[Second-degree atrioventricular block caused by Lyme disease]. / Tweedegraads atrioventriculair blok door lymeziekte.

BACKGROUND: Tick-borne diseases, including Lyme disease, are becoming increasingly common in Europe. Lyme disease has a wide variety of clinical manifestations, as a result of which physicians of diverse disciplines are coming into contact with such patients. CASE DESCRIPTION: A 58-year-old man was seen at the emergency room with a symptomatic Wenckebach-type second-degree atrioventricular (AV) block and periods of 2:1 AV block. Four weeks previously the patient had noticed a red skin lesion on his left lower leg. Under the working diagnosis of early disseminated Lyme disease with cardiac involvement, treatment with ceftriaxone was started. This diagnosis was supported by a positive Borrelia PCR and culture of a skin biopsy and positive Borreliaserology. The AV conduction disorders resolved completely after 2 weeks of treatment with antibiotics and it was not necessary to implant a pacemaker. CONCLUSION: A Borrelia infection is a reversible but rare cause of AV conduction disorders. In the event of sudden onset of symptoms or a severe or progressive AV conduction disorder, Lyme carditis should be considered, especially if the medical history or physical examination provides clues for Lyme disease.

Five-year clinical follow-up of the STENTYS self-apposing stent in complex coronary anatomy: a single-centre experience with report of specific angiographic indications.

OBJECTIVES: We sought to investigate angiographic indications for the use of the STENTYS technique and evaluated the long-term safety and clinical efficacy of the stent. BACKGROUND: Coronary lesions involving complex anatomy, including aneurysmatic, ectatic, or tapered vessel segments often carry a substantial risk of stent malapposition. The self-apposing stent technique may reduce the risk of stent malapposition and therefore improve clinical outcomes. METHODS: A total of 120 consecutive patients treated with the STENTYS stent were included (drug-eluting stent (DES) n = 101, bare-metal stent (BMS) n = 19). All lesions were scored for angiographic indications for the STENTYS stent, including aneurysms, ectasias, tapering, absolute diameters, bifurcation lesions, and saphenous vein grafts. Off-line quantitative coronary angiography analyses were performed pre-procedure and post-procedure. Five years follow-up was obtained including cardiac death, target vessel myocardial infarction (TV-MI), target vessel revascularisation, stent thrombosis, and the composite endpoint target vessel failure (cardiac death, TV-MI and target vessel revascularisation). RESULTS: Angiographic indications for STENTYS use were aneurysm (30%), ectasia (19%), tapering (27%), bifurcation lesions (8%), and saphenous vein graft lesions (16%) and absolute diameters (22%). Mean maximal diameter was 4.51 ± 0.99 mm. At 5­year follow-up target vessel failure rates were 24.1% in the total cohort (DES 22.8% vs. BMS 33%, p = 0.26). Definite stent thrombosis rate was 3.8% at 5­year follow-up in this cohort with complex and high-risk lesions (DES 4.5% vs. BMS 0%, p = 0.39). CONCLUSIONS: Angiographic indications for the use of the self-apposing stent were complex lesions with atypical coronary anatomy. Our data showed reasonable stent thrombosis rates at 5­year follow-up, considering the high-risk lesion characteristics.

Pre-hospital management, procedural performance and outcomes for primary percutaneous coronary intervention in ST-elevation myocardial infarction in the Netherlands: Insights from the Dutch cohort of the APPOSITION-III trial.

AIM: The aim of this study was to achieve useful insights into pre-hospital management and procedural performance for ST-elevation myocardial infarction (STEMI) in the Netherlands by extrapolating patient characteristics, and procedural and clinical outcomes of the Dutch patient cohort from the APPOSITION-III trial. METHODS: This is a retrospective analysis from the APPOSITION-III trial with respect to the geographical borders of STEMI management. The APPOSITION-III trial was a European registry for the use of the STENTYS self-expandable stent in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). 965 Patients were enrolled mainly in the Netherlands (n = 420, 43.5 % of the overall study population), Germany (n = 165) and France (n = 131). The data from the Dutch cohort were compared with both the overall study population, and the French and German cohorts, respectively, as well as the European Society of Cardiology (ESC) STEMI guidelines. RESULTS: In this trial there was a wide inter-country variation on symptom-to-balloon time, 165 minutes (120-318) in the Netherlands, 270 minutes (180-650) in Germany and 360 minutes (120-480) in France, respectively. In general, a preload of dual antiplatelet therapy (DAPT) combined with heparin was more often performed in the Dutch and French cohort than in the German cohort. DAPT at discharge was high across the whole APPOSITION-III population. No important differences were seen between the different groups according to the endpoints major adverse cardiac event and stent thrombosis. CONCLUSION: In the Dutch cohort of an European multicentre STEMI study (APPOSITION-III trial), the performance in terms of symptom-to-balloon time, and pre-, peri- and post-procedural medical treatment is in line with the recommendations of ESC STEMI guidelines.

How to define bifurcation lesion complexity and how to successfully perform percutaneous treatment.

Historically, percutaneous coronary interventions (PCI) of bifurcation lesions have been associated with a lower procedural success rate, a higher complication rate, and less favorable clinical outcomes, compared to PCI of non-bifurcation lesions. However, percutaneous treatment of coronary bifurcation lesions have been improved over the past decade due to improvements in stent design and the introduction of specific bifurcation stent techniques. Some even argue that PCI of bifurcation lesions should no longer be considered as being complex. However, recent studies have shown that there are still certain bifurcation lesion subtypes which are at higher risk for adverse cardiac events after PCI. Future efforts, including the development of a dedicated bifurcation device, should be focused on this specific high-risk subgroup, including distal left main bifurcations.

Self-expanding intracoronary stents in the treatment of coronary artery disease: new developments and future directions.

The first stent implanted in the human coronary circulation was a self-expandable (SE) stent and was introduced almost simultaneously with the first balloon-expandable (BE) stents in the late 1980s. Nowadays, the majority of the available stents are delivered by balloon expansion. While BE stents reach their final size at the time of implantation, the SE stent continues to enlarge days to weeks after implantation. Potential advantages of the self-expandable and self-apposing properties of nitinol stents, a super-elastic metallic alloy of nickel and titanium, could be reduction of acute and late acquired stent malapposition with a subsequently decreased risk of target vessel restenosis. Several nitinol stents have been developed and clinically evaluated and are now in use in daily clinical practice. However, it is important to further improve and optimize the SE stent design and apply newer strategies to the development of next generation SE stents. The present review will provide an overview of the development of these devices and the currently available clinical evidence of the contemporary SE stents.

Bioresorbable scaffolds: talking about a new interventional revolution [corrected].

After the introduction of coronary balloon angioplasty, bare-metal, and drug-eluting stents, fully bioresorbable scaffolds (BRS) could be the fourth revolution in interventional cardiology. The BRS technology shares the advantages of metallic stents regarding acute gain and prevention of acute vessel occlusion by providing transient scaffolding, while potentially overcoming many of the safety concerns of drug-eluting stents. Furthermore, without a permanent metallic cage, the vessel could remodel favourably and atherosclerotic plaques could regress in the long-term. This attracted increased interest and several BRS have been developed. In this review we will describe all BRS which are thus far clinically evaluated and provide an overview of ongoing clinical studies. Although the technology seems to be very promising, more studies including patients with more complex lesions are needed to evaluate whether the BRS can be used in daily clinical practice and if it is indeed becoming a new interventional revolution.

Six-month clinical outcomes of the Tryton Side Branch Stent for the treatment of bifurcation lesions.

AIMS: Percutaneous coronary intervention (PCI) of a bifurcation lesion (BL) is still associated with poorer clinical outcomes when compared with PCI of a non-BL. Therefore, several dedicated coronary bifurcation stents, such as the Tryton Side Branch Stent™ (Tryton Medical, Durham, NC, USA), were developed to improve clinical outcomes. We investigated 6-month clinical outcomes after placement of a Tryton stent in 91 patients treated for 93 BLs in our centre. METHODS AND RESULTS: All consecutive patients who have undergone PCI of a BL treated with the Tryton stent in our centre were included. Outcomes were defined as any death, cardiac death, myocardial infarction (MI), any revascularisation, ischaemia-driven target vessel revascularisation (TVR), ischaemia-driven target lesion revascularisation (TLR), stent thrombosis, and target vessel failure (TVF; composite of cardiac death, MI, and ischaemia-driven TVR). Event rates were estimated using the Kaplan-Meier method. Thirty-eight (42 %) patients with acute coronary syndrome (ACS) were included (16 % ST-segment elevation MI (STEMI)). The 6-month event rates were 5.4 % (death), 4.3 % (cardiac death), 2.2 % (MI), 4.5 % (any revascularisation), 4.5 % (TVR), 4.5 % (TLR) and 9.7 % (TVF). CONCLUSION: In a real-world all-comers single-centre registry, the use of the Tryton Side Branch Stent was associated with acceptable procedural and promising clinical outcomes at 6 months, including ACS and STEMI patients.