Intracardiac total anomalous pulmonary venous return or septum primum malposition? Complete repair in left atrial isomerism.

Total anomalous pulmonary venous return due to septum primum malposition is a poorly understood condition despite being very common in left atrial isomerism or polysplenia syndrome. Due to the leftward displacement of the septum primum, either the two right pulmonary veins or all four pulmonary veins can drain abnormally into the right atrium, despite their correct position. In other words, the four pulmonary veins (or the two right pulmonary veins), looking from outside the heart, return at the back of the atrium in the normal position. Nevertheless, from the inside of the heart, two or all four pulmonary veins drain into the right atrium due to the leftward displacement of the septum primum. As an example, we report a 5-month-old patient with severe malposition of the septum primum and consequent total anomalous pulmonary venous drainage into the right atrium. The patient underwent surgical correction with resection of the malpositioned septum primum and reconstruction of a normal interatrial septation with a pericardial patch.

The Norwood operation performed with the heart beating and no prosthetic materials.

The Norwood procedure performed with the heart beating is a useful and attractive way to perform the stage I palliation for hypoplastic left heart syndrome. It allows completion of the surgical procedure without stopping the heart and without using deep hypothermia and circulatory arrest. Therefore it could be an attractive solution for reducing the adverse effects of the operation and the rate of postoperative complications. Moreover, this technique avoids the use of prosthetic materials, thus minimizing long-term complications and reoperations, and promotes a more physiological growth of the anatomical structures. However, the high level of expertise required to perform this type of complex neonatal procedure with the heart beating may be limited to only a few centers in the world thus far.

Type A Aortic Dissection in an 11-month-old Infant With Loeys-Dietz Syndrome.

Type A aortic dissection is a very uncommon finding in children, especially among infants, where no cases seem to have been described. We report the case of an 11-month-old boy with Loeys-Dietz syndrome and asymptomatic type A aortic dissection involving the aortic root that was successfully repaired.

Multiple MGuard stent implantation to treat massive right coronary artery dissection during primary coronary angioplasty.

Here we report a case of a 79-year-old woman with inferior myocardial infarction, transferred to our cath lab to perform a primary percutaneous coronary intervention (PPCI). During the procedure, a massive dissection complicated the thrombotic lesion of the right coronary artery (RCA). In this case, we decided to use the MGuard stent to treat both the large dissection and the thrombotic lesion. MGuard stent is a combination of a coronary stent merged with an embolic protection device. After multiple MGuard stent implantation we obtained a complete resolution of the coronary dissection obtaining a patent RCA with normal antegrade flow.

Is direct stenting superior to stenting with predilation in patients treated with percutaneous coronary intervention? Results from a meta-analysis of 24 randomised controlled trials.

BACKGROUND: In the last decade, direct stenting has been proposed as an alternative strategy to conventional stenting with balloon predilation. The aim of this study was to perform a meta-analysis of randomised trials comparing a direct stenting strategy versus a conventional one. METHODS: A literature search was performed using Medline, EMBASE, the Cochrane Central Register of Controlled Trials, scientific session abstracts and relevant websites, from inception of each database to June 2009. Included studies comprised randomised controlled trials evaluating direct versus conventional stenting in patients undergoing percutaneous coronary intervention. Primary endpoint was the composite of death or myocardial infarction and secondary endpoints were myocardial infarction and target-vessel revascularisation occurrence. RESULTS: 24 trials met inclusion criteria, with 6803 patients enrolled (3412 or 50.15% randomised to direct stenting and 3391 or 49.85% randomised to conventional stenting). Up to 6-month follow-up, the composite of death or myocardial infarction was significantly reduced with direct stenting compared with conventional stenting (3.95% versus 5.10% respectively, OR=0.76 (95% CI 0.60 to 0.96), p=0.02). This reduction was primarily driven by a lower myocardial infarction occurrence (3.16% versus 4.04%, respectively, OR=0.77 (0.59 to 0.99), p=0.04). Furthermore, direct stenting was not associated with a reduction in target-vessel revascularisation (6.50% versus 6.96%, respectively, OR=0.92 (0.76 to 1.12), p=0.42). CONCLUSION: This meta-analysis demonstrates that, in selected coronary lesions, direct stenting improves outcome in patients undergoing percutaneous coronary intervention, primarily reducing myocardial infarction incidence.

Effect of drug-eluting stents in patients with acute ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: a meta-analysis of randomised trials and an adjusted indirect comparison.

AIMS: The role of drug-eluting stent (DES) remains an unsettled issue in patients with ST-segment elevation myocardial infarction (STEMI). Therefore, we performed a meta-analysis of randomised trials to evaluate the clinical outcome of DES as compared with bare-metal stent (BMS) after percutaneous coronary intervention (PCI). METHODS AND RESULTS: We undertook a literature search until July 2009. Thirteen clinical trials met inclusion criteria, with 7,244 patients enrolled. Up to 1-year, patients treated with DES as compared with BMS experienced less target-vessel revascularisation (TVR) (5.11% versus 11.19% respectively, p<0.00001) and recurrent myocardial infarction rates (3.03% versus 3.70% respectively, p=0.02). In addition, no significant differences were found in terms of cardiac death (2.80% versus 3.52%, p=0.21) and stent thrombosis (2.65% versus 2.76%, p=0.37). Using the adjusted indirect comparison, a significant difference between sirolimus- and paclitaxel-eluting stent was found when TVR was evaluated (OR [95% CI] =0.59 [0.40-0.89], p=0.01), without differences in other clinical outcomes. CONCLUSIONS: In patients undergoing PCI for STEMI, treatment with DES is associated with decreased TVR and myocardial infarction rates, without increasing cardiac death or stent thrombosis occurrence. Sirolimus-eluting stent is associated with a greater TVR reduction as compared to paclitaxel-eluting stent.

Tirofiban administration and percutaneous coronary intervention with stenting of saphenous vein graft thrombosis.

Distal embolization during percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) lesions is associated with a high risk of myonecrosis and myocardial infarction. PCI guidelines advocate the use of distal embolic protection devices, when technically feasible, in patients undergoing PCI for SVG disease. To date, alternative management strategies are not fully investigated. We report a case of an 84-year-old male patient with acute coronary syndrome who underwent PCI for a quite occlusive stenosis of an SVG on the first diagonal branch of the left anterior descending artery complicated by wide endoluminal thrombosis with poor antegrade coronary blood flow and absent opacity of the distal first diagonal vessel. A strategy of delayed PCI after upstream, 48 h long tirofiban administration in order to obtain a thrombus burden reduction was decided. After tirofiban administration, a high-level thrombus resolution was obtained, with a significant improvement in coronary flow, and a successful PCI with stenting was performed. There was neither clinical nor instrumental periprocedural sign of ischemia, and the patient remained asymptomatic throughout his hospital stay. Preprocedural tirofiban administration followed by PCI with stenting of an SVG thrombotic lesion without a distal protection device might be a well-tolerated and feasible option for patients with degenerated SVG disease. Further studies are needed to further expand our findings.

[Cycle ergometer stress testing for identification of significant coronary artery disease: improved accuracy by the use of chronotropic reserve adjustment of ST-segment depression]. / Accuratezza diagnostica del test al cicloergometro: superiorità dell'indicizzazione del sottoslivellamento del tratto ST per la riserva cronotropa nell'identificare una coronaropatia emodinamicamente significativa.

BACKGROUND: Diagnostic reliability of indexations of peak exercise ST-segment depression (deltaST) for heart rate reserve (HRi) or chronotropic reserve (CR) to identify significant coronary artery disease (CAD) by bicycle exercise testing has not been evaluated previously. METHODS: Upright bicycle exercise testing (25 W increment every 3 min) was performed in consecutive patients in primary prevention with at least one of the following criteria: history of exercise-induced chest discomfort and cardiovascular risk factors; overt peripheral arterial disease; type 2 diabetes associated with two or more additional cardiovascular risk factors. Coronary angiography was performed to define significant CAD (stenosis > or = 70% of the main coronary arteries or of their major branches, or isolated left main stenosis > or = 50%, or two or more stenoses 50-69%). Duke angina index was used to grade exercise-induced chest pain; deltaST, ST/HRi and ST/CR were calculated at peak exercise; three different criteria for the definition of inducible myocardial ischemia were tested versus significant CAD: peak deltaST > or =100 microV, ST/HRi > 1.69 microV/b/min or ST/CR > 1.76 microV/%. RESULTS: Of the study sample (n = 46), 40% had typical angina; during stress test 80% showed deltaST > or = 100 microV; 76% had ST/HRi > 1.69 microV/b/min; 62% had ST/CR >1.76 microV/%. Diagnostic accuracy of deltaST > or = 100 microV, of ST/HRi > 1.69 micro5V/b/min, and of ST/CR > 1.76 microV/% were 78%, 72%, and 89% respectively (p < 0.001 for the difference in diagnostic performance). ST/CR > 1.76 microV/% showed the highest diagnostic accuracy both in patients with submaximal exercise (96%) and in women (92%). Similarly, ST/CR >1.76 microV/% was associated with the highest diagnostic accuracy both in patients with maximal exercise (78%) and in men (88%). Analyses of the ROC curve revealed that ST/CR was associated with the greatest area under the curve, and a population-specific cut-off of 1.77 microV/% was associated with a sensitivity of 88% and a specificity of 90%. CONCLUSIONS: Our pilot study suggests that in patients undergoing bicycle stress testing for differential diagnosis or screening of significant CAD, and with moderate-to-high pre-test probability, the use of ST/CR > 1.76 microV/% may provide elevated sensitivity and specificity, and the best diagnostic accuracy, which was consistent in patients with submaximal exercise test and in women.

Acute aortic syndromes at high surgical risk: the endovascular approach.

AIMS: Acute aortic syndromes (AAS) still represent life-threatening conditions. The aim of this study was to describe our experience in the management of patients (pts) with AAS and to evaluate the safety and feasibility of endovascular treatment (EVT) in high surgical risk patients. METHODS AND RESULTS: One hundred and four patients underwent EVT. We selected 56 pts with AAS: 17 complicated type B aortic dissections, five traumatic aortic ruptures at the isthmus, 11 thoracic aneurysms and 23 pts with large AAA with impending rupture. All these pts were at high surgical risk because of their comorbidities and/or their emergency situation. They were clinically followed during hospitalisation and they underwent a 2 mm-interval CT-scan two weeks, six and 12 months after discharge and every year after. Death, paraplegia, open surgical conversion did not occur. Two pts underwent a successful secondary EVT for type I endoleak. One patient with thoracic aortic aneurysm died of septic shock from pneumonia 78 days after discharge and two pts with AAA suffering from a severe three-vessel coronary disease experienced sudden death at one year follow-up. CONCLUSIONS: EVT seems to be a safe and effective therapeutic option with good short- and midterm results in patients with AAS at high surgical risk. Thus, it can be considered as a less-invasive alternative in patients considered otherwise unsuitable for conventional surgery, even though a careful, continued follow-up is still necessary to confirm the long-term safety and effectiveness of EVT in AAS.

Cycle-ergometry stress testing and use of chronotropic reserve adjustment of ST depression for identification of significant coronary artery disease in clinical practice.

Diagnostic reliability of indexations of peak exercise ST segment depression (DeltaST) for heart rate reserve (HRi) or chronotropic reserve (CR) to identify significant coronary artery disease (CAD) by cycle-ergometer exercise testing has not been evaluated previously. Exercise testing by upright cycle-ergometer (25 W/3 min) were performed in consecutive patients in primary prevention with history of exercise-related chest discomfort and cardiovascular risk factors, or with overt peripheral artery disease, with or type-2 diabetes associated with two or more additional cardiovascular risk factors. Coronary angiography was performed after the test to assess significant CAD. Three different criteria for definition of inducible myocardial ischemia were tested versus significant CAD: peak DeltaST>or=100 microV, ST/HRi>1.69 microV/bpm or ST/CR>1.76 microV/%. Diagnostic accuracy vs. CAD of DeltaST>or=100 microV, of ST/HRi>1.69 microV/bpm, and of ST/CR>1.76 microV/% were 78%, 72%, and 89% respectively; sensitivity and specificity of the three criteria were 91% and 50%, 84% and 43%, 88% and 93%, respectively. Abnormal ST/CR predicted CAD independent of risk factors, pre-test probability, and more strongly than DeltaST. Combination of ST/HRi and ST/CR criteria did not improve CAD prediction. In conclusions, in clinical setting in patients in primary prevention but with moderate-to-high pre-test probability of CAD, exercise testing by cycle-ergometry and use of ST/CR>1.76 microV/% showed elevated sensitivity and specificity, and the best accuracy for diagnosis of significant CAD.