Predictors of target lesion failure after treatment of left main, bifurcation, or chronic total occlusion lesions with ultrathin-strut drug-eluting coronary stents in the ULTRA registry.

BACKGROUND: Data about the long-term performance of new-generation ultrathin-strut drug-eluting stents (DES) in challenging coronary lesions, such as left main (LM), bifurcation, and chronic total occlusion (CTO) lesions are scant. METHODS: The international multicenter retrospective observational ULTRA study included consecutive patients treated from September 2016 to August 2021 with ultrathin-strut (<70 µm) DES in challenging de novo lesions. Primary endpoint was target lesion failure (TLF): composite of cardiac death, target-lesion revascularization (TLR), target-vessel myocardial infarction (TVMI), or definite stent thrombosis (ST). Secondary endpoints included all-cause death, acute myocardial infarction (AMI), target vessel revascularization, and TLF components. TLF predictors were assessed with Cox multivariable analysis. RESULTS: Of 1801 patients (age: 66.6 ± 11.2 years; male: 1410 [78.3%]), 170 (9.4%) experienced TLF during follow-up of 3.1 ± 1.4 years. In patients with LM, CTO, and bifurcation lesions, TLF rates were 13.5%, 9.9%, and 8.9%, respectively. Overall, 160 (8.9%) patients died (74 [4.1%] from cardiac causes). AMI and TVMI rates were 6.0% and 3.2%, respectively. ST occurred in 11 (1.1%) patients while 77 (4.3%) underwent TLR. Multivariable analysis identified the following predictors of TLF: age, STEMI with cardiogenic shock, impaired left ventricular ejection fraction, diabetes, and renal dysfunction. Among the procedural variables, total stent length increased TLF risk (HR: 1.01, 95% CI: 1-1.02 per mm increase), while intracoronary imaging reduced the risk substantially (HR: 0.35, 95% CI: 0.12-0.82). CONCLUSIONS: Ultrathin-strut DES showed high efficacy and satisfactory safety, even in patients with challenging coronary lesions. Yet, despite using contemporary gold-standard DES, the association persisted between established patient- and procedure-related features of risk and impaired 3-year clinical outcome.

Safety and efficacy of polymer-free biolimus-eluting stents versus ultrathin stents in unprotected left main or coronary bifurcation: A propensity score analysis from the RAIN and CHANCE registries.

OBJECTIVES: Evaluate safety and efficacy of polymer-free biolimus-eluting stents (PF-BESs) versus ultrathin stents in unprotected left main (ULM) or bifurcation. BACKGROUND: PF-BESs due to reduced length of dual antiplatelet therapy (DAPT) are increasingly used. However, there are limited data about safety and efficacy for ULM or bifurcation. METHODS: We selected all-patients treated for ULM or bifurcation from two multicenter real life registries (RAIN [NCT03544294] evaluating ultrathin stents, CHANCE [NCT03622203] appraising PF-BES). After propensity score with matching, the primary endpoint was major adverse cardiac events (MACE; a composite of all-cause death, myocardial infarction, target lesion revascularization [TLR], and stent thrombosis [ST]), while its components along with target vessel revascularization (TVR) secondary endpoints. RESULTS: Three thousand and three patients treated with ultrathin stents and 446 with PF-BESs, resulting respectively in 562 and 281 after propensity score with matching (33 and 22%, respectively, with ULM disease). After 12 (8-20) months, rates of MACE were similar (9 vs. 8%, p = 0.56) without difference in TLR and ST (3.0 vs. 1.7%, p = .19 and 1.8 vs. 1.1%, p = .42). These results were consistent for ULM group (3 vs. 1.7% and 1.8 vs. 1.1%, p = .49 and .76), for non-ULM group (2.1 vs. 3.4%, p = .56 and 1.2 vs. 1.7%, p = .78) and for two-stent strategy (8.7 vs. 4.5% and 4.3 vs. 3.2%, p = .75 and .91). Among patients treated with 1 month of DAPT in both groups, those with ultrathin stents experienced higher rates of MACE related to all-cause death (22 vs. 12%, p = .04) with higher although not significant rates of ST (3 vs. 0%, p = .45). CONCLUSIONS: PF-BES implanted on ULM or BiF offered freedom from TLR and ST comparable to ultrathin stents. PF-BESs patients assuming DAPT for 1 month experienced a lower despite not significant incidence of ST.

Autonomic Tone Activity Before the Onset of Atrial Fibrillation.

INTRODUCTION: The autonomic nervous system has been proven to play a major role in the onset of atrial fibrillation (AF), along with a predisposing substrate and a specific trigger event usually consisting of a premature supraventricular ectopic beat (SVEB). By means of heart rate variability (HRV) analysis, we investigated the activity of the autonomic nervous system before SVEBs nontriggering and triggering AF. METHODS AND RESULTS: We evaluated 28 patients with at least 1 episode of sustained AF (>30 seconds) recorded during 24-hour Holter monitorings. We performed HRV analysis during the hour preceding 35 AF onsets and compared these results with the HRV values before nontriggering SVEBs with similar prematurity. According to the low frequency (LF)/high frequency (HF) ratio in the 5 minutes before the onset, AF episodes were classified as either vagal (LF/HF ratio <1.5) or adrenergic (LF/HF ratio ≥1.5).Vagal episodes (16) showed a decrease in LF (from 50.81 ± 1.67 to 32.73 ± 3.54) and an increase in HF (from 36.00 ± 2.30 to 54.7 ± 3.69) throughout the hour preceding the onset. Adrenergic episodes (19) had opposite changes in LF (from 55.4 ± 4.95 to 67.51 ± 5.24) and HF (from 33.78 ± 5.82 to 27.96 ± 3.51) during the same period. No similar trends were observed before the selected nontriggering SVEBs. CONCLUSION: Only SVEBs occurring during a phase of hyperactivity of one of the 2 branches of the autonomic nervous system are able to trigger episodes of AF.

Left Atrial Substrate Modification Targeting Low-Voltage Areas for Catheter Ablation of Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: This meta-analysis aims to assess the impact of a voltage-guided substrate modification by targeting low-voltage area (LVA) in addition to pulmonary vein isolation (PVI) in patients undergoing catheter ablation for atrial fibrillation (AF). METHODS: MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and "voltage* OR substrate* OR fibrosis OR fibrotic area*" were screened and studies included if matching inclusion and exclusion criteria. RESULTS: Six studies were included. Patients enrolled were 885 (517 in the study group and 368 in the control group). Median age was 60 years; 92% had nonparoxysmal AF. At a mean follow-up of 17 months, 70% of patients in the study group vs. 43% in the control group were free from AF/atrial tachycardia (AT) recurrences (odds ratio [OR] = 3.41, 95% confidence interval [CI] 2.22-5.24). LVA ablation in addition to PVI was more effective than PVI alone and PVI + conventional wide empirical ablation (70% vs. 43%, OR = 3.41, 95% CI 2.22-5.24), without increasing the adverse event rate (2.5% vs. 6%, OR = 0.43, 95% CI 0.15-1.26). Compared to PVI + conventional wide empirical ablation, LVA ablation reduced the occurrence of postablation AT (14% vs. 46%, OR = 0.16, 95% CI 0.07-0.37), procedure time (176 min vs. 220 min, OR = 0.36, 95% CI 0.24-0.56), fluoroscopy time (25 min vs. 31 min, OR = 0.22, 95% CI 0.12-0.39), and radiofrequency time (55 min vs. 90 min, OR = 0.49, 95% CI 0.27-0.90). CONCLUSIONS: A voltage-guided substrate modification by targeting LVA in addition to PVI is more effective, safer, and holds a lower proarrhythmic potential than conventional ablation approaches. Further randomized studies are necessary to confirm these findings.

Impact of statin adherence and interruption within 6 months after ST-segment elevation myocardial infarction (STEMI): Results from the real-world regional registry FAST-STEMI.

BACKGROUND: The impact of statin therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) in real- world patients is understudied. AIMS: To identify predictors of low adherence and discontinuation to statin therapy within 6 months after STEMI and to estimate their impact on cardiovascular outcomes at one year follow-up. METHODS: We evaluated real-world adherence to statin therapy by comparing the number of bought tablets to the expected ones at 1 year follow-up through pharmacy registries. A total of 6043 STEMI patients admitted from 2012 to 2017 were enrolled in the FAST STEMI registry and followed up for 4,7 ± 1,6 years; 304 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events, and ischemic stroke. The compliance cut-off chosen was 80% as mainly reported in literature. RESULTS: From a total of 5744 patients, 418 (7,2%) patients interrupted statin therapy within 6 months after STEMI, whereas 3337 (58,1%) presented >80% adherence to statin therapy. Statin optimal adherence (>80%) resulted as protective factor towards both cardiovascular (0.1% vs 4.6%; AdjHR 0.025, 95%CI 0.008-0.079, p < 0.001) and all-cause mortality (0.3% vs 13.4%; Adj HR 0.032, 95%CI 0.018-0.059, p < 0.001) at 1 year follow-up. Further, a significant reduction of ischemic stroke incidence (1% vs 2.5%, p = 0.001) was seen in the optimal adherent group. Statin discontinuation within 6 months after STEMI showed an increase of both cardiovascular (5% vs 1.7%; AdjHR 2.23; 95%CI 1.37-3.65; p = 0,001) and all-cause mortality (14.8% vs 5.1%, AdjHR 2.32; 95%CI 1.73-3.11; p ã€ˆ0,001) at 1 year follow-up. After multivariate analysis age over 75 years old, known ischemic cardiopathy and female gender resulted as predictors of therapy discontinuation. Age over 75 years old, chronic kidney disease, previous atrial fibrillation, vasculopathy, known ischemic cardiopathy were found to be predictors of low statin adherence. CONCLUSIONS: n our real-world registry low statin adherence and discontinuation therapy within 6 months after STEMI were independently associated to an increase of cardiovascular and all-cause mortality at 1 year follow-up. Low statin adherence led to higher rates of ischemic stroke.

Impact of COVID-19 pandemic and infection on in hospital survival for patients presenting with acute coronary syndromes: A multicenter registry.

INTRODUCTION: The impact of Covid-19 on the survival of patients presenting with acute coronary syndrome (ACS) remains to be defined. METHODS: Consecutive patients presenting with ACS at 18 Centers in Northern-Italy during the Covid-19 outbreak were included. In-hospital all-cause death was the primary outcome. In-hospital cardiovascular death along with mechanical and electrical complications were the secondary ones. A case period (February 20, 2020-May 3, 2020) was compared vs. same-year (January 1-February 19, 2020) and previous-year control periods (February 20-May 3, 2019). ACS patients with Covid-19 were further compared with those without. RESULTS: Among 779 ACS patients admitted during the case period, 67 (8.6%) tested positive for Covid-19. In-hospital all-cause mortality was significantly higher during the case period compared to the control periods (6.4% vs. 3.5% vs. 4.4% respectively; p 0.026), but similar after excluding patients with COVID-19 (4.5% vs. 3.5% vs. 4.4%; p 0.73). Cardiovascular mortality was similar between the study groups. After multivariable adjustment, admission for ACS during the COVID-19 outbreak had no impact on in-hospital mortality. In the case period, patients with concomitant ACS and Covid-19 experienced significantly higher in-hospital mortality (25% vs. 5%, p < 0.001) compared to patients without. Moreover, higher rates of cardiovascular death, cardiogenic shock and sustained ventricular tachycardia were found in Covid-19 patients. CONCLUSION: ACS patients presenting during the Covid-19 pandemic experienced increased all-cause mortality, driven by Covid-19 positive status due to higher rates of cardiogenic shock and sustained ventricular tachycardia. No differences in cardiovascular mortality compared to non-pandemic scenarios were reported.

Prevalence and Clinical Significance of Latent Brugada Syndrome in Atrial Fibrillation Patients Below 45 Years of Age.

Aim: This study aims to describe prevalence and clinical significance of latent Brugada syndrome (BrS) in a young population with atrial fibrillation (AF). Methods: Between September 2015 and November 2017, among 111 AF patients below 45 years of age, those without pre-existing pathologies and/or known risk factors were selected for the study. Based on baseline 12-lead-24-h Holter electrocardiogram (ECG), previous class 1C antiarrhythmic drug therapy, or ajmaline testing, patients were stratified as latent type 1 BrS or not. Results: Within the 78 enrolled patients, 13 (16.7%; group 1) revealed a type 1 BrS ECG pattern, while 65 (83.3%; group 2) did not. Mean age was 37 ± 8 vs. 35 ± 7 (p = 0.42), and males were 7 (54%) vs. 54 (83%) (p = 0.02) in the two groups, respectively. Family history of BrS was significantly more common within group 1 patients (2, 15% vs. 0; p = 0.03), and 4 (31%) patients experienced syncope in group 1 vs. 5 (8%) in group 2 (p = 0.02). After a mean follow-up of 42 ± 18 months from the index AF event, more than 80% of the patients, in both study groups, were in sinus rhythm. Conclusion: In young patients with AF without pre-existing pathologies and/or known risk factors, latent BrS should be suspected. Syncope and a family history of BrS emerge as easily identifiable factors related to BrS. Long-term sinus rhythm maintenance appears satisfactory, either in the presence or not of BrS.

Angiographic control versus ischaemia-driven management of patients undergoing percutaneous revascularisation of the unprotected left main coronary artery with second-generation drug-eluting stents: rationale and design of the PULSE trial.

BACKGROUND: The role of planned angiographic control (PAC) over a conservative management driven by symptoms and ischaemia following percutaneous coronary intervention (PCI) of the unprotected left main (ULM) with second-generation drug-eluting stents remains controversial. PAC may timely detect intrastent restenosis, but it is still unclear if this translated into improved prognosis. METHODS AND ANALYSIS: PULSE is a prospective, multicentre, open-label, randomised controlled trial. Consecutive patients treated with PCI on ULM will be included, and after the index revascularisation patients will be randomised to PAC strategy performed with CT coronary after 6 months versus a conservative symptoms and ischaemia-driven follow-up management. Follow-up will be for at least 18 months from randomisation. Major adverse cardiovascular events at 18 months (a composite endpoint including death, cardiovascular death, myocardial infarction (MI) (excluding periprocedural MI), unstable angina, stent thrombosis) will be the primary efficacy outcome. Secondary outcomes will include any unplanned target lesion revascularisation (TLR) and TLR driven by PAC. Safety endpoints embrace worsening of renal failure and bleeding events. A sample size of 550 patients (275 per group) is required to have a 80% chance of detecting, as significant at the 5% level, a 7.5% relative reduction in the primary outcome. TRIAL REGISTRATION NUMBER: NCT04144881.

Impact of Kissing Balloon in Patients Treated With Ultrathin Stents for Left Main Lesions and Bifurcations: An Analysis From the RAIN-CARDIOGROUP VII Study.

BACKGROUND: There are limited data regarding the impact of final kissing balloon (FKI) in patients treated with percutaneous coronary intervention using ultrathin stents in left main or bifurcations. METHODS: All patients undergoing left main or bifurcations percutaneous coronary intervention enrolled in the RAIN registry (Very Thin Stents for Patients With MAIN or BiF in Real Life: The RAIN, a Multicenter Study) evaluating ultrathin stents were included. Major adverse cardiac event (a composite of all-cause death, myocardial infarction, target lesion revascularization, and stent thrombosis) was the primary end point, while its components, along with target vessel revascularization, were the secondary end points. The main analysis was performed comparing patients with and without FKI after adjustment with inverse probability of treatment weighting. Subgroup analyses were performed according to FKI (short [<3 mm] versus long overlap), strategy (provisional versus 2-stent), routine versus bail-out FKI, and the use of imaging and proximal optimization technique. RESULTS: Two thousand seven hundred forty-two patients were included. At 16 months (8-20) follow-up, inverse probability of treatment weighting adjusted rates of major adverse cardiac event were similar between FKI and no-FKI group (15.1% versus 15.5%; P=0.967), this result did not change with use of imaging, proximal optimization technique, or routine versus bail-out FKI. In the 2-stent subgroup, FKI was associated with lower rates of target vessel revascularization (7.8% versus 15.9%; P=0.030) and target lesion revascularization (7.3% versus 15.2%; P=0.032). Short overlap FKI was associated with a lower rate of target lesion revascularization compared with no FKI (2.6% versus 5.4%; P=0.034), while long overlap was not (6.8% versus 5.4%; P=0.567). CONCLUSIONS: In patients with bifurcations or unprotected left main treated with ultrathin stents, short overlap FKI is associated with less restenosis. In a 2-stent strategy, FKI was associated with less target vessel revascularization and restenosis. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03544294.

[Infero-postero-lateral acute myocardial infarction caused by left ventricular myxoma embolism]. / Infarto miocardico infero-postero-laterale secondario ad embolizzazione di mixoma ventricolare sinistro.

The majority of myxomas are located in the left atrium (75%) followed by the right atrium (20%). In rare cases, myxomas can be found in the ventricles, with 2.5% reported for myxomas in the left ventricle. Systemic emboli, mostly cerebral, occur in two thirds of such patients, while coronary emboli are rare. Here we report a case of left ventricular myxoma causing infero-postero-lateral myocardial infarction, successfully treated by intracoronary thromboaspiration of myxoma embolus.

Contemporary management of pericardial effusion: practical aspects for clinical practice.

A pericardial effusion (PE) is a relatively common finding in clinical practice. It may be either isolated or associated with pericarditis with or without an underlying disease. The aetiology is varied and may be either infectious (especially tuberculosis as the most common cause in developing countries) or non-infectious (cancer, systemic inflammatory diseases). The management is essentially guided by the hemodynamic effect (presence or absence of cardiac tamponade), the presence of concomitant pericarditis or underlying disease, and its size and duration. The present paper reviews the current knowledge on the aetiology, classification, diagnosis, management, therapy, and prognosis of PE in clinical practice.

Phenotypic expression of ARVC: How 12 lead ECG can predict left or right ventricle involvement. A familiar case series and a review of literature.

AIMS: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart-muscle disease primarily affecting the right ventricle (RV) and potentially causing sudden death in young people. The natural history of the disease is firstly characterized by a concealed form progressing over a biventricular involvement. Three different cases coming from the same family are presented together with a review of the literature. METHODS AND RESULTS: Multi-parameter analysis including imaging and electrocardiographic analysis is presented since the first medical referral with follow-up ranging from 11 to 38years. Case 1 presented a typical RV involvement in agreement with the ECG pattern. Case 2 presented a prevalent left ventricular involvement leading from the beginning to a pattern of dilated cardiomyopathy in agreement with his ECG evolution over the years. On the other side, Case 3 came to observation with a typical RV involvement (similar to Case 1) but with ECG evolution of typical left ventricle involvement (similar to Case 2). The genetic analysis showed a mutation in desmoglein-2 (DSG2) gene: p. Arg49His. Comparison between size and localization of ventricular dyskinesia at cardiovascular imaging and the surface 12 lead electrocardiography are proposed. CONCLUSIONS: ARVC may lead to an extreme phenotypic variability in clinical manifestations even within patients coming from the same family in which ARVC is caused by the same genetic mutation. ECG progression over time reflects disease evolution and in particular cases may anticipate wall motion abnormalities by years.

Long-term events following atrial fibrillation rate control or transcatheter ablation: a multicenter observational study.

BACKGROUND: Atrial fibrillation increases thromboembolic risk. Oral anticoagulation with antivitamin K (AVK) reduces thromboembolic event rate, but increases hemorrhagic risk. OBJECTIVE: The aim of the present study was to describe long-term cerebral thromboembolic/hemorrhagic event rates in atrial fibrillation patients managed by rhythm control, pursued by atrial fibrillation transcatheter ablation (AFTCA), and rate control strategy. METHODS AND RESULTS: One thousand and five hundred consecutive patients referring to three medical care centers for atrial fibrillation were retrospectively divided into three groups: AFTCA maintaining AVK (group A); AFTCA discontinuing AVK (group B); and rate control strategy and AVK (group C). Thromboembolic and hemorrhagic events were recorded in 60 ±â€Š28 months of follow-up. Thromboembolic events did not differ between the groups (5/500, 1% group A; 7/500, 1.4% group B; 11/500, 2.2% group C; P = 0.45), and hemorrhagic events were greater in group A (9/500, 1.8%) and C (12/500, 2.4%) than in group B (no events; P = 0.003). Among patients with CHA2DS2 VASc score 2 or less, thromboembolic events did not differ in the group discontinuing AVK (group B, 4/388, 1%) or not (group A, 1/319, 0.3%; P = 0.38), whereas hemorrhagic events were more common in patients on AVK (5/319, 1.5% group A and 3/175, 1.7% group C; P = 0.02) compared with those discontinuing AVK (0/388, group B). Following AFTCA (groups A and B), 299/1000 experienced atrial fibrillation relapses; all thromboembolic events (12/299, 4%) occurred within these patients (P < 0.001). CONCLUSION: Considering this multicenter design study, AVK continuation following AFTCA, especially within patients with low-to-intermediate thromboembolic risk, confers a hemorrhagic risk greater to the thromboembolic protective effect. All thromboembolic events following AFTCA occur within patients experiencing atrial fibrillation relapses; therefore, in patients with high thromboembolic risk routine rhythm monitoring is essential after AVK discontinuation.

Long-term progression from paroxysmal to permanent atrial fibrillation following transcatheter ablation in a large single-center experience.

BACKGROUND: The natural history of atrial fibrillation (AF) is characterized by gradual increase in duration and frequency of relapses until a definitive shift to permanent AF. Heart disease and comorbidities modulate AF progression. However, to date the influence of catheter ablation on AF evolution has rarely been investigated. OBJECTIVE: The purpose of this study was to identify long-term predictors of AF progression in a large cohort of patients undergoing AF transcatheter ablation (AFTCA). METHODS: A total of 889 patients (mean age 57 ± 11 years; 53.3% paroxysmal AF, 40.5% persistent AF, 6.2% long-standing AF) underwent AFTCA. All patients underwent pulmonary vein isolation, with linear lesions and complex fractionated atrial electrogram ablation reserved for patients with persistent/long-standing AF and/or confirmed structural heart disease. RESULTS: After median follow-up of 64 months (range 41-84 years), AF progression despite AFTCA occurred in 57 cases (6.4%). However, AF progression was much more pronounced in patients with persistent (10%) or long-standing persistent AF (14.6%) than in those with paroxysmal AF (2.7%, P <.001). Furthermore, AF progression was more frequently reported in patients who presented with underlying comorbidities/cardiomyopathies (9.1%) than in those who presented with lone AF (29.9%, P <.001). At multivariate analysis, comorbidities/cardiomyopathies and baseline persistent/long-standing AF proved to be independent predictors of progression (odds ratio 11.3, 95% confidence interval 2.6-48.0, P <.001, and odds ratio 1.6, 95% confidence interval 1.2-2.1, P <.001, respectively). CONCLUSION: The presence of comorbidities/cardiomyopathies and persistent/long-standing AF seem to predict AF progression in patients undergoing AFTCA. Performing AFTCA in the paroxysmal phase of the arrhythmia may reduce progression of AF to its permanent form.