Safety and feasibility of transradial access for percutaneous coronary intervention in chronic total occlusions.

INTRODUCTION AND OBJECTIVES: Transfemoral access is the most frequently used vascular approach in chronic total occlusion percutaneous coronary interventions (CTO-PCI). The aim of this study was to evaluate the safety and feasibility of a transradial access CTO-PCI program and its impact on angiographic and clinical results and length of hospital stay. METHODS: Retrospective multicenter cohort study including 2550 consecutive CTO-PCI procedures included in a multicenter registry with accurate information on vascular access. A total of 896 procedures were performed as radial-only access while 1654 were performed through at least 1 femoral puncture. Clinical and angiographic data were collected. RESULTS: The mean age was 66.3± 11.4 years. The mean Japan-chronic total occlusion score (2.7±0.3) was similar in the 2 groups. Successful revascularization was achieved in 2009 (79.6%) cases, 78.2% and 82.1% in the femoral and radial access cohorts, respectively (P=.002). Periprocedural in-hospital complications were observed in 5.1% and 2.3% (P=.02), with fewer access site-dependant vascular complications in the transradial cohort (2.3% vs 0.2%; P=.009). The mean length of hospital stay was significantly shorter in the transradial access group (0.89±1.4 vs 2.2±3.2 days, P<.001). CONCLUSIONS: A transradial program for CTO-PCI is safe and effective in most CTO lesions. The transradial strategy has fewer vascular complications and shorter length of hospital stay without compromising the success rate.

[Acute reperfusion therapy in elderly women with acute myocardial infarction with ST-segment elevation: efficacy in the reduction of their mortality]. / Tratamiento de revascularización en fase aguda del infarto de miocardio con elevación del segmento ST en mujeres ancianas: eficacia en la reducción de su mortalidad.

BACKGROUND AND OBJECTIVE: Elderly patients with acute coronary syndromes, particularly elderly women, suffer higher mortality and more morbidity than their younger counterparts. We try to document the outcome, treatment received and prognostic factors in this group. PATIENTS AND METHOD: All data for ST-segment elevation myocardial infarction in women aged >/= 75 admitted to our hospital from 2002 to 2007 were retrospectively collected, including epidemiological and clinical variables, vascular complications, in-hospital outcome and middle-term follow-up. These data were analysed and compared depending on reperfusion therapy or not on admission. We determined the causes of not receiving this therapy and the causes of mortality. RESULTS: A total of 195 females were identified. Mean age was 82.7, diabetics 33% and 41% had anterior wall myocardial infarction. Killip III-IV was found in 26.2%. 25.6% of patients underwent reperfusion therapy. In-hospital mortality was 28.7% and 6-months mortality was 39.8%. During one-year follow-up, the major cardiac events rate in these patients was 45.7%. Age, left bundle-branch block o pacemaker rhythm in the electrocardiogram, delayed admission and medical decision were associated with lower reperfusion therapy rates. Death rate was clearly lower (2.7 times) in treated patients although relative risk of bleeding complications was higher. The absence of reperfusion therapy, high Killip on admission and low left ventricular ejection fraction were independently associated with higher mortality. CONCLUSIONS: Acute myocardial infarction in elderly women remains a high morbidity and mortality pathology. This group is less likely to receive acute reperfusion therapies, which have apparently been proven to improve outcome and decrease the mortality rate.

Simple versus complex approaches to treating coronary bifurcation lesions: direct assessment of stent strut apposition by optical coherence tomography.

INTRODUCTION AND OBJECTIVES: Stenting of coronary bifurcation lesions carries an increased risk of stent deformation and malapposition. Anatomical and pathological observations indicate that the high stent thrombosis rate in bifurcations is due to malapposition of stent struts. METHODS: Strut apposition was assessed with optical coherence tomography (OCT) in bifurcation lesions treated either using the simple technique of stent implantation in the main vessel only or a complex technique (i.e. Culotte's). A strut was regarded as malapposed if the gap between its endoluminal surface and the vessel wall was greater than its thickness plus an OCT resolution error margin of 15 microm. RESULTS: Simple and complex (i.e. Culotte's) approaches were used in 17 and 14 patients, respectively. Strut malapposition was significantly more frequent for the half of the bifurcation on same side as the vessel side branch (median, 46.1%; interquartile range [IQR], 35.3-62.5%) than for the half opposite the side branch (9.1%; IQR, 2.2-21.6%), the distal segment (7.5%; IQR, 2.3-20.2%) or the proximal segment (12.6%; IQR, 7.8-23.1%; P< .0001); the gap between strut and vessel wall in malapposed struts was significantly greater in the first segment than the others: 98 microm (IQR, 37-297 microm) vs. 31 microm (IQR, 13-74 microm), 49 microm (IQR, 20-100 microm) and 38 microm (IQR, 17-90 microm), respectively (P< .0001). Using the complex technique had no effect on the prevalence of strut malapposition in the four segments relative to the simple technique (P=.31) but was associated with a smaller gap in the proximal segment (47 microm vs. 60 microm; P=.0008). CONCLUSIONS: In coronary bifurcation lesions, strut malapposition occurred most frequently and was most significant close to the side branch ostium. The use of Culotte's technique did not significantly increase the prevalence of strut malapposition compared with a simple technique.

Optical coherence tomography assessment of a new dedicated bifurcation stent.

AIMS: Dedicated bifurcation stents should facilitate deployment and improve coverage of bifurcational lesions. We used optical coherence tomography (OCT) to assess bifurcation lesions treated with a dedicated stent implanted in the side branch (SB) in conjunction with drug eluting stents in the main vessel (MV) in a culotte-like fashion. METHODS AND RESULTS: Nine patients treated with the Tryton stent underwent postprocedural OCT examination. Total percent of malapposed struts per patient was 18.1+/-8.7%. The longitudinal distribution of the percent of malapposed struts per patient showed that the prevalence of malapposed struts was significantly higher at the level of the bifurcation (33.3%), than in both the proximal segment and the distal segment (18.5% and 9.8%, respectively, p=0.011). When the bifurcation was divided into two halves (opposite SB and toward SB), the highest percent of malapposed struts was toward the SB (47.6%). Also the wall-strut distance for malapposed struts was significantly higher in the bifurcation half toward the SB than in the proximal and the distal segment. CONCLUSIONS: Malapposed struts are frequent in bifurcations despite the use of a dedicated stent. The highest frequency and largest vessel wall-stent strut distance are observed in the bifurcation half toward the SB.

Hidroneumopericardio iatrogénico tras pericardiocentesis / Iatrogenic Hidropneumopericardium after Pericardiocentesis

El hidroneumopericardio se define por la presencia de líquido y aire en la cavidad pericárdica. Se trata de una afección infrecuente en los adultos, habitualmente asociada a buen pronóstico, pero que puede resultar potencialmente grave. Presentamos el caso de un paciente trasplantado renal que debutó con taponamiento cardíaco y que precisó pericardiocentesis; varios días después, presentó un cuadro de dolor torácico debido a un hidroneumopericardio iatrogénico. Las pruebas de imagen son claves en la obtención de este diagnóstico.

Hydropneumopericardium is defined by the accumulation of serous fluid and gas in the pericardial sac. It is uncommon in adults, usually associated with favorable outcomes; yet, it may be severe occasionally. We present the case of a kidney transplant patient who developed cardiac tamponade requiring pericardiocentesis. Several days after the procedure, the patient presented chest pain due to iatrogenic hydropneumopericardium. Image tests are essential to make this diagnosis.

Vasoespasmo coronario asintomático y arritmias ventriculares graves / Asymptomatic Coronary Artery Spasm and Severe Ventricular Arrhythmias

El vasoespasmo coronario generalmente evoluciona con episodios de dolor torácico y elevación del ST. No obstante, existen casos de vasoespasmo sin dolor torácico con taquiarritmias ventriculares documentadas. Su incidencia se desconoce y debe incluirse en el diagnóstico diferencial de taquicardia o fibrilación ventricular idiopática. En esta presentación se describe el caso de un paciente con historia de dos cuadros sincopales sin cardiopatía estructural aparente. La monitorización electrocardiográfica continua objetivó episodios de elevación del ST que conducían a taquicardia ventricular polimorfa. Con el diagnóstico de vasoespasmo coronario asintomático se inició tratamiento con calcioantagonistas y se implantó un cardiodesfibrilador automático.

Coronary artery spasm usually results in episodes of chest pain and ST-segment elevation. However, it may occasionally occur in the absence of angina with documented severe ventricular arrhythmias. The incidence of this condition is unknown and should be included in the differential diagnosis of idiopathic ventricular tachycardia or fibrillation. We describe the case of a patient with a history of two episodes of syncope without apparent structural heart disease. Continuous ECG monitoring revealed the presence of episodes of ST-segment elevation leading to polymorphic ventricular tachycardia. Asymptomatic coronary artery spasm was diagnosed and treatment with calcium channel blockers was initiated; an implantable cardioverter defibrillator device was implanted.

El tratamiento conservador parece la mejor opción para los aneurismas coronarios sin estenosis / Conservative treatment is apparently the best option in coronary aneurysms without associated stenosis

Los aneurismas coronarios son una patología infrecuente, con una incidencia variable según la población estudiada. La causa más frecuente es la aterosclerosis coronaria, por lo que suele asociarse a estenosis en las coronarias. Realizamos una revisión de todos los estudios angiográficos efectuados en los últimos 10 años en nuestro laboratorio, más de 12 000 pacientes. Trece pacientes mostraron dilataciones aneurismáticas en las coronarias sin relación con estenosis adyacentes. El motivo de ingreso fue un síndrome coronario agudo en la mayoría de los casos, lo que pone de manifiesto la elevada morbilidad asociada de esta patología. Tiene una clara relación con el sexo masculino, sin que hayamos podido encontrar una explicación para esta asociación. A pesar de la ausencia de estenosis coronarias asociadas, creemos que la enfermedad aterosclerótica podría ser su causa etiológica. Debido a la ausencia de grandes registros no se conoce la evolución real de los aneurismas coronarios sin estenosis significativas asociadas y de probable etiología aterosclerótica. En función de nuestra experiencia y de la revisión bibliográfica efectuada, el tratamiento farmacológico conservador es una buena opción en la mayor parte de los pacientes, con buen pronóstico en la evolución a mediano y largo plazo.