Immediate results of bifurcational stenting assessed with optical coherence tomography.

BACKGROUND: A tubular stent may adapt with difficulty to coronary bifurcation lesions (CBLs). METHODS: Time domain or frequency domain (FD) optical coherence tomography (OCT) was performed to assess strut apposition immediately after stent implantation across four segments inside the bifurcation, in a consecutive series of patients. OCT pullbacks were performed in the main vessel (MV). RESULTS: A total of 13,142 struts in 45 CBL in 41 patients were assessed. Strut malapposition was significantly more frequent in the half bifurcation facing the side-branch (SB) ostium (42.9%) than in the proximal segment of the bifurcation 11.8%, half bifurcation opposite the SB 6.7%, or the distal segment 5.7% (all P < 0.0001). Lesions (n = 15) treated with stenting of both MV and SB had a total higher rate of malapposition than those (n = 30) treated with stenting of the MV only (17.6% vs. 9.5%; P = 0.0014). In latter group, lesions treated with FD-OCT-guided stent implantation (n = 13) presented a lower rate of malapposition than those treated with conventional angiographic-guided stent implantation (n = 17) (7.1% vs. 17.5%; P = 0.005). CONCLUSIONS: In CBL, strut malapposition is particularly high at the SB ostium. However, a strategy of stenting MV only with adjunctive FD-OCT guidance is associated with lower rates of malapposition.

Early and late troponin T determination after elective cardiac surgery. Two different meanings.

AIM: Although Troponins are demonstrated to be better predictors than CK-MB in quantification of myocardial damage, the relation between cut-off values for the diagnosis of perioperative myocardial infarction (PMI) and sample time is still not clear. In the present study we sought to analyse the clinical consequence of an early and late cTnt determinations after elective cardiac surgery. MATERIAL OF STUDY: Data of 117 patients undergone elective open heart surgery between January 2006 and June 2007 were prospectively collected. PMI was detected on the basis of postoperative electrocardiography/echocardiography and hemodynamic state. RESULTS: The in-hospital mortality was 1.7%. Eight patients (6.8%) presented PMI. Receiver-operating characteristic (ROC) analyses showed a cTnt cut-off of 1.22 mg/L (CI 0.94 to 0.99, P = 0.0001, 100% sensitivity and 96% specificity) on arrival to ICU for the diagnosis of PMI. On the second post-operative day the cut-off value was 2.8 mg/L (CI 95% 0.84 to 0.98, P = 0.0001) (sensitivity 66% and specificity 100%). At this time the Pearson's test revealed the best correlation to ICU (P = 0.008) and in-hospital (P = 0.01) length of stay (LOS). DISCUSSION: A better sensibility of cTnt in diagnosis of PMI in the early postoperative period has been demonstrated to be associated to an increasing specificity in the late post-operative period. CONCLUSIONS: PMI must be suspected in patients with a cTnt > 1.22 mg/L. A second later assessment on the 2nd post-operative can exclude false positives and significantly predict the ICU and the in-hospital length of stay.

Local and general anaesthesia do not influence outcome of transfemoral aortic valve implantation.

BACKGROUND: There is great variability for the type of anaesthesia used during TAVI, with no clear consensus coming from comparative studies or guidelines. We sought to detect regional differences in the anaesthetic management of patients undergoing transcatheter aortic valve implantation (TAVI) in Europe and to evaluate the relationship between type of anaesthesia and in-hospital and 1 year outcome. METHODS: Between January 2011 and May 2012 the Sentinel European TAVI Pilot Registry enrolled 2807 patients treated via a transfemoral approach using either local (LA-group, 1095 patients, 39%) or general anaesthesia (GA-group, 1712 patients, 61%). RESULTS: A wide variation in LA use was evident amongst the 10 participating countries. The use of LA has increased over time (from a mean of 37.5% of procedures in the first year, to 57% in last 6 months, p<0.01). MI, major stroke as well as in-hospital death rate (7.0% LA vs 5.3% GA, p=0.053) had a similar incidence between groups, confirmed in multivariate regression analysis after adjusting for confounders. Dividing our population in tertiles according to the Log-EuroSCORE we found similar mortality under LA, whilst mortality was higher in the highest risk tertile under GA. Survival at 1 year, compared by Kaplan-Meier analysis, was similar between groups (log-rank: p=0.1505). CONCLUSIONS: Selection of anaesthesia appears to be more influenced by national practice and operator preference than patient characteristics. In the absence of an observed difference in outcomes for either approach, there is no compelling argument to suggest that operators and centres should change their anaesthetic practice.

Frequency domain optical coherence tomography for guidance of coronary stenting.

OBJECTIVE: To evaluate the role of Frequency domain optical coherence tomography (FD-OCT) in guiding stent implantation procedures. METHODS: Dragonfly-imaging catheter was used pre-intervention, after pre-dilatation or at various stages of stent deployment/post-dilatation to assess lesion severity, characteristics and guide stent expansion/apposition. RESULTS: We performed 398 OCT pull-backs in 108 consecutive patients. The 371 pull-backs analysable, had an average length of 35 mm and encompassed 193 lesions (1.8 lesions per patient). Seventy-six percent of patient had AHA-ACC-class B-C lesions. In the pre-intervention group deferral of treatment was decided for 13/68 pullbacks (19.1%), whereas strategies different from conventional predilatation (e.g. thrombectomy, rotablator, cutting-balloon) were decided in 23 cases (33.8%). After full lesion dilatation 96 pullbacks (25.9%, pre-stenting group) were performed, 46 (47.9%) of which suggested proceeding directly with stenting while 50 (52.1%) suggesting further treatment. Out of the 207 pullbacks in post-stenting group, 29 (14%) suggested new stent implantation because of dissection or residual stenosis; 64 (30.9%) suggested further optimization with high pressure/larger-sized balloon. Average number of pull-backs per patient was 3.4 requiring 75.8 ± 19.3 ml of iopamidol. No major complications were observed. Five cases (4.6%) of contrast-induced nephropathy were reported. CONCLUSIONS: Repeated examinations with FD-OCT can be safely used to guide stent selection and improve stent expansion and apposition.

Increase in J-CTO lesion complexity score explains the disparity between recanalisation success and evolution of chronic total occlusion strategies: insights from a single-centre 10-year experience.

OBJECTIVE: To investigate whether treatment of lesions of greater complexity is now undertaken and to assess the rates of procedural success per class of lesion complexity. DESIGN: Observational study. SETTING: Despite impressive progress in treatment strategies and equipment, the success rate of percutaneous coronary intervention for chronic total occlusion (CTO) has remained relatively stable. PARTICIPANTS: 483 patients consecutively treated with CTO from 2003 to 2012. MAIN OUTCOME MEASURES: The Multicenter CTO Registry of Japan (J-CTO) score was used to classify lesion complexity. The study population was subdivided into an early (period 1, n=288) and a late (period 2, n=195) period according to the routine implementation of novel techniques and advanced equipment. RESULTS: Period 2 was marked by more 'difficult' and 'very difficult' lesions (J-CTO grades 2 and 3) being attempted, with procedural success increasing from 68.4% to 88.1% (p<0.001) and from 42.0% to 78.9% (p<0.001), respectively. 'Easy' and 'intermediate' lesions (J-CTO grades 0 and 1) were less common, but with similarly high success rates (89.1% vs 96.6% (p=0.45) for easy, and 86.3% vs 86.1% (p=0.99) for intermediate). Period 2 was characterised by a trend for more successful procedures overall (by 6.1%, p=0.09). Procedural complications were similarly low in both periods. J-CTO score and technical era were identified as independent correlates of success in the total population by logistic regression analysis. CONCLUSIONS: Advanced CTO techniques and equipment have resulted in an increase in the successful treatment of highly complex lesions. Total success rate did not substantially improve, as it was counterbalanced by the increased rate at which complex lesions were attempted.

Obstructive sleep apnea severity is associated with left ventricular mass independent of other cardiovascular risk factors in morbid obesity.

OBJECTIVE: To evaluate the relation between obstructive sleep apnea (OSA) and left ventricular mass (LVM) in morbid obesity and the influence of gender, menopausal status, anthropometry, body composition, hypertension, and other cardiovascular risk factors in this relationship. DESIGN: Cross-sectional descriptive study. METHODS: Polysomnographic and echocardiographic studies were performed in a cohort of 242 patients (86 men, 100 premenopausal (PreM) and 56 postmenopausal (PostM) women), with grade II obesity and above (BMI: 43.7 ± 0.4 kg/m(2)) to investigate OSA and LVM respectively. Anthropometry, body composition, glucose tolerance, and blood pressure were also recorded. RESULTS: OSA to different degrees was diagnosed in 76.2% of the patients (n: 166), its prevalence being 90.9% (n: 70) for men, and 76% (n: 38) and 63.8% (n: 58) for PostM and PreM women, respectively (p < 0.01). LVM excess was greatest for PostM women (90.2%), followed by men (81.9%) and PreM females (69.6%) (p < 0.01). LVM values increased in accordance to OSA severity (absence, 193.7 ± 6.9 g; mild, 192.6 ± 7.8 g; moderate, 240.5 ± 12.5 g; severe, 273.6 ± 14.6 g; p < 0.01). LVM magnitude correlated with the menopausal state, age, central adiposity, hypertension (HT), type 2 diabetes (DM), desaturation index (DI), and apnea-hypopnea index (AHI) (r = 0.41; p < 0.01). The relationship between LVM and AHI persisted in the multivariate analysis (ß = 0.25; p < 0.05) after adjusting for age, gender, menopausal state, BMI, waist circumference, neck circumference, DI, fasting plasma glucose, DM, and HT. But if tobacco habits are included, the statistical difference disappears (ß = 0.22; p = 0.06). CONCLUSIONS: Morbid obesity is frequently associated with abnormal LVM, particularly in patients with OSA; this association is independent of HT, BMI, body composition, and other clinical factors, supporting a direct role of OSA on LVM in morbid obesity. This suggests that OSA and LVM might be taken as predictors of the cardiovascular risk in these patients.

Dual-source CT coronary angiogram in heart transplant recipients in comparison with dobutamine stress echocardiography for detection of cardiac allograft vasculopathy.

Conventional coronary angiography (CCA) is the gold standard in the diagnosis of cardiac allograft vasculopathy (CAV) in heart transplant recipients. Dobutamine stress echocardiography (DSE) is a useful technique for screening. Dual-source computed tomography (DSCT) is the last generation of computed tomography scanners, which could be useful to noninvasively assess CAV. Thirty cardiac transplant recipients underwent DSE and DSCT coronary angiogram. Exclusion criteria were as follows: renal insufficiency, iodinated contrast media allergy, less than 12 months since transplant, and unstable clinical conditions. DSE showed ischemia in two patients. At DSCT scan 13 patients had a normal angiogram, 13 ones wall thickening and four significant diseases. DSCT showed a sensitivity of 100% with a specificity of 92%. DSCT allowed detection of more patients with CAV than DSE. Four patients showed significant CAV at DSCT compared with two at DSE. Thirteen patients showed initial signs of disease at DSCT despite a normal DSE.