Anxiety and Perception of Disease Control in Multiple Sclerosis Subjects Treated with Natalizumab.

Multiple sclerosis subjects treated with natalizumab face anxiety about developing progressive multifocal leukoencephalopathy (PML), besides the psychological distress caused by the disease. The aim of this study is to investigate whether increasing the frequency of neurological and nuclear magnetic resonance screening may affect anxiety and the perception of disease control in patients treated with natalizumab. A total of 62 relapsing-remitting multiple sclerosis patients were recruited from 2019 to 2020. All patients received conventional infusion treatments with natalizumab, along with a screening protocol for PML. Three clinical assessments were considered: at the beginning of the study (T0), after 3 months (T1) and after 6 months (T2). Patients were classified into three levels of risk, where level 1 represented a low risk of PML and level 3 a high risk. This classification determined treatment and screening protocol, i.e., the frequency of performing the Stratify test and the brain 3T NMR exam, as well as the frequency of infusion treatments. Anxiety and perception of disease control were assessed at T0, T1, and T2 by a skilled psychologist. The Friedman test and the Wilcoxon signed-rank test were used to compare outcomes at baseline with the two follow-ups. Statistical test results showed that the risk of PML (per 1000 patients) was significantly lower in women than in men (W = 198.5; p = 0.01). Moreover, significant differences between baseline and the two follow-ups were found, both for anxiety (F(2) = 122.6, p < 0.001) and for perception of disease control (F(2) = 123.5, p < 0.001). In both cases, there was significant improvement between baseline (T0) and the end of the study (T2) in any risk level (p < 0.001). An increase in the number of follow-ups, as well as an increase in instrumental investigations, might have a positive effect on both anxiety and the perception of disease control. However, there are many variables involved in the disease process that have an impact on patients' psychological well-being. Therefore, further and more extensive studies are necessary to evaluate how, and how much, each variable impacts the disease course.

Prediction of All-Cause Mortality Following Percutaneous Coronary Intervention in Bifurcation Lesions Using Machine Learning Algorithms.

Stratifying prognosis following coronary bifurcation percutaneous coronary intervention (PCI) is an unmet clinical need that may be fulfilled through the adoption of machine learning (ML) algorithms to refine outcome predictions. We sought to develop an ML-based risk stratification model built on clinical, anatomical, and procedural features to predict all-cause mortality following contemporary bifurcation PCI. Multiple ML models to predict all-cause mortality were tested on a cohort of 2393 patients (training, n = 1795; internal validation, n = 598) undergoing bifurcation PCI with contemporary stents from the real-world RAIN registry. Twenty-five commonly available patient-/lesion-related features were selected to train ML models. The best model was validated in an external cohort of 1701 patients undergoing bifurcation PCI from the DUTCH PEERS and BIO-RESORT trial cohorts. At ROC curves, the AUC for the prediction of 2-year mortality was 0.79 (0.74-0.83) in the overall population, 0.74 (0.62-0.85) at internal validation and 0.71 (0.62-0.79) at external validation. Performance at risk ranking analysis, k-center cross-validation, and continual learning confirmed the generalizability of the models, also available as an online interface. The RAIN-ML prediction model represents the first tool combining clinical, anatomical, and procedural features to predict all-cause mortality among patients undergoing contemporary bifurcation PCI with reliable performance.

Neuropsychological Disability in the Case of Natalizumab-Related Progressive Multifocal Leukoencephalopathy.

BACKGROUND: Progressive multifocal leukoencephalopathy (PML) is a viral disease characterized by progressive damage or inflammation of the cerebral white matter that can be encountered in patients with multiple sclerosis (MS). There are cases of PML caused by pharmacological agents including natalizumab. Therefore, in patients treated with this drug, early identification of PML allows changes in the treatment plan, reducing the risks of morbidity and mortality. CASE PRESENTATION: We reported the case of a 57-year-old female diagnosed with relapsing-remitting MS, who presented with PML related to natalizumab. The patient presented with change in behavioral, radiological abnormalities in the left parieto-temporal lobes. We described the longitudinal course of PML, from the diagnosis until the patient's death, documenting the progressive deterioration of her cognitive functioning, supported by changes on sequential brain scans and neurophysiological data. CONCLUSION: The neuropsychological impairment documented in this case study expands the range of treatment-related complications associated with natalizumab, and provides evidence that occurrence of "atypical" cognitive deficits in MS may support the early diagnosis of PML.

Comparison of ECMO vs ECpella in Patients With Non-Post-Pericardiotomy Cardiogenic Shock: An Updated Meta-Analysis.

INTRODUCTION: The impact of Impella and ECMO (ECPELLA) in cardiogenic shock (CS) remains to be defined. The aim of this meta-analysis is to evaluate the benefit of ECPELLA compared to VA-ECMO in patients with non post-pericardiotomy CS. METHODS: All studies reporting short term outcomes of ECpella or VA ECMO in non post-pericardiotomy CS were included. The primary endpoint was 30-day mortality. Vascular and bleeding complications and LVAD implantation/heart transplant within 30-days were assessed as secondary outcomes. RESULTS: Of 407 studies identified, 13 observational studies (13,682 patients, 13,270 with ECMO and 412 with ECpella) were included in this analysis. 30-day mortality was 55.8% (51.6-59.9) in the VA-ECMO group and 58.3% (53.5-63.0) in the ECpella group. At meta-regression analysis the implantation of IABP did not affect mortality in the ECMO group. The rate of major bleeding in patients on VA-ECMO and ECpella support were 21.3% (16.9-26.5) and 33.1% (25.9-41.2) respectively, while the rates of the composite outcome of LVAD implantation and heart transplantation within 30-days in patients on VA-ECMO and ECpella support were 14.4% (9.0-22.2) and 10.8%. When directly compared in 3 studies, ECpella showed a positive effect on 30-day mortality compared to ECMO (OR: 1.81: 1.039-3.159). CONCLUSION: Our data suggest that ECpella may reduce 30-day mortality and increase left ventricle recovery, despite increased of bleeding rates.

Ultrasound- Versus Fluoroscopy-Guided Femoral Access for Percutaneous Coronary Intervention of Chronic Total Occlusions: Insights From FOUND BLOOD CTO Registry.

OBJECTIVE: To compare vascular complications in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) using ultrasound guidance (USG) versus fluoroscopy guidance (FSG) for femoral access. BACKGROUND: In patients undergoing PCI, using the arterial femoral access increases the risk of vascular complications compared using the radial access. USG reduces time to access, number of attempts, and vascular complications compared with FSG, but the efficacy of USG has never been tested in the setting of CTO-PCI. METHODS: A total of 197 patients undergoing CTO-PCI using at least a femoral vascular access from November 2015 to September 2020 were screened. The primary outcome was a composite of local hematoma, pseudoaneurysm, retroperitoneal hemorrhage, arteriovenous fistula or hemoglobin drop ≥3 g/dL during hospitalization. The independent association between USG and the primary outcome of interest was explored. RESULTS: The primary outcome occurred in 17.3% of patients. Patients in the USG group had a significantly lower incidence of vascular complications compared with patients in the FSG group (8.5% vs. 21.0%, p = 0.039), driven by a reduction of localized hematomas (3.4% vs 13.0%, p = 0.042). After adjustment for type of CTO approach and heparin dose, USG was significantly associated with a reduced relative risk of the composite primary outcome (adjusted odds ratio 0.16, 95% confidence interval 0.05 to 0.51; p = 0.002). CONCLUSION: USG in CTO-PCI is associated with a decreased risk of vascular complications, primarily driven by a reduction in local hematomas, especially in complex CTO-PCI where the larger use of heparin increases the risk of vascular complications.

The role of teriflunomide in Multiple Sclerosis patient: an observational study.

Teriflunomide is a drug with immunosuppressive and selective immunomodulatory action, characterized by anti-inflammatory and antiproliferative properties. Several clinical studies have demonstrated the efficacy and safety of this drug in Multiple Sclerosis, estimating a significant improvement in cognitive performance.The aim of our study is to evaluate the effects of teriflunomide by analysing the correlation between brain atrophy and the general cognitive profile and evaluating long-term changes. The effect of teriflunomide was studied in 30 patients with multiple sclerosis and 30 control subjects. Patients underwent a full cognitive profile assessment using the Brief Repeatable Battery of Neuropsychological Tests and a neuroimaging examination with a 3.0 T working scanner.Our results suggested that treatment with teriflunomide could potentially not only slow down the accumulation of microstructural tissue damage in Grey Matter and With Matter, but also better preserve the cognitive profile, particularly by highlighting the benefits in the memory domain. Thanks to drug therapy, brain volume in our patients has remained constant, leading to improvements in memory, indicating teriflunomide as a neuroprotective potential and further strengthening the evidence of a link between loss of brain volume and cognitive impairment.

Performance of Thin-Strut Stents in Non-Left Main Bifurcation Coronary Lesions: A RAIN Subanalysis.

OBJECTIVES: This study assesses the safety and efficacy of thin-strut stents in non-left main (non-LM) bifurcation coronary lesions. BACKGROUND: Thinner struts of recent drug-eluting stent (DES) devices are associated with improved outcomes, but data about their performance in challenging scenarios are scant. METHODS: RAIN was a retrospective multicenter registry enrolling patients with coronary bifurcation lesions or left main (LM) disease treated with thin-strut DESs. Target-lesion revascularization (TLR) was the primary endpoint, while major adverse clinical event (MACE) rate, a composite of all-cause death, myocardial infarction (MI), target-vessel revascularization (TVR), TLR, and stent thrombosis (ST), and its single components were the secondary endpoints. Multivariable analysis was performed to identify predictors of TLR. Outcome incidences according to stenting strategy (provisional vs 2-stent technique), use of final kissing balloon (FKB), and intravascular ultrasound/optical coherence tomography optimization were further investigated in prespecified subanalyses. RESULTS: A total of 1803 patients (59% acute coronary syndrome, 41% stable coronary artery disease) with non-LM bifurcations were enrolled. After a median follow-up of 12 months, TLR incidence was 2.5% (2.2% for provisional stenting and 3.5% for 2-stent technique). MACE rate was 9.4% (all-cause death, 4.1%; MI, 3.2%; TVR, 3.7%; definite ST, 1.1%). After multivariable adjustment, postdilation (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.15-0.71; P<.01) and provisional stenting (HR, 0.62; 95% CI, 0.55-0.89; P=.03) were associated with lower TLR rates. FKB was associated with a lower incidence of TLR in the 2-stent subgroup (P=.03). Intracoronary imaging had no significant impact on the primary endpoint. CONCLUSIONS: Thin-strut DES options represent an effective choice in bifurcation lesions. Postdilation and provisional stenting are associated with a reduced risk of TLR. FKB should be recommended in 2-stent techniques.

[Devices for the prevention of contrast-induced acute kidney injury in interventional cardiology]. / Dispositivi medici per la prevenzione del danno renale acuto da mezzo di contrasto in cardiologia interventistica.

Contrast-induced acute kidney injury (CI-AKI) consists in acute decline in renal function following iodinated contrast media exposure. It has a significant impact on long-term prognosis and mortality, development of chronic kidney disease and on the rate of hospitalization due to cardiovascular or renal events. Anamnestic and procedural aspects linked to higher risk of CI-AKI have been investigated and new devices have been designed in order to prevent it. This paper deals with CI-AKI in interventional cardiology, focusing on patients' risk stratification, contrast media agent selection and contrast media volume reduction strategies, in order to suggest a standardized algorithm.

Does the left circumflex coronary artery location impact on the success of chronic total occlusion recanalization? A single-center cohort study.

We sought to determine whether the chronic total occlusions (CTO) recanalization results differ between circumflex artery (CX) and other coronary arteries in our center. The study dataset encompassed 428 consecutive procedures. J-CTO score was highest in the right coronary artery (RCA) and lowest in CX lesions. After adjusting for the J-CTO score, age, body mass index, baseline creatinine, diabetes, dyslipidemia and hypertension the odds ratio for procedural success in CX compared to the other arteries was not statistically significant. We found no difference in success rates of recanalizing CTO in CX compared to other coronary arteries.

Accuracy of the PARIS score and PCI complexity to predict ischemic events in patients treated with very thin stents in unprotected left main or coronary bifurcations.

BACKGROUND: The PARIS risk score (PARIS-rs) and percutaneous coronary intervention complexity (PCI-c) predict clinical and procedural residual ischemic risk following PCI. Their accuracy in patients undergoing unprotected left main (ULM) or bifurcation PCI has not been assessed. METHODS: The predictive performances of the PARIS-rs (categorized as low, intermediate, and high) and PCI-c (according to guideline-endorsed criteria) were evaluated in 3,002 patients undergoing ULM/bifurcation PCI with very thin strut stents. RESULTS: After 16 (12-22) months, increasing PARIS-rs (8.8% vs. 14.1% vs. 27.4%, p < .001) and PCI-c (15.2% vs. 11%, p = .025) were associated with higher rates of major adverse cardiac events ([MACE], a composite of death, myocardial infarction [MI], and target vessel revascularization), driven by MI/death for PARIS-rs and target lesion revascularization/stent thrombosis for PCI-c (area under the curves for MACE: PARIS-rs 0.60 vs. PCI-c 0.52, p-for-difference < .001). PCI-c accuracy for MACE was higher in low-clinical-risk patients; while PARIS-rs was more accurate in low-procedural-risk patients. ≥12-month dual antiplatelet therapy (DAPT) was associated with a lower MACE rate in high PARIS-rs patients, (adjusted-hazard ratio 0.42 [95% CI: 0.22-0.83], p = .012), with no benefit in low to intermediate PARIS-rs patients. No incremental benefit with longer DAPT was observed in complex PCI. CONCLUSIONS: In the setting of ULM/bifurcation PCI, the residual ischemic risk is better predicted by a clinical risk estimator than by PCI complexity, which rather appears to reflect stent/procedure-related events. Careful procedural risk estimation is warranted in patients at low clinical risk, where PCI complexity may substantially contribute to the overall residual ischemic risk.

Using the coronary lithotripsy system for coronary artery disease.

Severe coronary artery calcification increases percutaneous treatment complexity and the risk of intraprocedural complications, affecting acute and long-term outcomes. Current use of specialty balloons and atherectomy technologies is limited due to the higher risk of complications, degree of technical difficulty and operator experience. Intravascular lithotripsy (IVL) is a novel technology for severe calcified coronary artery disease that facilitates vessel preparation, enhancing vessel compliance. IVL system emits sonic waves that penetrate through vascular layers and disrupt both superficial and deep calcium, leaving the soft tissue unharmed. The purpose of the present review is to provide a summary of the evidence currently available on this therapy, including a practical description of the components and function of the shockwave coronary IVL system.

Impact of stent thickness on clinical outcomes in small vessel and bifurcation lesions: a RAIN-CARDIOGROUP VII sub-study.

BACKGROUND: The clinical impact of stent strut thickness in coronary bifurcation lesions in small vessels has not been assessed in a real-world population. METHODS: All 506 patients enrolled in the RAIN study, undergoing PCI in a vessel with a diameter 2.5 mm or less were retrospectively evaluated and divided into two groups according to stent strut thickness: 74 µm (n = 206) versus 81 µm (n = 300); 87.1% of the lesions involved bifurcations. TLF [defined as a composite of myocardial infarction (MI) and target lesion revascularization (TLR)] was the primary endpoint, with MACE (a composite of death, MI and TLR), its components and stent thrombosis the secondary endpoint. RESULTS: After 16 (14-18) months, a lower incidence of TLF (4.3 vs. 9.8%, P = 0.026) and ST (1.0 vs. 3.0%, P = 0.042) was seen in the 74 µm group, whereas MACE occurred in 60 of 506 patients, with no statistical difference between the two groups (9.7 vs. 13.3%, P = 0.070). At multivariate analysis, chronic renal failure increased the risk of TLF while thinner strut was an independent protective factor (hazard ratio 0.51, CI 0.17-0.85, P = 0.005). CONCLUSION: In this real-world population, patients being treated for small vessels lesions with thinner strut stents had lower rates of TLF, MI and ST.

[Treatment of coronary artery calcification: state of the art]. / Trattamento della malattia coronarica calcifica: stato dell'arte.

Coronary artery calcification enhances percutaneous treatment complexity, increasing the likelihood of procedural failure and complications and affecting acute and long-term outcomes. In order to deal with such lesions, several devices and technologies, including balloons, atherectomy and intravascular lithotripsy, have been developed. The combination of the aforementioned technologies and the guidance of intracoronary imaging can help skilled interventional cardiologists in achieving better acute and long-term results in this setting. The purpose of the present review is to provide an appraisal of the devices dedicated to the treatment of calcified lesions, including the description of components and function and how to integrate them into a practical, standardized approach.

Tratamiento percutáneo de oclusiones coronarias crónicas aorto-ostiales: resultados y consideraciones técnicas de un registro multicéntrico / Percutaneous coronary intervention in aorto-ostial coronary chronic total occlusion: outcomes and technical considerations in a multicenter registry

INTRODUCCIÓN Y OBJETIVOS: La intervención coronaria percutánea (ICP) de oclusiones coronarias totales crónicas (OTC) aorto-ostiales constituye un reto como subgrupo. El objetivo de este estudio es analizar los aspectos técnicos y resultados tras la ICP de OTC aorto-ostiales en un registro multicéntrico. MÉTODOS: Se incluyó a los pacientes de 4 centros con una OTC aorto-ostial tratados con ICP entre febrero de 2013 y diciembre de 2018. Se analizaron las tasas de éxito, los aspectos del procedimiento y los resultados. RESULTADOS: Se incluyó a 103 pacientes. La media de edad fue 64±10 años y la puntuación J-OTC, 3,1±1,1. Había 31 OTC (30,4%) con ausencia total de muñón. El éxito técnico y del procedimiento se obtuvo en 79 (76,7%) y 78 (75,7%) de los pacientes respectivamente. El abordaje retrógrado fue la técnica de cruce exitosa más frecuente (n=49; 62,0%), especialmente en OTC sin muñón (el 82,6 frente al 53,5%; p = 0,02). La ausencia de colaterales intervencionistas fue la única variable asociada con fallo técnico (OR=12,38; IC95%, 4,02-38,15; p <0,001). En 4 pacientes (3,9%) se produjeron perforaciones coronarias, todas tratadas exitosamente con stent cubierto (sin tamponamiento) y 2 pacientes (1,9%) sufrieron un accidente cerebrovascular (1 fue transitorio). Tras una mediana de seguimiento de 31 meses, 3 pacientes (2,9%) murieron por causa cardiovascular y 13 (12,6%) requirieron nueva revascularización del vaso diana. CONCLUSIONES: Las OTC aorto-ostiales representan un subgrupo técnicamente complejo. Sin embargo, operadores expertos pueden obtener una tasa de éxito aceptable con resultados favorables al seguimiento. La presencia de colaterales intervencionistas, que permiten el acceso retrógrado, parece ser clave para que el procedimiento sea exitoso

INTRODUCTION AND OBJECTIVES: Percutaneous coronary intervention (PCI) for aorto-ostial chronic total coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry. METHODS: Patients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December 2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed. RESULTS: A total of 103 patients were included. Mean age was 64±10 years and the mean J-CTO score was 3.1±1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent successful crossing technique (n=49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs 53.5%; P=.02). The only variable independently associated with technical failure was the absence of interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P <.001). Coronary perforation occurred in 4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and 2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of 31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel revascularization. CONCLUSIONS: Aorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable success rate with favorable outcomes during follow-up can be achieved by experienced operators. The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success

A Sex-Based Analysis From the RAIN-CARDIOGROUP VII Study (VeRy Thin Stents for Patients With Left MAIn or BifurcatioN in Real Life) on Left Main Stenting.

INTRODUCTION: There is a lack of data on clinical outcomes of percutaneous coronary intervention (PCI) with ultrathin stents on unprotected left main (ULM) coronary artery comparing women and men. METHODS: All patients treated with ULM-PCI with ultrathin stents (struts ≤81 µm) enrolled in the RAIN-CARDIOGROUP VII study were analyzed according to a sex-assessment evaluation. Major adverse cardiovascular event (MACE, a composite of all-cause death, myocardial infarction, target-lesion revascularization [TLR], and stent thrombosis) was the primary endpoint, whereas single components of MACE were the secondary endpoints. RESULTS: Out of a cohort of 793 patients, a total of 172 women (21.7%) and 621 men (78.3%) were included. Compared with men, women were older and less frequently smokers, had more frequently a history of previous PCI, and presented more frequently with an acute coronary syndrome. Among women, ostial lesions were more prevalent and mean stent diameter was lower compared with men. After 13.4 months (range, 8.4-21.6 months), 32 women (18.6%) and 106 men (17.1%) experienced MACE (P=.64). Censoring follow-up data at 3 years, no differences were observed in MACE (16.9 vs 14.7 per 100•patient-years; log-rank P=.61) and their single components between women and men. At multivariate analysis, chronic kidney disease (hazard ratio [HR], 1.91: 95% confidence interval [CI], 1.23 to -2.95; P<.01) and acute coronary syndrome presentation (HR, 1.84; 95% CI, 1.22-2.77; P=.01) were independent predictors of MACE overall. Larger stent size (HR, 0.65; 95% CI, 0.48-0.89; P<.01) and longer dual-antiplatelet therapy duration (HR, 0.95; 95% CI, 0.90-0.99; P=.03) were associated with a reduced risk of MACE during the subsequent follow-up. CONCLUSION: Ultrathin stents offer low rates of MACE and TLR in the overall population without significant differences between sexes.

Comparison of bioresorbable vs durable polymer drug-eluting stents in unprotected left main (from the RAIN-CARDIOGROUP VII Study).

BACKGROUND: There are limited data regarding the impact of bioresorbable polymer drug eluting stent (BP-DES) compared to durable polymer drug eluting stent (DP-DES) in patients treated with percutaneous coronary intervention using ultrathin stents in left main or bifurcations. METHODS: In the RAIN registry (ClinicalTrials NCT03544294, june 2018 retrospectively registered) patients with a ULM or bifurcation stenosis treated with PCI using ultrathin stents (struts thinner than 81 µm) were enrolled. The primary endpoint was the rate of target lesion revascularization (TLR); major adverse cardiovascular events (MACE, a composite of all-cause death, myocardial infarction, TLR and stent thrombosis) and its components, along with target vessel revascularization (TVR) were the secondary ones. A propensity score with matching analysis to compare patients treated with BP-DES versus DP-DES was also assessed. RESULTS: From 3001 enrolled patients, after propensity score analysis 1400 patients (700 for each group) were selected. Among them, 352 had ULM disease and 1048 had non-LM bifurcations. At 16 months (12-22), rates of TLR (3.7% vs 2.9%, p = 0.22) and MACE were similar (12.3% vs. 11.6%, p = 0.74) as well as for the other endpoints. Sensitivity analysis of outcomes after a two-stents strategy, showed better outcome in term of MACE (20.4% vs 10%, p = 0.03) and TVR (12% vs 4.6%, p = 0.05) and a trend towards lower TLR in patients treated with BP-DES. CONCLUSION: In patients with bifurcations or ULM treated with ultrathin stents BP-DES seems to perform similarly to DP-DES: the trends toward improved clinical outcomes in patients treated with the BP-DES might potentially be of value for speculating the stent choice in selected high-risk subgroups of patients at increased risk of ischemic events. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03544294. Retrospectively registered June 1, 2018.

[Management of coronary perforations during angioplasty]. / Gestione delle perforazioni coronariche durante angioplastica coronarica.

Coronary perforation represents a terrible complication of percutaneous coronary intervention (PCI) which, if not promptly recognized and treated, can lead to catastrophic consequences for the patient. Hence, acquisition of the basic techniques for the treatment of coronary perforations is critical for the interventional cardiologist in order to safely perform PCIs. Although the incidence of coronary perforations remains low during PCI, it is possible to recognize some subgroups of patients and some types of coronary lesions, such as chronic coronary total occlusions, that are associated with increased risk. The treatments currently available depend on the type and site of coronary perforation, therefore timely recognition is of paramount importance in order to be able to quickly establish the most appropriate treatment.

Quality of life in patients with multiple sclerosis and caregivers. Predictive factors: An observational study.

PURPOSE: Multiple sclerosis (MS) is a neurodegenerative and autoimmune disease, which can significantly affect not only the quality of life (QoL) of affected people but also that of their careers who care for them. The main objective of this study was to assess the extent to which the patient's clinical, cognitive and psychological conditions affect his or her QoL and that of the caregiver. METHODS: We examined a number of patients with clinically defined MS. In this study 78 patient-assistant pairs were enrolled. RESULTS: Our results showed a significant correlation between the change in the patient's state of health and the quality of life of caregivers, especially in specific social and work areas. In addition, the age and the physical and mental health of patients emerged as predictive factors on the quality of caregivers. CONCLUSIONS: This study has shown that degenerative and chronic diseases, such as multiple sclerosis, can be predictors of stress and poor quality of life for careers. Future studies should further clarify the impact that the psychological conditions of MS patients have on the quality of life of careers.

Percutaneous coronary intervention in aorto-ostial coronary chronic total occlusion: outcomes and technical considerations in a multicenter registry.

INTRODUCTION AND OBJECTIVES: Percutaneous coronary intervention (PCI) for aorto-ostial chronic total coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry. METHODS: Patients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December 2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed. RESULTS: A total of 103 patients were included. Mean age was 64±10 years and the mean J-CTO score was 3.1±1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent successful crossing technique (n=49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs 53.5%; P=.02). The only variable independently associated with technical failure was the absence of interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P <.001). Coronary perforation occurred in 4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and 2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of 31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel revascularization. CONCLUSIONS: Aorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable success rate with favorable outcomes during follow-up can be achieved by experienced operators. The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success.