Superiority of 3D planimetry over pressure half-time method for the assessment of mitral valve area after percutaneous edge-to-edge mitral repair.

INTRODUCTION AND OBJECTIVES: There is limited evidence to identify the most accurate method for measuring the mitral valve area (MVA) after percutaneous edge-to-edge mitral repair. Our objective was to evaluate the optimal method in this context and its correlation with the mean transmitral gradient. METHODS: A registry of patients undergoing percutaneous mitral repair was conducted, analyzing different methods of measuring MVA and their correlation with the mean gradient. RESULTS: We analyzed data from 167 patients. The mean age was 76±10.3 years, 54% were men, and 46% were women. Etiology was degenerative in 45%, functional in 39%, and mixed in 16%. Postclip MVA measurements were 1.89±0.60 cm2 using pressure half-time (PHT), 2.87±0.83 cm2 using 3D planimetry, and the mean gradient was 3±1.19mmHg. MVA using 3D planimetry showed a stronger correlation with the mean gradient (r=0.46, P<.001) than MVA obtained by PHT (r=0.19, P=.048). Interobserver agreement was also higher with 3D planimetry than with PHT (intraclass correlation coefficient of 0.90 vs 0.81 and variation coefficient of 9.6 vs 19.7%, respectively). CONCLUSIONS: Our study demonstrates that the PHT method significantly underestimates MVA after clip implantation compared with direct measurement using transesophageal 3D planimetry. The latter method also correlates better with postimplantation gradients and has less interobserver variability. These results suggest that 3D planimetry is a more appropriate method for assessing postclip mitral stenosis.

Interregional variability in the use of cardiovascular technologies (2011-2019). Correlation with economic indicators, admissions, and in-hospital mortality.

INTRODUCTION AND OBJECTIVES: Equal opportunities to access technical advances with recognized clinical value should be a priority of the publicly-funded health system. We analyzed variability among all the Spanish autonomous communities in the use of cardiovascular techniques with an established indication and its relationship with economic indicators, burden of disease, and hospital mortality. METHODS: The activity registries of various Associations of the Spanish Society of Cardiology from 2011 to 2019 were analyzed for coronary angiography, overall percutaneous coronary intervention (PCI), primary PCI, implantable cardioverter-defibrillators (ICD), cardiac resynchronization therapy, and transcatheter aortic valve replacement (TAVR). Economic indices (gross domestic product and per capita health care expenditure) were obtained from public sources and data on attendance rates and mortality from the Resources and Quality in Cardiology (RECALCAR) reports of the Spanish Society of Cardiology. We analyzed the coefficient of variation for activity and the correlation of activity with regional economic indices, attendance rates, and risk-adjusted rates of in-hospital mortality. RESULTS: We identified wide variability in the use of technologies, especially for primary PCI (18%), ICD (22%), cardiac resynchronization therapy (36%), and TAVR (42%). A certain correlation with attendance rates was seen only for overall PCI and ICD. In general, no significant correlation was found between the use of the techniques and the economic indices of wealth and expenditure. The correlation with in-hospital mortality showed no significant results, although this was the analysis with the greatest limitations because the impact of these techniques on survival is exerted more in the mid- and long-term. CONCLUSIONS: The results of this study, despite its inherent limitations, show marked variability between autonomous communities in the use of cardiovascular technologies, which is not explained by economic differences or by hospital attendance rates due to the corresponding diseases.

Sex Differences in Long-Term Outcomes in Patients With Deferred Revascularization Following Fractional Flow Reserve Assessment: International Collaboration Registry of Comprehensive Physiologic Evaluation.

Background Sex-specific differences may influence prognosis after deferred revascularization following fractional flow reserve (FFR) measurement. This study sought to investigate the sex differences in long-term prognosis of patients with deferred revascularization following FFR assessment. Methods and Results A total of 879 patients (879 vessels) with deferred revascularization with FFR >0.75 who underwent FFR and coronary flow reserve measurements were enrolled from 3 countries (Korea, Japan, and Spain). Long-term outcomes were assessed in 649 men and 230 women by the patient-oriented composite outcome (POCO, a composite of any death, any myocardial infarction, and any revascularization). We applied inverse-probability weighting based on propensity scores to account for differences at baseline between women and men (age, hyperlipidemia, diabetes mellitus, diameter stenosis, lesion length, multivessel disease, FFR, coronary flow reserve. The median follow-up duration was 1855 days (745-1855 days). Median FFR values were 0.88 (0.83-0.93) in men and 0.89 (0.85-0.94) in women, respectively. The occurrences of POCO were significantly high in men compared with that in women (10.5% versus 4.2%, P=0.007). Kaplan-Meier analysis revealed that women had a significantly lower risk of POCO (χ2=7.2, P=0.007). Multivariate COX proportional hazards regression analysis revealed that age, male, diabetes mellitus, diameter stenosis, lesion length, and coronary flow reserve were independent predictors of POCO. After applying IPW, the hazard ratio of males for POCO was 2.07 (95% CI, 1.07-4.04, P=0.032). Conclusions This large multinational study reveals that long-term outcome differs between women and men in favor of women after FFR-guided revascularization deferral. Clinical Trial Registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02186093.

Cost-effectiveness of everolimus-eluting versus bare-metal stents in ST-segment elevation myocardial infarction: An analysis from the EXAMINATION randomized controlled trial.

BACKGROUND: Use of everolimus-eluting stents (EES) has proven to be clinically effective and safe in patients with ST-segment elevation myocardial infarction but it remains unclear whether it is cost-effective compared to bare-metal stents (BMS) in the long-term. We sought to assess the cost-effectiveness of EES versus BMS based on the 5-year results of the EXAMINATION trial, from a Spanish health service perspective. METHODS: Decision analysis of the use of EES versus BMS was based on the patient-level clinical outcome data of the EXAMINATION trial. The analysis adopted a lifelong time horizon, assuming that long-term survival was independent of the initial treatment strategy after the end of follow-up. Life-expectancy, health-state utility scores and unit costs were extracted from published literature and publicly available sources. Non-parametric bootstrapping was combined with probabilistic sensitivity analysis to co-assess the impact of patient-level variation and parameter uncertainty. The main outcomes were total costs and quality-adjusted life-years. The incremental cost-effectiveness ratio was expressed as cost per quality-adjusted life-years gained. Costs and effects were discounted at 3%. RESULTS: The model predicted an average survival time in patients receiving EES and BMS of 10.52 and 10.38 undiscounted years, respectively. Over the life-long time horizon, the EES strategy was €430 more costly than BMS (€8,305 vs. €7,874), but went along with incremental gains of 0.10 quality-adjusted life-years. This resulted in an average incremental cost-effectiveness ratio over all simulations of €3,948 per quality-adjusted life-years gained and was below a willingness-to-pay threshold of €25,000 per quality-adjusted life-years gained in 86.9% of simulation runs. CONCLUSIONS: Despite higher total costs relative to BMS, EES appeared to be a cost-effective therapy for ST-segment elevation myocardial infarction patients due to their incremental effectiveness. Predicted incremental cost-effectiveness ratios were below generally acceptable threshold values.

Influence of Microcirculatory Dysfunction on Angiography-Based Functional Assessment of Coronary Stenoses.

OBJECTIVES: The authors sought to evaluate the influence of coronary microcirculatory dysfunction (CMD) on the diagnostic performance of the quantitative flow ratio (QFR). BACKGROUND: Functional angiographic assessment of coronary stenoses based on fluid dynamics, such as QFR, constitutes an attractive alternative to fractional flow reserve (FFR). However, it is unknown whether CMD affects the reliability of angiography-based functional indices. METHODS: FFR and the index of microcirculatory resistance (IMR) were measured in 300 vessels (248 patients) as part of a multicenter international registry. QFR was calculated at a blinded core laboratory. Vessels were classified into 2 groups according to microcirculatory status: low IMR (<23 U), and high IMR (≥23 U, CMD). The impact of CMD on the diagnostic performance of QFR, as well as on incremental value of QFR over quantitative angiography, was assessed using FFR as reference. RESULTS: Percent diameter stenosis (%DS) and FFR were similar in low- and high-IMR groups (%DS 51 ± 12% vs. 53 ± 11%; p = 0.16; FFR 0.80 ± 0.11 vs. 0.81 ± 0.11; p = 0.23, respectively). In the overall cohort, classification agreement (CA) between QFR and FFR and diagnostic efficiency of QFR (area under the receiver-operating characteristics curve [AUC]) were high (CA: 88%; AUC: 0.93 [95% confidence interval (CI): 0.90 to 0.96]). However, when assessed according to microcirculatory status, a significantly lower CA and AUC of QFR were found in the high-IMR group as compared with the low-IMR group (CA: 76% vs. 92%; p < 0.001; AUC: 0.88 [95% CI: 0.79 to 0.94] vs. 0.96 [95% CI: 0.92 to 0.98]; p < 0.05). Compared with angiographic assessment, QFR increased by 0.20 (p < 0.001) and by 0.16 (p < 0.001) the AUC of %DS in low- and high-IMR groups, respectively. Independent predictors of misclassification between QFR and FFR were high IMR and acute coronary syndrome. CONCLUSIONS: CMD decreases the diagnostic performance of QFR. However, even in the presence of CMD, QFR remains superior to angiography alone in ascertaining functional stenosis severity.

Coronary aneurysms in the acute patient: Incidence, characterization and long-term management results.

BACKGROUND: Coronary aneurysms (1.5 times dilation the reference-vessel) are uncommon and have been diagnosed with increasing frequency with coronary angiography. The incidence varies from 1.5% to 5%. Reported complications are multiple: thrombosis, distal embolization, rupture and vasospasm, causing ischemia, heart failure or arrhythmias. However, the natural history and prognosis remains obscure. We aimed to describe the characteristics of acute patients with coronary aneurysms. METHODS: Prospective coronariography registry of patients with the diagnosis of coronary aneurysm between 2002 and 2013. Among 51,555 consecutive coronary angiograms, 414 patients with aneurysms were reported, of which 256 were considered acute (82% NSTE-ACS). RESULTS: Predominantly male (80%, mean age 65.5years), cardiovascular risk factors were common (hypertension 65%, dyslipidemia 65%, obesity 25%, diabetes mellitus 28.5%, and smokers 67%). With frequent coronary stenoses (94%), mostly with one aneurysm (80%), it was observed more frequently in the anterior descending artery. After a median follow-up of 52months, 53 died (14 cardiac causes) and 42% presented a cardiovascular event. Complications from the aneurysm were found in 4. The duration of dual antiplatelet therapy, LVEF, age and peripheral vascular disease highlighted in the multivariate analysis of death. CONCLUSION: The presence of coronary aneurysms in patients undergoing coronary angiography with an acute event is low. Patients who present them also have a large burden of atherosclerotic risk factors. In the long-term, the probability of cardiovascular complications is high, but only a small proportion are due to the aneurysm itself. A more intense and prolonged antithrombotic treatment may result in lower mortality rates.

Influence of the amount of myocardium subtended to a coronary stenosis on the index of microcirculatory resistance. Implications for the invasive assessment of microcirculatory function in ischaemic heart disease.

AIMS: The index of microcirculatory resistance (IMR) is increasingly used to quantify microcirculatory function. However, in normal coronary arteries, resistance increases with the branching structure of the coronary tree, which suggests that IMR could be influenced by the amount of downstream myocardial mass (MM). We aimed to evaluate the influence of the amount of MM subtended to an intermediate stenosis on the IMR. METHODS AND RESULTS: IMR, fractional flow reserve and coronary flow reserve (CFR) were measured in 123 coronary arteries (102 patients) with intermediate stenosis. Jeopardised MM was estimated with the Myocardial Jeopardy Index (MJI). MM was inversely associated with IMR (R.

Low coronary microcirculatory resistance associated with profound hypotension during intravenous adenosine infusion: implications for the functional assessment of coronary stenoses.

BACKGROUND: Intravenous adenosine infusion produces coronary and systemic vasodilatation, generally leading to systemic hypotension. However, adenosine-induced hypotension during stable hyperemia is heterogeneous, and its relevance to coronary stenoses assessment with fractional flow reserve (FFR) remains largely unknown. METHODS AND RESULTS: FFR, coronary flow reserve, and index of microcirculatory resistance were measured in 93 stenosed arteries (79 patients). Clinical and intracoronary measurements were analyzed among tertiles of the percentage degree of adenosine-induced hypotension, defined as follows: %ΔP(a)=-[100-(hyperemic aortic pressure×100/baseline aortic pressure)]. Overall, %ΔP(a) was -13.6±12.0%. Body mass index was associated with %ΔP(a) (r=0.258; P=0.025) and obesity, an independent predictor of profound adenosine-induced hypotension (tertile 3 of %ΔP(a); odds ratio, 3.95 [95% confidence interval, 1.48-10.54]; P=0.006). %ΔP(a) was associated with index of microcirculatory resistance (ρ=0.311; P=0.002), coronary flow reserve (r=-0.246; P=0.017), and marginally with FFR (r=0.203; P=0.051). However, index of microcirculatory resistance (ß=0.003; P<0.001) and not %ΔP(a) (ß=-0.001; P=0.564) was a predictor of FFR. Compared with tertiles 1 and 2 of %ΔP(a) (n=62 [66.6%]), stenoses assessed during profound adenosine-induced hypotension (n=31 [33.3%]) had lower index of microcirculatory resistance (12.4 [8.6-22.7] versus 20 [15.8-35.5]; P=0.001) and FFR values (0.77±0.13 versus 0.83±0.12; P=0.021), as well as a nonsignificant increase in coronary flow reserve (2.5±1.1 versus 2.2±0.87; P=0.170). CONCLUSIONS: The modification of systemic blood pressure during intravenous adenosine infusion is related to hyperemic microcirculatory resistance in the heart. Profound adenosine-induced hypotension is associated with obesity, lower coronary microcirculatory resistance, and lower FFR values.

Morphometric assessment of coronary stenosis relevance with optical coherence tomography: a comparison with fractional flow reserve and intravascular ultrasound.

OBJECTIVES: The study sought to assess the diagnostic efficiency of optical coherence tomography (OCT) in identifying hemodynamically severe coronary stenoses as determined by fractional flow reserve (FFR). Concomitant OCT and intravascular ultrasound (IVUS) area measurements were performed in a subgroup of patients to compare the diagnostic efficiency of both techniques. BACKGROUND: The value of OCT to determine stenosis severity remains unsettled. METHODS: Sixty-one stenoses with intermediate angiographic severity were studied in 56 patients. Stenoses were labeled as severe if FFR ≤0.80. OCT interrogation was performed in all cases, with concomitant IVUS imaging in 47 cases. RESULTS: Angiographic stenosis severity was 50.9 ± 8% diameter stenosis with 1.28 ± 0.3 mm minimal lumen diameter. FFR was ≤0.80 in 28 (45.9%) stenoses. An overall moderate diagnostic efficiency of OCT was found (area under the curve [AUC]: 0.74; 95% confidence interval [CI]: 0.61 to 0.84), with sensitivity/specificity of 82%/63% associated with an optimal cutoff value of 1.95 mm(2). Comparison of the results in patients with simultaneous IVUS and OCT imaging revealed no significant differences in the diagnostic efficiency of OCT (AUC: 0.70; 95% CI: 0.55 to 0.83) and IVUS (AUC. 0.63; 95% CI: 0.47 to 0.77; p = 0.19). Sensitivity/specificity for IVUS was 67%/65% for an optimal cutoff value of 2.36 mm(2). In the subgroup of small vessels (reference diameter <3 mm) OCT showed a significantly better diagnostic efficiency (AUC: 0.77; 95% CI: 0.60 to 0.89) than IVUS (AUC: 0.63; 95% CI: 0.46 to 0.78) to identify functionally significant stenoses (p = 0.04). CONCLUSIONS: OCT has a moderate diagnostic efficiency in identifying hemodynamically severe coronary stenoses. Although OCT seems slightly superior to IVUS for this purpose (particularly in vessels <3 mm), its low specificity precludes its use as a substitute of FFR for functional stenosis assessment.

[Assessment of dynamic coronary plaque changes and the clinical consequences in type-II diabetic patients: a serial intracoronary ultrasound study]. / Evaluación de los cambios dinámicos de las placas coronarias y sus consecuencias clínicas en pacientes con diabetes mellitus tipo 2: un estudio de ecografía intracoronaria seriada.

INTRODUCTION AND OBJECTIVES: One of the aims of secondary prevention is to achieve plaque stabilization. This study sought to investigate the clinical consequences and predictive factors of the change in the type of plaque (CTP) as assessed by serial intracoronary ultrasound in type II diabetic patients with known coronary artery disease. METHODS: 237 segments (45 patients) from the DIABETES I, II, and III trials were included. Intracoronary ultrasound from motorized pullbacks (0.5mm/s) after index procedure and at 9-month angiographic follow-up was performed in the same coronary segment. Nontreated mild lesions (angiographic stenosis <25%) with ≥0.5mm plaque thickening and ≥5mm of length assessed by intracoronary ultrasound were included. As different types of plaques may be encountered throughout a given coronary lesion, each study lesion was divided into 3 segments for serial quantitative and qualitative analyses. Statistical adjustment by multiple lesion segments per patient (generalized estimating equations method) was performed. A CTP was defined as any qualitative change in plaque type at follow-up. At 1-year follow-up, major adverse cardiac events - death, myocardial infarction and target vessel revascularization) - were recorded. RESULTS: A CTP was observed in 48 lesions (20.2%) and occurred more frequently (52.1%) in mixed plaques. Independent predictors of CTP were glycated hemoglobin levels (odds ratio [OR] 1.2; 95% confidence interval [CI] 1.01-1.5; P=.04); glycoprotein IIb-IIIa inhibitors (OR 0.3; 95% CI 0.1-0.7; P=.004) and statin administration (OR 0.3; 95% CI 0.1-0.8; P=.02). At 1-year follow-up CTP was associated with an increase in major adverse cardiac events rate (CTP 20.8% vs non-CTP 13.8%, P=.008; hazard ratio=1.9, 95% CI 1.3-1.9, P=.01). CONCLUSIONS: Qualitative changes in mild stenosis documented by intracoronary ultrasound in type II diabetics are associated with suboptimal secondary prevention and may have clinical consequences. Full English text available from: www.revespcardiol.org.

Assessment of microcirculatory remodeling with intracoronary flow velocity and pressure measurements: validation with endomyocardial sampling in cardiac allografts.

BACKGROUND: Intracoronary physiology techniques have been validated extensively for the assessment of epicardial stenoses but not for the lone study of coronary microcirculation. We performed a comparison between 4 intracoronary physiological indices with the actual structural microcirculatory changes documented in transplanted hearts. METHODS AND RESULTS: In 17 cardiac allograft patients without coronary stenoses, ECG, intracoronary Doppler flow velocity, and aortic pressure were digitally recorded before and during maximal hyperemia with a dedicated system. Postprocessing of data yielded 4 indices of microcirculatory status: coronary flow velocity reserve (2.13+/-0.59), instantaneous hyperemic diastolic velocity pressure slope (2.33+/-1.25 cm x s x (-1)mm Hg(-1)), coronary resistance index (1.65+/-0.88 mm Hg x cm(-1) x s(-1)), and coronary resistance reserve (2.36+/-0.65). Quantitative morphometry was performed in endomyocardial biopsies during the same hospital intake; arteriolar obliteration (76.57+/-6.95%) and density (2.00+/-1.22 arterioles per 1 mm(2)) and capillary density (645+/-179 capillaries per 1 mm(2)) were measured. Univariate regression analysis between intracoronary measurements and histological findings revealed that instantaneous hyperemic diastolic velocity-pressure slope correlated with arteriolar obliteration (r=0.58, P=0.014) and capillary density (r=0.60, P=0.012). Statistical adjustment revealed an independent contribution of arteriolar obliteration (beta=0.61, P=0.0009) and capillary density (beta=-0.60, P=0.0008) to instantaneous hyperemic diastolic velocity-pressure slope values, resulting in an excellent predictive model (r=0.84, P=0.0002). Coronary resistance index correlated only with capillary density (r=0.70, P=0.019). Relative indices (coronary flow velocity reserve and coronary resistance reserve) did not correlate significantly with arteriolar obliteration, capillary density, or arteriolar density. CONCLUSIONS: Intracoronary indices derived from pressure and flow, particularly instantaneous hyperemic diastolic velocity-pressure slope, appear to be superior to coronary flow velocity reserve in detecting structural microcirculatory changes. Both arteriolar obliteration and capillary rarefaction seem to influence microcirculatory hemodynamics independently.

Assessment of potential relationship between wall shear stress and arterial wall response after bare metal stent and sirolimus-eluting stent implantation in patients with diabetes mellitus.

BACKGROUND: Wall shear stress (WSS) has been associated with neointimal hyperplasia (NIH) following bare metal stent (BMS) implantation. Drug-eluting stents (DES) almost abolish NIH. Conversely, diabetes mellitus amplifies NIH response. The association between WSS and arterial wall response following DES and BMS implantation in diabetic patients remains to be evaluated. METHODS: The study involved 20 diabetic patients randomized to BMS (n = 9) or sirolimus-eluting stent (SES; n = 11) implantation in native coronary arteries. A computational fluid dynamic model applied 3D intravascular ultrasound (IVUS) and two-plane angiographic to measure WSS (Pa). IVUS assessments were performed post-procedure and at 9-months follow-up. The target segment encompassed the stent plus 5 mm distal and proximal edges. A total of 93 subsegments were evaluated: in-stent segments divided in three subsegments (proximal, mid and distal; n = 60) and proximal and distal edges (n = 33). RESULTS: Stent length was similar between BMS (17.4 +/- 7.3 mm) and SES (19.8 +/- 6.8 mm) groups. NIH was observed in all BMS subsegments (n = 27) versus one subsegment in the SES group (n = 33). WSS ranged from 0.52 to 4.20 Pa in the BMS and from 0.42 to 3.06 Pa in the SES group. There was no correlation between WSS and NIH in either stent group. In addition, there were no correlation between the change of external elastic membrane (EEM) or plaque growth at the edges and WSS. CONCLUSION: WSS was not associated with NIH after implantation of SES or BMS in diabetic patients. Plaque growth or the change of EEM at the edges were not associated with WSS either.

Angiographic and 3D intravascular ultrasound assessment of overlapping bare metal stent and three different formulations of drug-eluting stents in patients with diabetes mellitus.

OBJECTIVES: The aim of this study was to examine the impact of overlapping bare-metal stent (BMS) and three different formulations of drug-eluting stent (DES) on intimal hyperplasia (IH) response of patients with diabetes mellitus (DM). METHODS: Forty-nine DM patients treated with overlapping BMS (19 lesions), sirolimus-eluting stent (SES 12 lesions), paclitaxel-eluting stent (PES 8 lesions) or tacrolimus-eluting stent (TES 10 lesions) were studied. Baseline and 9-month follow-up volumetric intravascular vascular ultrasound (IVUS) and quantitative coronary angiography (QCA) analysis were performed in the entire stented segment and in the overlapped (OL) and non-overlapped (non-OL) subsegments. Clinical outcomes were evaluated at 1-year follow-up. RESULTS: Post-procedure (PO-) QCA measurements were similar in all stent groups, and between OL and non-OL subsegments in each individual type of stents. Percent IH was lower in SES and PES vs. BMS (p < 0.05). Percent IH was significantly greater in OL subsegment compared with non-OL subsegment in BMS (p < 0.05), but not in all type of DES groups. SES showed significantly less %IH compared with PES and TES in OL and non-OL subsegments. Vessel area at the OL remained unchanged from PO to FU in all type of DES and BMS groups. There were no aneurysm formation and no stent thrombosis up to 1-year follow-up. CONCLUSIONS: Overlapping BMS is associated with enhanced IH response in diabetic patients, whereas overlapping DES, particularly SES and PES, appear effective to inhibit IH without detectable late vascular adverse effects.

Iatrogenic dissection of the ascending aorta following heart catheterisation: incidence, management and outcome.

AIMS: Iatrogenic ascending aorta dissection (AAD) is an uncommon complication following heart catheterisation. AIMS of this study were to determine the incidence, to identify the predisposing procedural factors and to define the management and the outcomes of patients suffering from iatrogenic AD. METHODS AND RESULTS: Between January 1996 and May 2005, iatrogenic AAD that occurred during cardiac catheterisations, were retrospectively identified from clinical and peri-procedural data prospectively collected in a dedicated database. At least 1-month clinical follow-up (median 25 months; range 5-77) was obtained in all patients complicated with iatrogenic AD. The overall incidence of iatrogenic AAD was 0.04%; this incidence was significantly higher after interventional procedures (0.12%) than after diagnostic procedures (0.01%; p=0.0001). Most of dissections were located in the right coronary sinus (12 patients; 67%) and limited to the corresponding coronary sinus (Dunning class I: 11 patients; 61%). Manoeuvres most often involved were coronary engagement with the use of non-conventional catheters. Conservative treatment with sealing the entry door by a stent 10 patients (56%) or expectant management 7 patients (39%) resulted in favourable outcomes as none of patients died during hospitalisation and follow-up. CONCLUSIONS: Iatrogenic AAD is a rare complication following cardiac catheterisation that in the vast majority of patients may benefit from conservative treatment with good long-term outcomes.