Impact of vessel volume on thermodilution measurements in patients with coronary microvascular dysfunction.

BACKGROUND: Two invasive methods are available to estimate microvascular resistance: bolus and continuous thermodilution. Comparative studies have revealed a lack of concordance between measurements of microvascular resistance obtained through these techniques. AIMS: This study aimed to examine the influence of vessel volume on bolus thermodilution measurements. METHODS: We prospectively included patients with angina with non-obstructive coronary arteries (ANOCA) undergoing bolus and continuous thermodilution assessments. All patients underwent coronary CT angiography to extract vessel volume. Coronary microvascular dysfunction was defined as coronary flow reserve (CFR) < 2.0. Measurements of absolute microvascular resistance (in Woods units) and index of microvascular resistance (IMR) were compared before and after volumetric adjustment. RESULTS: Overall, 94 patients with ANOCA were included in this study. The mean age was 64.7 ± 10.8 years, 48% were female, and 19% had diabetes. The prevalence of CMD was 16% based on bolus thermodilution, while continuous thermodilution yielded a prevalence of 27% (Cohen's Kappa 0.44, 95% CI 0.23-0.65). There was no correlation in microvascular resistance between techniques (r = 0.17, 95% CI -0.04 to 0.36, p = 0.104). The adjustment of IMR by vessel volume significantly increased the agreement with absolute microvascular resistance derived from continuous thermodilution (r = 0.48, 95% CI 0.31-0.63, p < 0.001). CONCLUSIONS: In patients with ANOCA, invasive methods based on coronary thermodilution yielded conflicting results for the assessment of CMD. Adjusting IMR with vessel volume improved the agreement with continuous thermodilution for the assessment of microvascular resistance. These findings strongly suggest the importance of considering vessel volume when interpreting bolus thermodilution assessment.

Combined Cardiac Damage Staging by Echocardiography and Cardiac Catheterization in Patients With Clinically Significant Aortic Stenosis.

BACKGROUND: Cardiac damage (CD) staging enhances risk stratification in patients with clinically significant aortic stenosis (AS). We aimed to assess the prognostic value and reclassification rate of right heart catheterization (RHC) compared with transthoracic echocardiography (TTE) in characterising CD staging at 3-year follow-up in patients with clinically significant AS, to identify patients that would benefit from RHC for prognostic stratification, and to test the prognostic value of combined CD staging. METHODS: An observational cohort study of 432 AS patients undergoing TTE and RHC were divided into moderate or asymptomatic severe (m/asAS) and symptomatic severe (ssAS) AS. Kaplan-Meier curves were used to compare survival. The accuracy in prognostic stratification was tested by area under the receiver operating characteristic curve analysis and Delong test. RESULTS: In both cohorts, TTE- and RHC-derived staging systems had prognostic value, although the agreement between them appeared moderate. A higher proportion of patients were assigned to stage 2 by TTE than by RHC. Patients in TTE-derived stage 2 had a high reclassification rate, with 40%-50% presenting with right chamber involvement (stages 3-4) according to RHC. Discordant cases were significantly older, with higher prevalence of atrial fibrillation, markedly elevated N-terminal pro-B-type natriuretic peptide, and higher indexed left atrial volume, E/e', and systolic pulmonary artery pressure vs concordant cases (P < 0.05). The combined CD staging, integrating TTE and RHC, was more accurate in predicting mortality than the TTE-derived system (P < 0.05). CONCLUSIONS: In patients with m/asAS and ssAS, the combined CD staging, derived from TTE and RHC, was more accurate in predicting mortality than TTE alone. In a subset of AS patients, the integration of RHC may significantly improve prognostic stratification.

Ischemia With No Obstructive Coronary Artery Disease: Are Misdiagnosis and Undertreatment Always Behind the Corner?

Ischemia with no obstructive coronary artery disease (INOCA) is not an uncommon diagnosis in patients presenting with chest pain who undergo clinically indicated coronary angiography. However, the symptoms reported by patients with INOCA may be heterogeneous, leading to misdiagnosis and undertreatment. Herein we report 3 clinical cases of INOCA misdiagnosis and describe how the cases were reinvestigated following the appropriate diagnostic pathway. (Level of Difficulty: Advanced.).

Comprehensive invasive evaluation of coronary microcirculation in patients with Takotsubo syndrome.

BACKGROUND AND AIMS: The etiology and pathophysiology of Takotsubo syndrome (TTS) remain a matter of debate. In murine models of coronary microvascular dysfunction (CMD), abnormalities in myocardial perfusion led to the development of TTS. Importantly, TTS was reversible when normal perfusion was restored. However, in clinical practice, the assessment of coronary microcirculation in patients with TTS has primarily relied on non-invasive or indirect, angiography-derived methods. METHODS AND RESULTS: For the first time, we performed invasive microcirculatory assessment, by both validated techniques currently available in the catheterization laboratory, namely intracoronary bolus and continuous thermodilution, in patients with TTS, upon hospital admission and at short term follow-up. Our findings demonstrate that CMD was consistently present in all patients upon hospital admission, as assessed by both techniques. At a median follow-up of 3 months, after the recovery of left ventricular ejection fraction, two third of patients no longer exhibited CMD. CONCLUSIONS: These findings support the hypothesis that an acute and transient worsening in coronary microvascular function plays a pivotal role in the pathophysiology of TTS.

[Ischemia with non-obstructive coronary artery disease: state-of-the-art review]. / L'ischemia miocardica in assenza di coronaropatia ostruttiva: stato dell'arte.

Chest pain affects more than 100 million people globally, however up to 70% of patients undergoing invasive angiography do not have obstructive coronary artery disease and ischemia with non-obstructive coronary artery disease (INOCA) is often a cause of the clinical picture. The symptoms reported by INOCA patients are very heterogeneous and often misdiagnosed as non-cardiac leading to under-diagnosis/investigation and under-treatment. The underlying pathophysiological mechanisms of INOCA are multiple and include coronary vasospasm and microvascular dysfunction. Most importantly, this condition must not be considered benign: compared to asymptomatic individuals, INOCA patients present an increased incidence of cardiovascular events, rehospitalizations, as well as impaired quality of life, with increasing costs for healthcare systems. The aims of this review are to describe the pathophysiological and clinical characteristics of INOCA and to provide guidance to the medical community on the diagnostic approaches and management of INOCA, also via a series of clinical case reports.

Dual left anterior descending coronary artery and anomalous origin of left circumflex artery: a novel coronary anomaly revealed by CCTA.

In the rare coronary anomaly of Dual LAD, two segments of the vessel reside within the anterior interventricular sulcus. In our case, the short LAD originated from the Left Coronary Sinus (LCS), while the long LAD emerged from the Right Coronary Sinus (RCS). The LCx arose from the RCS, and the RCA displayed typical features. This anomaly was deemed incidental, prompting routine follow-up. It underscores the significance of integrating CCTA for a thorough assessment, offering crucial insights for patient management.

Innovative Device-Based Strategies for Managing Acute Decompensated Heart Failure.

Acute decompensated heart failure (ADHF) is a major cause of hospitalizations in older adults, leading to high mortality, morbidity, and healthcare costs. To address the persistent poor outcomes in ADHF, novel device-based approaches targeting specific pathophysiological mechanisms are urgently needed. The recently introduced DRI2P2S classification categorizes these innovative therapies based on their mechanisms. Devices include dilators (increasing venous capacitance), removers (directly removing sodium and water), inotropes (enhancing left ventricular contractility), interstitials (accelerating lymph removal), pushers (increasing renal arterial pressure), pullers (decreasing renal venous pressure), and selective drippers (selective intrarenal drug infusion). Some are tailored for chronic HF, while others focus on the acute setting. Most devices are in early development, necessitating further research to understand mechanisms, assess clinical effectiveness, and ensure safety before routine use in ADHF management. Exploring these innovative device-based strategies may lead to improved outcomes and revolutionize HF treatment in the future.

Sex-based Differences in Percutaneous Coronary Intervention Outcomes in Patients with Ischaemic Heart Disease.

In high-income countries, ischaemic heart disease is the leading cause of death in women and men, accounting for more than 20% of deaths in both sexes. However, women are less likely to receive guideline-recommended percutaneous coronary intervention (PCI) than men. Women undergoing PCI have poorer unadjusted outcomes because they are older and have greater comorbidity than men, but uncertainty remains whether sex affects outcome after these differences in clinical characteristics are considered. In this paper, we review recent published evidence comparing outcomes between men and women undergoing PCI. We focus on the sex differences in PCI outcomes in different scenarios: acute coronary syndromes, stable angina and complex lesions, including the approach of left main coronary artery. We also review how gender is considered in recent guidelines and offer a common clinical scenario to illustrate the contemporary management strategies an interventional cardiologist should consider when performing PCI on a female patient.

Mortality across treatment strategies in intermediate-to-high risk pulmonary embolism in the modern era: A meta-analysis of observational studies and RCTs.

INTRODUCTION: Pulmonary embolism (PE) represents one of the leading causes of death worldwide and mainly treated with medical management, although the utility of more invasive approaches has emerged more recently. This meta-analysis aims to evaluate the 30-day mortality of intermediate-to-high risk PE across different treatment strategies. METHODS: A systematic literature review and meta-analysis was conducted using PubMed and Cochrane databases. All studies reporting 30-day mortality rates in intermediate-to-high-risk PE were included. Meta-regression analysis and sensitivity analysis were performed on the primary endpoint, 30-day mortality, and secondary endpoints (RV/LV ratio, mPAP, and long-term mortality, any bleeding events). RESULTS: Of the 2390 studies published between 2000 and 2022, 76 studies (74 observational and 2 RCTs for a total of 1,194,285 patients in the medical cohort and 3007 in the interventional cohort) were included. The median age was 71.4 (IQR 62.8-77.3) years, 53.6% were women. 30-day mortality in the patients treated with medical management was 9.1% (6.6-12.6). In the interventional cohort, 30-day mortality was 2.1% (1.5-3.1) while the pre- vs post-procedure change in mean difference was -6.1 mmHg (-11.2 to -1.1) for mPAP and - 0.41 (-0.51 to - 0.31) for RV/LV ratio. The overall bleeding rate in the interventional cohort was 4.9% (CI 2.6-8.9), without differences between the two strategies (RR 1.26 CI 0.89-1.78). CONCLUSION: Intermediate-high-risk mortality in pulmonary embolisms treated with medical management remains high in the modern era. Despite the absence of comparative studies, an interventional approach may have a lower 30-day mortality rate and a good safety profile.

Impact of in-Hospital Left Ventricular Ejection Fraction Recovery on Long-Term Outcomes in Patients Who Underwent Impella Support for HR PCI or Cardiogenic Shock: A Sub-Analysis from the IMP-IT Registry.

(1) Background: Percutaneous left ventricle assist devices (pLVADs) demonstrated an improvement in mid-term clinical outcomes in selected patients with severely depressed left ventricular ejection fraction (LVEF) undergoing percutaneous coronary interventions. However, the prognostic impact of in-hospital LVEF recovery is unclear. Accordingly, the present sub-analysis aims to evaluate the impact of LVEF recovery in both cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR PCI) supported with pLVADs in the IMP-IT registry. (2) Methods: A total of 279 patients (116 patients in CS and 163 patients in HR PCI) treated with Impella 2.5 or CP in the IMP-IT registry were included in this analysis, after excluding those who died while in the hospital or with missing data on LVEF recovery. The primary study objective was a composite of all-cause death, rehospitalisation for heart failure, left ventricle assist device (LVAD) implantation, or heart transplantation (HT), overall referred to as the major adverse cardiac events (MACE) at 1 year. The study aimed to evaluate the impact of in-hospital LVEF recovery on the primary study objective in patients treated with Impella for HR PCI and CS, respectively. (3) Results: The mean in-hospital change in LVEF was 10 ± 1% (p < 0.001) in the CS cohort and 3 ± 7% (p < 0.001) in the HR PCI group, achieved by 44% and 40% of patients, respectively. In the CS group, patients with less than 10% in-hospital LVEF recovery experienced higher rates of MACE at 1 year of follow-up (FU) (51% vs. 21%, HR 3.8, CI 1.7-8.4, p < 0.01). After multivariate analysis, LVEF recovery was the main independent protective factor for MACE at FU (HR 0.23, CI 0.08-0.64, p = 0.02). In the HR PCI group, LVEF recovery (>3%) was not associated with lower MACE at multivariable analysis (HR 0.73, CI 0.31-1.72, p = 0.17). Conversely, the completeness of revascularisation was found to be a protective factor for MACE (HR 0.11, CI 0.02-0.62, p = 0.02) (4) Conclusions: Significant LVEF recovery was associated with improved outcomes in CS patients treated with PCI during mechanical circulatory support with Impella, whereas complete revascularisation showed a significant clinical relevance in HR PCI.

Peripartum Cardiogenic Shock and Mechanical Circulatory Support.

Despite remarkable improvements in the past two decades, the annual cardiovascular mortality rate has remained higher for women than for men. Pregnant women represent an underinvestigated population in clinical research, and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Regarding advanced heart failure during pregnancy, interventional approaches are effective but still underutilised. Percutaneous mechanical circulatory support is a valuable option for peripartum cardiogenic shock, although its use during pregnancy is still limited. Survival rates have improved in recent years, but further emphasis on the importance of early recognition and initiation of heart failure treatment in this patient group is warranted. The aims of this review are to summarise the current literature on the implementation of mechanical circulatory support in cardiogenic shock during pregnancy and delivery and to understand the role of percutaneous ventricular assist devices in the management of such conditions.

Impella RP for Patients with Acute Right Ventricular Failure and Cardiogenic Shock: A Subanalysis from the IMP-IT Registry.

The use of percutaneous right ventricular assist devices (pRVADs) to support patients with right ventricular (RV)-predominant cardiogenic shock (CS) refractory to optimal medical therapy is increasing progressively, and the Impella RP is the first FDA-approved pRVAD in such a clinical scenario. The aim of the present study is to report the outcomes of patients treated with Impella RP in the IMP-IT (IMPella Mechanical Circulatory Support Device in Italy) registry, a multicenter registry that evaluated the trends in use and clinical outcomes of the Impella in the setting of CS and high-risk percutaneous coronary intervention in Italy. A total of 15 patients who received Impella RP were enrolled. In 40% of the patients, the main cause was ST-segment elevation myocardial infarction. A total of 40% of patients required biventricular support with a left Impella. Device-related complications were reported in 46.7% of patients. Overall, the in-hospital mortality was 46.7%, whereas the one-year mortality was 53.3%. The composite rate of all-cause death, heart failure (HF) hospitalization, left ventricular assist device (LVAD) and heart transplant at one year was 60%. The Impella RP has favorable survival outcomes in RV-predominant cardiogenic shock. However, the device-related complications are frequent and should be carefully weighed when considering escalation to Impella RP.