ImpaCt of an Optimal Implantation Strategy on Absorb Long-Term Outcomes: The CIAO Registry.

AIM: To compare the long-term outcomes of patients implanted with Absorb bioresorbable scaffold (BRS) with optimal versus suboptimal technique. METHODS AND RESULTS: All patients who received an Absorb between March 2012 and January 2016 were selected from 19 Italian centers databases to assess the impact of an optimal implantation technique (CIAO criteria) on long-term device-oriented composite end-point (DOCE) - including cardiac death (CD), target-vessel myocardial infarction (TV-MI) and ischemia-driven target lesion revascularization (ID-TLR) - on its single components and on scaffold thrombosis (ScT). CIAO criteria consist of predilation (balloon/vessel ratio 1:1), correct sizing (BRS/proximal reference vessel diameter -RVD- ratio 0.8-1.2) and high-pressure postdilation with non-compliant (NC) balloon (≥20 atm for balloon/BRS ratio 1:1 or ≥16 atm for a 0.25-0.5 mm oversized balloon). Among the 1.434 patients analyzed, 464 (32.4%) fulfilled all CIAO criteria for every BRS implanted (CIAO 3 group), while 970 (67.6%) did not in at least one of the received BRS (CIAO 0-1-2 group). At 31.0 (interquartile range -IQR- 24.8-38.5) months follow-up, CIAO criteria did not impact on DOCE (8.2% vs. 8.0%, p = 0.92), ID-TLR (6.9% vs. 7.1%, p = 0.72) or ScT (1.9% vs. 1.8%, p = 0.80) in the overall population. At multivariate analysis overall BRS length (p = 0.001), severely calcified lesions (p = 0.03) and absence of CIAO criteria (CIAO 0, p = 0.005) were independent predictors of DOCE in long-term follow-up. CONCLUSION: Our data suggest that strict application of an optimal Absorb implantation technique doesn't improve long-term DOCE or ScT but may mitigate the worse outcome of patients with calcific lesions.

Blood metabolomic fingerprint is distinct in healthy coronary and in stenosing or microvascular ischemic heart disease.

BACKGROUND: The endothelium is a key variable in the pathogenesis of atherosclerosis and its complications, particularly coronary artery disease (CAD). Current evidence suggests that the endothelial status can be regarded as an integrated index of individual atherogenic and anti-atherogenic properties, and that the interaction between circulating factors and the arterial wall might be critical for atherogenesis. In organism-level investigations, a functional view is provided by metabolomics, the study of the metabolic profile of small molecules. We sought to verify whether metabolomic analysis can reveal the presence of coronary microenvironment peculiarities associated with distinct manifestations of CAD. METHODS: Thirty-two coronary blood samples were analyzed using 1H-NMR-based metabolomics. Samples collected from patients with evidence of myocardial ischemia formed the case group, and were further divided into the stenotic-disease (SD) group (N = 13) and absence of stenosis (microvascular disease; "Micro") group (N = 8); specimens of patients presenting no evidence of ischemic heart disease (dilated cardiomyopathy, valvular diseases) constituted the control group (N = 11). RESULTS: Application of an orthogonal partial least squares discriminant analysis (OPLS-DA) model to the entire dataset clearly separated the samples into 3 groups, indicating 3 distinct metabolic fingerprints. Relative to control-group members, Micro patients showed a higher content of 2-hydroxybutirate, alanine, leucine, isoleucine, and N-acetyl groups and lower levels of creatine/phosphocreatine, creatinine, and glucose, whereas SD patients showed higher levels of 3-hydroxybutirate and acetate and a lower content of 2-hydroxybutirate. Moreover, relative to SD patients, Micro patients showed higher levels of 2-hydroxybutirate, alanine, leucine, and N-acetyl groups and lower levels of 3-hydroxybutirate and acetate. CONCLUSIONS: Specific coronary microenvironments are likely associated with distinct development and pathological expression of CAD.

Care quality monitoring of a ST-segment elevation myocardial infarction programme over a 5-year period.

AIMS: The aim of this study is to investigate the long-term impact of a prehospital ECG programme on treatment times for patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS: From January 2008 to December 2012, 213 STEMI patients transported by the Emergency Medical System (EMS) underwent primary PCI in our Hospital. The protocol included ECG tele-transmission, early activation of the cath lab and direct routing of the patient for primary PCI. Fifty-four patients referred by EMS in 2007, when ECG tele-transmission was unavailable, were used as controls. First diagnostic ECG-to-balloon time, door-to-balloon time and total ischemic time were collected for all patients. RESULTS: First diagnostic ECG-to-balloon time decreased from 125.5 min in 2007 to 104 min in the first year after implementation of the STEMI programme (2008). Successively, it declined to 81 min by the end of the study period (2012) (P < 0.0001). Door-to-balloon time decreased notably from 92.5 min in 2007 to 40.5 min by the end of the study period (p < 0.0001). Total ischemic time fell from 200 min in 2007 to 170 min in 2008 and it further declined to 163.5 min in 2012 (p < 0.042). CONCLUSIONS: We report progressive improvements in times to treatment over a 5-year period in a STEMI program for patients referred by the EMS. The importance of data collection and monitoring is highlighted by our results.

[The network for acute coronary syndromes in the metropolitan area of Cagliari (Italy): management of ST-elevation myocardial infarction, reperfusion time, and adherence to guidelines]. / La rete per l'emergenza coronarica nell'Area Vasta di Cagliari: gestione dell'infarto miocardico acuto con sopraslivellamento del tratto ST, analisi dei tempi di riperfusione e aderenza alle linee guida.

BACKGROUND: An integrated network for the management of acute ST-elevation myocardial infarction (STEMI) allows a pre-hospital diagnosis and facilitates the best strategy to provide the most effective reperfusion therapy. This study aims to assess the network impact on timing and mode of reperfusion in the metropolitan area of Cagliari. METHODS: From January 1, 2008 to December 31, 2010 all patients affected by STEMI with symptom onset <12h were enrolled. We evaluated modality of hospital access, reperfusion therapies, and time for avoidable delay. The first medical contact-to-balloon time (FMC-to-balloon) was compared between patients without ECG transmission (No-ECG group) and those with ECG transmission and direct transport to the cath-lab (Cath-Lab-ECG group) or the emergency room/intensive cardiac care unit (ER/ICCU-ECG group). RESULTS: Out of 622 patients enrolled, 324 (52.1%) arrived to hospital by emergency medical systems. In this group a pre-hospital diagnosis was made in 79.3% of cases (n = 257); among them, 138 patients (53.7%) had a direct access to cath-lab, 99 to ICCU (38.5%), and 20 (7.8%) to ER. In the whole study population an urgent coronary angiography was performed in 612 patients (98.4%) and a primary percutaneous coronary intervention (p-PCI) in 589 (96.2%). In the Cath-Lab-ECG group the FMC-to-balloon was 89 ± 29 min (median 87 min, interquartile range 72-100), significantly lower than in the ER/ICCU-ECG group [122 ± 39 min (115 min)] and the No-ECG group [150 ± 54 min (139 min)] (p<0.01). A FMC-to-balloon ≤90 min was achieved in 66.4% of Cath-Lab-ECG patients, 22.1% of ER/ICCU-ECG patients, and 8.3% of No-ECG patients (Cath-Lab-ECG vs ER/ICCU-ECG, p<0.01). CONCLUSIONS: Our results show that an integrated network provides a pre-hospital diagnosis in the majority of STEMI. However, only a direct transport to the cath-lab allows to achieve a FMC-to-balloon ≤90 min in a large proportion of patients. Out of this condition, adherence to guideline-recommended time of ≤90 min is significantly lower.

Early noninvasive evaluation of coronary flow reserve after angioplasty in the left anterior descending coronary artery identifies patients at high risk of restenosis at follow-up.

BACKGROUND: Coronary restenosis is the most important clinical limitation after percutaneous coronary intervention (PCI), and coronary flow reserve (CFR) is reduced in the presence of significant coronary stenosis. This study evaluated whether detection of early reduction of Doppler echocardiographically derived CFR in the left anterior descending coronary artery can identify patients at high risk for developing restenosis after successful PCI. METHODS: Doppler echocardiographically derived CFR was studied in 124 consecutive patients at 1-month and 6-month follow-up after PCI in the left anterior descending coronary artery, together with coronary angiography. RESULTS: Restenosis was detected in 39 angiographic examinations (group A) and no coronary restenosis in the remaining 85 (group B) at 6 months. At 1 month, CFR was reduced in group A compared with group B (P < .0001), and a significant reduction of CFR in group A (P < .0001) but not in group B (P = .89) was detected at 6 months. CFR ≤ 2.5 at 1 month was 67% sensitive and 87% specific for predicting significant restenosis, with positive and negative predictive values of 67% and 87%, respectively. CONCLUSIONS: CFR ≤ 2.5 detected 1 month after PCI in the left anterior descending coronary artery has the potential to identify patients at higher risk for developing coronary restenosis and indicates the need for close clinical follow-up.

Echocardiographic accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty.

Percutaneous vertebroplasty (PVP) is a therapeutic, interventional radiological procedure involving bone cement injection into a vertebral body. Although PVP is considered a minimally invasive procedure, cement leakage into the perivertebral venous system can occur with its migration towards the right heart and the pulmonary circulation. We report a case of accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after PVP.

Multidetector-row CT angiography in the study of atherosclerotic carotid arteries.

Pathologies of the carotid arteries, and in particular atherosclerosis, are now an important medical problem. Stroke is the third leading cause of severe disability in the Western World leading to millions of deaths every year. Extracranial carotid atherosclerotic disease is the major risk factor for stroke. In years, with the advent of multidetector-row CT (MDCT) scanners and the use of specific angiographic protocols (MDCTA), CT imaging of the carotid arteries has become increasingly effective. In addition, the volume data obtained can be further rendered to generate high-quality two-dimensional and three-dimensional images. The purpose of this study was to review the atherosclerotic carotid arteries, their complications and how MDCTA depicts them, underlining the benefits and pitfalls of this diagnostic technique.

Steroid-eluting stents in patients with acute coronary syndrome: the dexamethasone eluting stent Italian registry.

OBJECTIVE: To assess immediate and mid-term clinical and angiographic outcomes of the dexamethasone drug-eluting stent (D-DES) in patients with acute coronary syndrome (ACS). PATIENTS AND METHODS: A prospective, nationwide, controlled, registry. Inflammation plays a key role in ACS, and the anti-inflammatory effects of local elution of dexamethasone in unstable plaques may represent a valid therapeutic approach. All patients had ACS on admission (n = 332). 81.5% of the patients had unstable angina and 18.5% had non-ST elevation myocardial infarction (MI). 47% had ST-T segment changes, 59% had troponin elevation, 77% had elevated C-reactive protein levels and 48% had intermediate-high Thrombolysis in Myocardial Infarction risk score. Patients were treated according to an early invasive approach with 420 D-DES in 387 coronary lesions. Primary end point was the cumulative incidence of death, MI and ischaemia-driven target vessel revascularisation (TVR) at 6 months. RESULTS: At 30 days, 2 (0.6%) patients died, and sub-acute stent thrombosis occurred in 2 patients. At 6 months, 328 (98.8%) patients were controlled, 3 (0.9%) patients had died, 7 (2.1%) had MI and 28 (8.5%) underwent ischaemia-driven TVR. Therefore, the primary end point occurred in 11.5% of patients. At multivariate analysis, multi-vessel coronary artery disease (odds ratio (OR) = 2.16, 95% CI = 1.47 to 3.17, p = 0.0001) and vessel diameter < or =2.75 mm (OR = 1.64, 95% CI = 1.08 to 2.49, p = 0.02) were independent predictors of 6-month clinical events. Global angiographic restenosis rate was 33.3%. CONCLUSION: This is the first large, multicentre analysis of the clinical and angiographic outcomes obtained with D-DES implanted in ACS. D-DES offers a low rate of clinical events at 6 months, but has no anti-restenosis effect.

Detection of coronary restenosis after coronary angioplasty by contrast-enhanced transthoracic echocardiographic Doppler assessment of coronary flow velocity reserve.

OBJECTIVES: This study sought to evaluate the diagnostic potential of contrast-enhanced transthoracic echocardiography (CE-TTE) during adenosine infusion, a noninvasive method for evaluating coronary flow reserve (CFR), in detecting restenosis after successful percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Restenosis is the most important limitation of PTCA, and CFR can be impaired in patients with angiographically documented significant coronary stenosis. METHODS: We performed 6 +/- 2 months of follow-up of 53 patients after successful elective PTCA in the left anterior descending coronary artery (LAD). Coronary angiography was performed at the end of the planned follow-up period or even before, if clinically indicated. Thus, of the 53 patients, a total of 63 angiographic studies were performed; CE-TTE assessment of CFR was achieved before each of the 63 angiographic studies. RESULTS: Coronary angiography revealed the presence of restenosis (defined as >50% stenosis at a previous PTCA site) in 32 angiographic examinations (group A) and no coronary restenosis in the remaining 31 examinations (group B). Coronary flow reserve was significantly reduced in group A compared with group B (1.65 +/- 0.5 vs. 3.17 +/- 0.8, p < or = 0.001). A noninvasive CFR value < or = 2 was 93% specific and 78% sensitive for detecting significant restenosis, with positive and negative diagnostic accuracies of 92% and 80%, respectively. CONCLUSIONS: Noninvasive CFR assessment by CE-TTE is an accurate method of monitoring significant restenosis in the LAD when following up patients submitted to elective PTCA.

Flail Tricuspid Valve in an Adult Patient with Congenitally Corrected Transposition of the Great Arteries.

We describe a case of a 50-year-old woman with congenitally corrected transposition of the great vessels, in whom severe left-sided tricuspid (systemic atrioventricular) valve insufficiency was the only associated anomaly. The tricuspid valve was dysplastic and abnormally oriented toward the interventricular septum, without the downward displacement of Ebstein's anomaly. The mechanism of atrioventricular regurgitation was unusual in that it consisted of the rupture of chordae tendineae of both the anterior and septal leaflets. The left-sided tricuspid valve was replaced with a St. Jude prosthesis and the postoperative course was uneventful.