Four-year outcomes of a single-center experience with coronary everolimus-eluting bioresorbable scaffolds.

BACKGROUND: Bioresorbable scaffolds (BRS) have been introduced to overcome the limitations of drug-eluting stents and the ABSORB (Everolimus-Eluting BRS, Abbott Vascular, Santa Clara, CA, USA) was the most extensively tested. Nevertheless, major RCTs reported higher rates of target lesion failures and BRS thrombosis at 3 years follow-up, bringing to the withdrawing of the device from the market. It has been suggested that a better lesions selection and an optimized implantation technique could mitigate the displayed adverse results. METHODS: Consecutive patients undergoing BRS implantation were included in this observational, single center study. Clinical follow-up was conducted up to 4 years. Endpoint of interest was the target lesion failure (TLF), a composite outcome including cardiac death, target vessel myocardial infarction and target lesion revascularization. RESULTS: A total of 62 patients with a mean age of 55±8.5 years were analyzed of which 70.9% presented with an acute coronary syndrome and 59.6% with myocardial infarction. A total of 100 lesions were treated and 51.6% were complex (B2/C). Predilatation was performed in all the case, post-dilatation in 74.1%. All the target vessel reference diameter (RVD) were >2.5 mm (average RVD 3.2±0.24 mm). At 4 years, the rate for TLF was 6.9%. Subgroup's analysis did not show significative differences among groups although consistently higher event rates were found for RVD <2.5 mm (12.6% vs. 6.4%, P=0.5), BRS overlapping (11.8% vs. 5%, P=0.2) and ticagrelor instead of clopidogrel on top of cardioaspirin (9.1% vs. 3%, P=0.2). CONCLUSIONS: This small-sized real-world registry displays lower rates of clinical events during long-term follow-up in respect to previous studies. The avoidance of implantation in small vessels, inclusion of acute myocardial infarction and extensive performance of BRS post-dilatation could explain the observed better results. Long-term outcomes of the ongoing ABSORB IV Trial are needed to confirm this data.

Electrocardiographic Changes Induced by Endurance Training and Pubertal Development in Male Children.

Training-induced electrocardiographic changes are common in adult athletes. However, a few data are available on electrocardiogram (ECG) in preadolescent athletes and little is known about the potential changes induced by training on 12-lead electrocardiogram (ECG) at rest. Twelve-lead ECGs at rest and complete echocardiographic examinations were performed in 94 children (57 endurance athletes, 37 sedentary controls; mean age 10.8 ± 0.2 and 10.2 ± 0.2 years, respectively) at baseline and after 5 months of growth and training in athletes and of natural growth in controls. At baseline, athletes had lower heart rate at rest compared with controls (p = 0.046) and a further decrease was observed after training (p <0.0001). An incomplete right bundle branch block was found in 19% of athletes and 15% of controls (p = 0.69) with no changes after training. Although none of the athletes showed negative T waves from V1 to V3, 6% of controls at baseline had T-wave inversion V1 to V3 with a decrease to 3% after 5 months (p = 0.16). The early repolarization pattern did not differ between athletes and controls and was correlated with Tanner's scale score in the overall population both at first and second evaluation (R = 0.30, R = 0.27, p = 0.005, p = 0.012, respectively). No correlations were found between ECG and echocardiographic data. In conclusion, 12-lead ECG at rest is not substantially affected by training in children, despite a physiological increase in cavity size. Thus, in preadolescent athletes, 12-lead ECG at rest does not reflect exercise-induced morphologic remodeling and seems to be influenced more by sexual maturation than by training.

Training-induced right ventricular remodelling in pre-adolescent endurance athletes: The athlete's heart in children.

AIMS: Little is known about the adaptation of the right ventricle (RV) to endurance exercise in children. The aim of this study was to assess the effects of 5months of intensive training on RV morphology and function in preadolescent endurance athletes. METHODS: Ninety-four children were evaluated in this study. Fifty-seven male competitive swimmers (aged 10.8±0.2years) were evaluated before (baseline) and after 5months of the training (peak-training), and compared to 37 age- and sex-matched non-athlete children evaluated at baseline and after 5months of natural growth. All subjects were asymptomatic, with negative family history for cardiomyopathies. RESULTS: At baseline no differences were found between athletes and controls for indexed RV outflow tract (RVOT) (18.5±2.7 vs. 16.8±5.0mm/m2, p=0.18) and RV basal end-diastolic diameter (EDD) (24.9±4.1 vs. 23.6±3.0mm/m2, p=0.15). After 5months, indexed RVOT and RV basal EDD significantly increased in athletes (20.2±2.9mm/m2 and 25.4±3.3mm/m2, p<0.0001 vs. baseline) while no differences were observed in controls (p=0.84 and p=0.25). Despite the increase in RV size, RV function remained normal in athletes, with no changes in RV fractional area change (p=0.97), s' value (p=0.22), and RV longitudinal strain (p=0.28). CONCLUSIONS: Endurance training influences the growing heart of male preadolescent athletes with an addictive increase in RV dimensions, with a preserved RV function. Therefore, in children engaged in endurance sports the increase in RV size associated with normal RV function represents a physiological expression of the athlete's heart and should not be misinterpreted as an expression of incipient RV cardiomyopathy.

Hand-held echocardiography: added value in clinical cardiological assessment.

BACKGROUND: The ultrasonic industry has recently produced echocardiographic Hand Held Devices (miniaturized, compact and battery-equipped echocardiographic systems). Their potential usefulness has been successfully assessed in a wide range of clinical conditions. The aim of the study was to verify if the routine use of a basic model of echocardiographic Hand Held Device (HHD) could be an important diagnostic tool during outpatient cardiologic consulting or in non-cardiologic hospital sections. METHODS: 87 consecutive patients were included in this study; they underwent routine physical examination, resting ECG and echocardiographic evaluation using a basic model of HHD performed by trained echocardiographists; the cardiologist, whenever possible, formulated a diagnosis. The percentage of subjects in whom the findings were judged reasonably adequate for final diagnostic and therapeutic conclusions was used to quantify the "conclusiveness" of HHD evaluation. Successively, all patients underwent a second echocardiographic evaluation, by an examiner with similar echocardiographic experience, performed using a Standard Echo Device (SED). The agreement between the first and the second echocardiographic exam was also assessed. RESULTS: Mean examination time was 6.7 +/- 1.5 min. using HHD vs. 13.6 +/- 2.4 min. using SED. The echocardiographic examination performed using HHD was considered satisfactory in 74/87 patients (85.1% conclusiveness). Among the 74 patients for whom the examination was conclusive, the diagnosis was concordant with that obtained with the SED examination in 62 cases (83.8% agreement). CONCLUSION: HHD may generally allow a reliable cardiologic basic evaluation of outpatient or subjects admitted to non-cardiologic sections, more specifically in particular subgroups of patients, with a gain in terms of time, shortening patient waiting lists and reducing healthy costs.

Effects of simvastatin on walking performance and symptoms of intermittent claudication in hypercholesterolemic patients with peripheral vascular disease.

PURPOSE: To analyze the effects of short-term therapy with simvastatin on walking performance in hypercholesterolemic patients with peripheral vascular disease. METHODS: Eighty-six patients with peripheral arterial disease (Fontaine stage II), intermittent claudication, and total cholesterol levels >220 mg/dL were enrolled in a randomized, placebo-controlled, double-blind study. Forty-three patients were assigned to simvastatin (40 mg/d); the remaining 43 patients were assigned to placebo treatment. All patients underwent an exercise test and clinical examination, and completed a self-assessment questionnaire at 0, 3, and 6 months. Pain-free and total walking distance, resting and postexercise ankle-brachial indexes, and questionnaire scores were determined at each follow-up. RESULTS: At 6 months, the mean pain-free walking distance had increased 90 meters (95% confidence interval [CI]: 64 to 116 meters; P <0.005) more in the simvastatin group than in the placebo group. Similar results were seen for the total walking distance (mean between-group difference in the change, 126 meters; 95% CI: 101 to 151 meters; P <0.001), and for the ankle-brachial index at rest (mean, 0.09; 95% CI: 0.06 to 0.12; P <0.01) and after exercise (mean, 0.19; 95% CI: 0.14 to 0.24; P <0.005). There was also a greater improvement in claudication symptoms among patients treated with simvastatin. The effects on walking performance, ankle-brachial indexes, and questionnaire scores had also been significant at 3 months. CONCLUSION: High-dose short-term therapy with simvastatin may improve walking performance, ankle-brachial pressure indexes, and symptoms of claudication in hypercholesterolemic patients with peripheral vascular disease.

Midwall mechanics in physiologic and hypertensive concentric hypertrophy.

OBJECTIVE: We sought to analyze and compare midwall fractional shortening (mFS), and its relations with circumferential end-systolic stress (cESS) and relative wall thickness (RWT), among subjects with physiologic concentric left ventricular (LV) hypertrophy, patients with hypertension and concentric LV hypertrophy, and control subjects. METHODS: A total of 51 normotensive athletes and 56 young patients with hypertension and echocardiographic evidence of concentric LV hypertrophy were enrolled. In addition, 49 age- and sex-matched control subjects were recruited. LV cavity size and wall thicknesses, LV mass, RWT, cESS, and mFS were determined by echocardiography. RESULTS: The 3 groups were similar in age, sex, height, weight, body surface area, LV diameters, and conventional indices of systolic function. LV thicknesses, RWT, LV mass, and LV mass index were similarly increased in the athletes and in the hypertensive group when compared with the control subjects. A similar depression in mFS was observed in both the athletes (22.4 +/- 2.6%) and hypertensive group (22.5 +/- 3.6%) in comparison with the control group (24.5 +/- 2.5%, P =.0003). The depression in mFS was still significant after taking into account the effect of cESS, but was no more evident after indexation of mFS by RWT or LV mass. At regression analysis, the relation between mFS and cESS showed a steeper negative slope in the patients with hypertension than in the other 2 groups. CONCLUSIONS: MFS is similarly depressed in physiologic and hypertensive concentric LV hypertrophy. The depression is abolished by adjustment for RWT or LV mass, suggesting that geometric factors are the major determinants of midwall performance in both types of concentric LV hypertrophy. However, an impaired response to different values of cESS seems to exist only in hypertensive concentric LV hypertrophy, because increasing levels of cESS may be associated with more evident mFS depression in patients with hypertension than in the athletes and control subjects.

Spontaneous acute coronary dissection after cocaine abuse in a young woman.

Spontaneous coronary artery dissection is an unusual trigger for acute coronary syndrome or sudden death, occurring more frequently in relatively young people and mainly in the female sex. The underlying mechanism is not completely understood, but predisposing factors may include metabolism and collagen synthesis disorders. The case of a 34-year-old woman who underwent coronary angiography for acute anterolateral myocardial ischemia after cocaine abuse is reported. Dissection of the left main trunk extending to both proximal descending anterior and circumflex arteries was detected and the patient was promptly and successfully managed with tirofiban hydrochloride infusion and urgent coronary artery bypass grafting.

Optical coherence tomography evidence of endothelial erosion as a cause of ST-segment elevation myocardial infarction.

High-resolution intracoronary imaging provided relevant insights into the field of pathophysiology of acute coronary syndromes (ACS). Human autopsy studies have shown that endothelial erosion may lead to intravascular thrombosis and acute myocardial infarction. We report the case of a 51-year-old woman presenting with ST-segment elevation ACS. In this patient, frequency domain optical coherence tomography (FD-OCT) was performed into the infarct-related artery, showing in-vivo findings suggestive of endothelial erosion, associated with no flow-obstructing luminal thrombus. In this rare case, endothelial erosion, and subsequent thrombosis, in the proximal third of the artery has probably caused embolization and thrombotic occlusion in the mid third. FD-OCT allowed us to obtain a rare in-vivo image of endothelial erosion, providing relevant insights into the setting of ACS.

Acute ST elevation myocardial infarction in pregnancy due to coronary vasospasm: a case report and review of literature.

Acute myocardial infarction during pregnancy is rare but may be associated with high risk complications. We present a very rare case about an acute myocardial infarction with anterior ST elevation in a 40-year-old woman, at 38th week of gestational period. The coronary arteriograms showed a diffuse left coronary vasospasm. The coronary arteriography at puerperium showed no organic narrowings. This is the first case with a well documented coronary artery vasospasm in pregnancy. Management should follow the usual principles of care for acute myocardial infarction. However, selection of diagnostic and therapeutic approaches may be greatly influenced by fetal safety.