Long-Term Outcomes of Left Main Bifurcation Double Stenting in Patients with STEMI and Cardiogenic Shock.

The contribution of different left main (LM) bifurcation stenting techniques on long-term CV mortality has been poorly investigated. We evaluated the 3-year outcomes of revascularization of unprotected complex bifurcation LM in patients with cardiogenic shock (CS) with LM bifurcation/distal disease as culprit lesion. We analyzed 752 consecutive patients with STEMI admitted to our centre from 1 January 2014 to 1 March 2018, searching for patients with CS and complex distal/bifurcation LM disease as culprit lesion who received, at operators' discretion, LM double stenting by means of Culotte, T-stenting/TAP or Nano-crush technique. Fifty-seven patients (23 females, mean age 62.3 ±â€¯10.5 years) with CS and STEMI with distal/bifurcation LM as culprit lesion were identified: 20 patients (35.0%) received Culotte, 16 patients (28.0%) received T-stenting/TAP and 20 (35.0%) received Nano-crush technique. At 3-year follow-up, clinical-driven target lesion revascularization, and mortality rate for all-causes were comparable among different stenting techniques. Conversely, considering 3-year CV mortality as outcome, a statistically significant difference was observed favoring Nano-crush when compared to patients treated with T stenting. Nano-crush obtained a larger improvement of ejection fraction on serial echocardiograms. CS with complex distal/bifurcation LM disease can be treated with acceptable rate of complication and short-term mortality using double stenting techniques. Techniques that minimize rewiring and kissing steps and shorten ischemic time should probably be preferred.

Culotte versus the novel nano-crush technique for unprotected complex bifurcation left main stenting: difference in procedural time, contrast volume and X-ray exposure and 3-years outcomes.

To assess the procedural performance and 3-years outcomes of unprotected complex bifurcation Left Main (LM) stenting using either Culotte or the novel nano-crush techniques, consisting in the use of two ultra-thin strut stents with a 1-ring stent crushed into the LM. We analysed the records of patients with complex distal/bifurcation LM disease and contraindications and/or refusal of bypass surgery, who from 1 January 2014 to 1 November 2017, received at operators' discretion LM double stenting by means of nano-crush technique using Orsiro (Biotronik Inc, Bulack, Switzerland) or Onyx (Medtronic Inc, Galway, Ireland) stents or Culotte stenting using same stent platforms. Among 65 patients (28 females, mean age 77.2 ± 6.2 years), 32 received nano-crush while 33 patients received Culotte technique. Mean angles between left anterior descending coronary artery and left circumflex was 63.6 ± 21.3°. Post-operative success was achieved in 100% of cases. Nano-crush patients showed lower contrast medium volume and X-ray exposure, shorter fluoroscopy and procedural times compared to Culotte patients group. At a mean follow-up of 27.4 ± 10.8 months, clinical-driven target lesion revascularization, myocardial infarction and cardiovascular death were 0 versus 4/33 (12.1%, p = 0.04), 1/32 (3.1%) versus 6/33 (18.1%, p = 0.03) and 2/32 (6.2%) versus 8/33 (24.2%, p = 0.04) in nano-crush versus Culotte patients, respectively. In this single center study, the nano-crush technique was associated with less use of contrast, less procedural time and less X-ray exposure compared to the culotte technique for the treatment of unprotected left main bifurcation lesions.

Usefulness of the Finet law to guide stent size selection in ostial left main stenting: Comparison with standard angiographic estimation.

BACKGROUNDS: Intravascular ultrasound has been suggested to optimize stent diameter and length in Left Main (LM) procedures, but in the real-world ostial LM stenting is often accomplished with angiography only guidance. The Finet law which regulates the fractal geometry of human bifurcation has the potential to increase the accuracy of stent-sizing. To retrospectively evaluating the impact on outcomes of the addition of Finet Law to standard quantitative coronary angiography (QCA) in guiding stent selection of ostial LM stenting compared to standard angiography estimation. METHODS: We retrospectively evaluated the clinical and instrumental records of patients with isolated ostial LM disease and bypass surgery contraindications or refusal as determined by the local Heart Team who received stenting from 1 January 2012 to 1 January 2017 at Rovigo General Hospital. Patients were discrimined on the basis of the addition to QCA angiographic evaluation of the Finet-law. RESULTS: Seventy-three patients (45 males, mean age 69.9 ±â€¯10.9 years old) ostial LM stenting, 36 patients using QCA and Finet law (QCA-Finet) and 37 using standard QCA angiographic (QCA-angio) evaluation of the vessel diameter. By QCA, vessel size, mean stent diameter at implantation and after post-dilatation were clearly bigger in the QCA+ Finet than QCA-angio (4.4 ±â€¯0.8 and 3.8 ±â€¯0.7, p < 0.001). At a mean follow-up of 5.0 ±â€¯0.4 years, cardiovascular mortality and cardiovascular events incidence were higher in QCA-angio compared to QCA+Finet group of patients. CONCLUSIONS: Our study suggested that adding the Finet law to standard angiography estimation of the LM stent size may improve long-term outcomes.

Hemodynamic comparison of different multisites and multipoint pacing strategies in cardiac resynchronization therapies.

PURPOSE: In order to increase the responder rate to CRT, stimulation of the left ventricular (LV) from multiple sites has been suggested as a promising alternative to standard biventricular pacing (BIV). The aim of the study was to compare, in a group of candidates for CRT, the effects of different pacing configurations-BIV, triple ventricular (TRIV) by means of two LV leads, multipoint (MPP), and multipoint plus a second LV lead (MPP + TRIV) pacing-on both hemodynamics and QRS duration. METHODS: Fifteen patients (13 male) with permanent AF (mean age 76 ± 7 years; left ventricular ejection fraction 33 ± 7%; 7 with ischemic cardiomyopathy; mean QRS duration 178 ± 25 ms) were selected as candidates for CRT. Two LV leads were positioned in two different branches of the coronary sinus. Acute hemodynamic response was evaluated by means of a RADI pressure wire as the variation in LVdp/dtmax. RESULTS: Per patient, 2.7 ± 0.7 veins and 5.2 ± 1.9 pacing sites were evaluated. From baseline values of 998 ± 186 mmHg/s, BIV, TRIV, MPP, and MPP-TRIV pacing increased LVdp/dtmax to 1200 ± 281 mmHg/s, 1226 ± 284 mmHg/s, 1274 ± 303 mmHg, and 1289 ± 298 mmHg, respectively (p < 0.001). Bonferroni post-hoc analysis showed significantly higher values during all pacing configurations in comparison with the baseline; moreover, higher values were recorded during MPP and MPP + TRIV than at the baseline or during BIV and also during MPP + TRIV than during TRIV. Mean QRS width decreased from 178 ± 25 ms at the baseline to 171 ± 21, 167 ± 20, 168 ± 20, and 164 ± 15 ms, during BIV, TRIV, MPP, and MPP-TRIV, respectively (p < 0.001). CONCLUSIONS: In patients with AF, the acute response to CRT improves as the size of the early activated LV region increases.

Ketamine and midazolam differently impact post-intubation hemodynamic profile when used as induction agents during emergency airway management in hemodynamically stable patients with ST elevation myocardial infarction.

We investigated the incidence of post-intubation hypotension (PIH) in hemodynamically stable patients with STEMI requiring rapid sequences intubation (RSI) and medicated with ketamine or midazolam as induction agent. STEMI patients admitted between 1st January 2009 and 1st January 2017 who did not receive any type of inotropic support before the endotracheal intubation (ETI) was reviewed. PIH was defined as a reduction greater than 20% or a drop of systolic blood pressure (SBP) below 90 mmHg within 10 min from the administration of the induction agent [ketamine (1 mg/kg) or midazolam (0.3 mg/kg)]. Over the study period, 136 patients (66 male and 70 females, mean age 72.25 ± 7.33 years) met the inclusion criteria. Patients treated with midazolam and ketamine were 63 and 73, respectively. PIH was observed in 38 (27.9%) patients after 10 min from ETI. Midazolam patients had a significant lower SBP at both 5 and 10 min after induction (97.75 ± 8.06 vs 100.81 ± 8.08, p = 0.029 and 92.83 ± 7.53 vs 101.58 ± 7.29, p < 0.0001, respectively) (ANOVA p < 0.0001). Age (OR 1.91, 95% CI 1.87-1.97, p = 0.001), history of arterial hypertension (OR 2.27, 95% CI 2.21-2.35, p = 0.0001), multivessel coronary artery disease (OR 2.66, 95% CI 2.58-2.71, p = 0.001), SI ≥0.9 (OR 2.41, 95% CI 2.36-2.48, p < 0.0001) and anterior STEMI (OR 2.51, 95% CI 2.48-2.57, p = 0.0001) resulted independent predictors of PIH in STEMI patients treated with midazolam, as induction agent, before ETI. Midazolam was more likely than ketamine to cause significant PIH when used as an induction agent for RSI in hemodynamically stable patients with STEMI.

Modified balloon aortic valvuloplasty in fragile symptomatic patients unsuitable for both surgical and percutaneous valve replacement.

BACKGROUND: Balloon Aortic valvuloplasty (BAV) is considered as a bridge therapy to percutaneous valve implantation or a palliative treatment in patients with aortic valve stenosis (AVS). Potential risk of complications, in particular in fragile patients, is still not negligible. AIM: To describe the technique and outcomes of modified BAV in fragile symptomatic patients unsuitable for other treatments using no-pacing and minimally invasive approach. METHODS: Symptomatic fragile patients with severe aortic valve stenosis judged unsuitable by the heart team for surgical or percutaneous valve implantation from 1 September 2013 to 1 September 2017 were offered modified BAV. Simplified procedural protocol included a 4F right radial artery access for gradient check, a 8F compatible undersized balloons, two partial inflations-trial before a full inflation with no-pace maker back-up, final pressure gradient recording and aortography. RESULTS: Thirty-four symptomatic fragile patients (mean age 80.9±4.9, range 73 to 91years, 100% Katz >6, mean Euroscore I 30.0±11.7%) underwent modified BAV in the last 5years with immediate success in all (100%). Mean aortic valve area increased from 0.58±0.2cm2 to 1.1±0.2cm2 (p<0.01) whereas mean peak gradient decreased from 75.6±11.3 to 35.8±11.2mmHg (p<0.01). Procedural complications were 14.7%. Thirty-day mortality was 11.8%. On a mean follow up of 38.4±4.6months four patients successfully repeated the procedure, while global mortality was 23.5% (8 patients). The other 22 patients maintained a NYHA class of 2.1±0.7. CONCLUSIONS: No-pacing minimally invasive BAV seems to have acceptable outcomes in patients with severe AVS and no other treatment options.

Comparative Computed Flow Dynamic Analysis of Different Optimization Techniques in Left Main Either Provisional or Culotte Stenting.

BACKGROUND AND OBJECTIVES: Provisional and culotte are the most commonly used techniques in left main (LM) stenting. The impact of different post-dilation techniques on fluid dynamic of LM bifurcation has not been yet investigated. The aim of this study is to evaluate, by means of computational fluid dynamic analysis (CFD), the impact of different post-dilation techniques including proximal optimization technique (POT), kissing balloon (KB), POT-Side-POT and POT-KB-POT, 2-steps Kissing (2SK) and Snuggle Kissing balloon (SKB) on flow dynamic profile after LM provisional or culotte stenting. METHODS: We considered an LM-LCA-LCX bifurcation reconstructed after reviewing 100 consecutive patients (mean age 71.4 ± 9.3 years, 49 males) with LM distal disease. The diameters of LAD and LCX were modelled according to the Finnet's law as following: LM 4.5 mm, LAD 3.5 mm, LCX 2.75 mm, with bifurcation angle set up at 55°. Xience third-generation stent (Abbot Inc., USA) was reconstructed and virtually implanted in provisional/cross-over and culotte fashion. POT, KB, POT-side-POT, POT-KB-POT, 2SK and SKB were virtually applied and analyzed in terms of the wall shear stress (WSS). RESULTS: Analyzing the provisional stenting, the 2SK and KB techniques had a statistically significant lower impact on the WSS at the carina, while POT seemed to obtain a neutral effect. In the wall opposite to the carina, the more physiological profile has been obtained by KB and POT with higher WSS value and smaller surface area of the lower WSS. In culotte stenting, at the carina, POT-KB-POT and 2SK had a very physiological profile; while at the wall opposite to the carina, 2SK and POT-KB-POT decreased significantly the surface area of the lower WSS compared to the other techniques. CONCLUSION: From the fluid dynamic point of view in LM provisional stenting, POT, 2SK and KB showed a similar beneficial impact on the bifurcation rheology, while in LM culotte stenting, POT-KB-POT and 2SK performed slightly better than the other techniques, probably reflecting a better strut apposition.

Incremental Value of the CRUSADE, ACUITY, and HAS-BLED Risk Scores for the Prediction of Hemorrhagic Events After Coronary Stent Implantation in Patients Undergoing Long or Short Duration of Dual Antiplatelet Therapy.

BACKGROUND: Multiple scores have been proposed to stratify bleeding risk, but their value to guide dual antiplatelet therapy duration has never been appraised. We compared the performance of the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines), ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy), and HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) scores in 1946 patients recruited in the Prolonging Dual Antiplatelet Treatment After Grading Stent-Induced Intimal Hyperplasia Study (PRODIGY) and assessed hemorrhagic and ischemic events in the 24- and 6-month dual antiplatelet therapy groups. METHODS AND RESULTS: Bleeding score performance was assessed with a Cox regression model and C statistics. Discriminative and reclassification power was assessed with net reclassification improvement and integrated discrimination improvement. The C statistic was similar between the CRUSADE score (area under the curve 0.71) and ACUITY (area under the curve 0.68), and higher than HAS-BLED (area under the curve 0.63). CRUSADE, but not ACUITY, improved reclassification (net reclassification index 0.39, P=0.005) and discrimination (integrated discrimination improvement index 0.0083, P=0.021) of major bleeding compared with HAS-BLED. Major bleeding and transfusions were higher in the 24- versus 6-month dual antiplatelet therapy groups in patients with a CRUSADE score >40 (hazard ratio for bleeding 2.69, P=0.035; hazard ratio for transfusions 4.65, P=0.009) but not in those with CRUSADE score ≤40 (hazard ratio for bleeding 1.50, P=0.25; hazard ratio for transfusions 1.37, P=0.44), with positive interaction (Pint=0.05 and Pint=0.01, respectively). The number of patients with high CRUSADE scores needed to treat for harm for major bleeding and transfusion were 17 and 15, respectively, with 24-month rather than 6-month dual antiplatelet therapy; corresponding figures in the overall population were 67 and 71, respectively. CONCLUSIONS: Our analysis suggests that the CRUSADE score predicts major bleeding similarly to ACUITY and better than HAS BLED in an all-comer population with percutaneous coronary intervention and potentially identifies patients at higher risk of hemorrhagic complications when treated with a long-term dual antiplatelet therapy regimen. CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique identifier: NCT00611286.

Comparison of myocardial deformation and velocity dyssynchrony for identification of responders to cardiac resynchronization therapy.

AIMS: It is unclear whether myocardial velocity or deformation indices of dyssynchrony are better at predicting response to cardiac resynchronization therapy (CRT). Therefore, two indices of left ventricular (LV) dyssynchrony based on myocardial velocity and deformation were compared to predict success of CRT. METHODS AND RESULTS: Sixty patients with dilated cardiomyopathy, New York Heart Association class III-IV, LV ejection fraction (EF) < or =35%, QRS >120 ms underwent CRT. The standard deviation of the averaged time-to-peak longitudinal negative strain (Tepsilon-SD) and positive systolic velocity (Tv-SD) of 12 LV segments were calculated before and after 6 months of CRT. Responders were defined at month 6 by > or =20% EF increase and/or > or =15% end-systolic volume (ESV) decrease with respect to baseline. On univariable analysis, baseline Tepsilon-SD and Tv-SD were both significantly associated with CRT response; however, the area under the receiver operating characteristic curve was better for Tepsilon-SD. On bivariable analysis, only Tepsilon-SD retained an independent prognostic value for CRT response. Results of the analysis did not change when the logistic models were adjusted for aetiology. CONCLUSION: Baseline dyssynchrony of longitudinal myocardial peak deformation (Tepsilon-SD) appears to be better than dyssynchrony of longitudinal myocardial peak systolic velocities (Tv-SD) for the identification of CRT responders.