = 35), while post-contrast changes in mPAP and mPAWP were not related to mortality. Patients with any post-contrast mPAWP > 18 mmHg had significantly higher mortality than those with post-contrast mPAWP ≤ 18 mmHg, CONCLUSIONS: In severe AS, a contrast challenge leads to post-contrast PH in ~40% of patients without pre-contrast PH. However, post-contrast haemodynamic changes do not adversely affect outcomes in patients undergoing AVR. Post-contrast PH represents an intermediate stage of 'cardiac damage', which may be attenuated or reversible after AVR.

Saphenous Vein Graft Sacrifice Following Native Vessel PCI is Safe and Associated with Favourable Longer-Term Outcomes.

BACKGROUND: Competitive flow from saphenous vein grafts (SVG) that remain patent following percutaneous coronary intervention (PCI) of the native vessel may compromise durability of the reconstructed vessel. SVG sacrifice has been advocated, but the safety and longer-term outcomes of this are unknown. METHODS: We retrospectively reviewed all post-bypass patients who following successful PCI of the native vessel underwent attempted saphenous vein graft (SVG) closure between January 2014 and July 2018 in two institutions. The co-primary end-points of interest were safety and target lesion failure (TLF), defined as a composite of cardiac death, target vessel recurrent myocardial infarction or clinically driven target lesion revascularisation (TLR). RESULTS: Of the 33 consecutive patients included, the reconstructed native vessel was a chronic total occlusion (CTO) in 93.9% of patients (n = 31) with a mean J-CTO score of 3.2 (±1.1) SVG closure was successful in 97.0% of patients (n = 32). Amplatzer Vascular Plugs (AVP; Abbott Vascular) were used in all patients with most grafts closed by a single plug (72.7%). The average procedure time was 20.1 min with evidence of a short learning curve. Over a mean follow up of 602 (±393) days from the date of SVG closure, the incidence of TLF was 9.1% (n = 3). There was an additional case of targe vessel failure (TVF) due to progression of native vessel disease not treated at the index procedure. SVG closure resulted in only 1 episode of "slow flow" that was transient and self-resolving. There were no other associated peri-procedural or in-hospital complications. CONCLUSION: Following native vessel PCI, SVG sacrifice may be considered to terminate the potentially deleterious effects of residual competitive flow. In selected cases, this approach achieves high success rate and favourable longer-term outcomes.

[Malignant hypoglycaemia]. / Maligne Hypoglykämie.

We describe the case of a 19-years old patient with seizure due to severe hypoglycaemia during general practitioner consultation. Because of hyperinsulinaemic hypoglycaemia and suspected liver metastasis a neuroendocrine hormone active tumor was suspected. After liver biopsy and CT scan a neuroendocrine pancreatic tumor could be diagnosed. Afterwards oncological therapy was induced.