Impact of Bifurcation Involvement and Location in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the EuroCTO Registry.

Bifurcation involvement close to or within the occluded segment poses increasing difficulties for chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). However, this variable is not considered in the angiography-based CTO scoring systems nor has been extensively investigated in large multicenter series. Accordingly, we analyzed a CTO-PCI registry involving 92 European centers to explore the incidence, angiographic and procedural characteristics, and outcomes specific to CTO-PCIs with bifurcation involvement. A total of 3,948 procedures performed between January and November 2023 were examined (33% with bifurcation involvement). Among bifurcation lesions, 38% and 37% were located within 5 mm of the proximal and distal cap, respectively, 16% within the CTO body, and in 9% of cases proximal and distal bifurcations coexisted. When compared with lesions without bifurcation involvement, CTO bifurcation lesions had higher complexity (J-CTO 2.33 ± 1.21 vs 2.11 ± 1.27, p <0.001) and were associated with higher use of additional devices (dual-lumen microcatheter in 27.6% vs 8.4%, p <0.001, and intravascular ultrasound in 32.2% vs 21.7%, p <0.001). Radiation dose (1,544 [836 to 2,819] vs 1,298.5 [699.1 to 2,386.6] mGy, p <0.001) and contrast volume (230 [160 to 300] vs 190 [130 to 250] ml, p <0.001) were also higher. Technical success was similar (91.5% with bifurcation involvement vs 90.4% without bifurcation involvement, p = 0.271). However, the bifurcation lesions within the CTO segment (intralesion) were associated with lower technical success than the other bifurcation-location subgroups (83.7% vs 93.3% proximal, 93.4% distal, and 89.0% proximal and distal, p <0.001). On multivariable analysis, the presence of an intralesion bifurcation was independently associated with technical failure (odds ratio 2.04, 95% confidence interval 1.24 to 3.35, p = 0.005). In conclusion, bifurcations are present in approximately one-third of CTOs who underwent PCI. PCI of CTOs with bifurcation can be achieved with high success rates except for bifurcations within the occluded segment, which were associated with higher technical failure.

Chronic total occlusion percutaneous coronary intervention in everyday clinical practice - an expert opinion of the Association of Cardiovascular Interventions of the Polish Cardiac Society.

Coronary chronic total occlusions (CTO) are increasingly encountered during invasive and non-invasive coronary angiography and remain the most challenging lesions for percutaneous revascularization. During recent years success rates and safety outcomes of CTO percutaneous coronary intervention (PCI) have substantially improved, particularly due to the introduction of new techniques and dedicated equipment as well as specialized training programs of CTO operators. Significantly, the steady advances in CTO PCI techniques have coincided with the new data from randomized clinical trials supporting the role of percutaneous recanalization of CTO in relieving angina and improving the quality of life. The current expert consensus document outlines the rationale, clinical outcomes as well as technical, safety and reimbursement issues of CTO PCI. In addition, the requirements for achieving and maintaining competency in CTO PCI among interventional cardiologists are discussed. Finally, we present the modified hybrid algorithm (the so-called Polish hybrid algorithm) providing some unique refinements to the contemporary CTO PCI strategies. Continuous efforts (including active engagement with the payer) are urgently needed to increase guideline-recommended referrals to CTO PCI, and thus improve the quality of life of CTO patients in Poland.

Percutaneous recanalisation of chronically occluded coronary arteries with the CrossBoss/Stingray system: first experience (report of three cases).

BACKGROUND AND AIM: Percutaneous coronary interventions (PCI) within chronically occluded coronary arteries remain challenging procedures with a lower success rate compared to classic PCI. However, over the last years we have witnessed many technological advances in the treatment of chronic total occlusion (CTO) including new wires, retrograde approach, subintimal tracking and re-entry technique, all underlying which the current success rate of up to 95% in dedicated centres. Subintimal space wire penetration is no longer a problem that would require terminating the procedure. It is now a desired part of hybrid CTO approach involving both antegrade and retrograde crossing and re-entry. The new device which facilitates controlled dissection and true lumen re-entry is the Boston Scientific Coronary CTO Crossing System consisting of a CrossBoss micro-catheter and Stingray balloon and dedicated wire. METHODS: On October 29th and 30th, 2014, percutaneous coronary recanalisation using the CrossBoss/Stingray system was performed in 3 men aged 63-75, with symptoms of stable CCS class II/III angina, without prior myocardial infarction in the area of CTO artery supply and with preserved myocardial contractility. Each patient underwent at least one previous unsuccesful antegrade/retrograde CTO recanalisation procedure. The J-CTO score was 3-4. RESULTS: The procedure was successful in all 3 patients: 2 right coronary arteries and 1 left anterior descending artery were opened. In all 3 cases, both the CrossBoss catheter and the Stingray re-entry system were used. Two to three drug eluting stents were implanted in each patient, with the total length of 62-106 mm and final TIMI 3 flow. The mean procedure time was 141 min (130-150 min), mean fluoroscopy time was 53 min (48-56 min), absorbed dose was 4772 mGy (4098-5633 mGy), dose area product was 565,208 cGy × cm² (535,109-590,266 cGy × cm²), and the mean contrast volume was 343 mL (320-350 mL). No procedure-related complications were note except for an asymptomatic increase in high-sensitivity troponin T level up to 157 ng/mL (reference range 0-14 ng/mL) in 1 patient. CONCLUSIONS: The Boston Scientific Coronary CTO Crossing System is a useful device for percutaneous recanalisation of chronically occluded coronary arteries. It helps to achieve procedural success in more complex cases within relatively short crossing times and with a limited amount of the contrast agent and X-ray dose.

Cardiac hemodynamics and proinflammatory cytokines during biatrial and right atrial appendage pacing in patients with interatrial block.

PURPOSE: Interatrial block (IAB) frequently coexists with sinus node disease and is considered a risk factor of left atrial dysfunction, atrial arrhythmias, and heart failure development. Conventional right atrial appendage (RAA) pacing impairs intra- and interatrial conductions and consequently prolongs P wave duration. Biatrial (BiA) pacing helps correct IAB, but its advantageous influence remains controversial. The aim of the study was to compare the effects of BiA and RAA pacing on cardiac hemodynamics and serum concentrations of inflammatory markers and neuropeptides. METHODS: Twenty-eight patients with IAB and preserved atrio-ventricular conduction treated with BiA pacing were studied. Standard invasive hemodynamic measurements were performed during BiA and RAA pacings. Furthermore, the influence of 1 week of BiA and RAA pacing on neuropeptides: atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) and markers of inflammation: high sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6), and neopterin was examined. RESULTS: BiA pacing resulted in significant increase of cardiac output (CO) and reduction of pulmonary capillary wedge pressure. We demonstrated significantly lower concentrations of ANP, hs-CRP, IL-6, and neopterin after 1 week of BiA in comparison to RAA pacing. BNP levels remained unchanged. CONCLUSIONS: BiA pacing in comparison to RAA pacing improves hemodynamic performance in patients with IAB and preserved atrio-ventricular conduction. BiA pacing is associated with reduction of ANP and markers of inflammation (hs-CRP, IL-6, and neopterin).

[Tako-tsubo cardiomyopathy in the course of carbon monoxide poisoning]. / Kardiomiopatia tako-tsubo w przebiegu zatrucia tlenkiem wegla.

Tako-tsubo cardiomyopathy is a clinical syndrome induced by a strong mental or physical stress, characterized by a transient hypokinesia, akinesia or dyskinesia middle segments of the left ventricle and apical, with associated electrocardiographic changes of ST-T segment like in acute coronary syndrome, with no significant changes in coronary arteries in coronary angiography. Tako-tsubo cardiomyopathy is mainly found in women in the sixth and seventh decade of life and represents 1-2% of cases originally diagnosed as acute coronary syndrome. We present a case of tako-tsubo syndrome in the course of carbon monoxide poisoning in a 56-year-old patient, with a positive history of ischemic heart disease and hypertension. Moreover, the reasons for its occurrence were considered based on clinical course, laboratory tests and imaging, and available literature.

[The concomitance of pericarditis constrictiva in patient with Silver-Russell syndrome, primary hyperparathyroidism and oncologic history: causal coincidence or pathogenetic sequence?]. / Zaciskajace zapalenie osierdzia u pacjentki z zespolem Silver-Russella, pierwotna nadczynnoscia przytarczyc i wywiadem onkologicznym: przypadkowa koincydencja czy sekwencja patogenetyczna?

The most common cause of calcific pericarditis is idiopathic. We report a case of a 24 year-old woman with Silver-Russell syndrome, history of Wilms' tumour in childhood, constrictive pericarditis and primary hyperparathyroidism. We analyse pathologic mechanisms of disseminated calcification and possible genetic factors that may contribute to aetiology and clinical presentation of calcific pericarditis.

Acute coronary syndrome - a frequent clinical manifestation of bare metal in-stent restenosis.

BACKGROUND: In-stent restenosis (ISR) complicates 20-30% of percutaneous coronary interventions (PCI) with bare metal stent (BMS) implantation. Although the widespread use of drug eluting stents (DES) across Europe caused a considerable reduction of BMS implantations, their number is still lower than the number of BMS implantations in several countries. AIM: The clinical presentation of ISR has not been well characterissed. Thus, we attempted to analyze this condition and assess the treatment of ISR in everyday clinical practice. METHODS: We searched our database for all cases of bare metal ISR between 1999 and 2007. Follow-up angiography after PCI was not a routine procedure but a clinically driven examination. Clinical presentations of ISR were divided into: stable angina, and acute coronary syndromes (ACS), i.e. unstable angina (UA) and myocardial infarction (MI) (further subdivided into NSTEMI and STEMI). Analysis included variables associated with different clinical manifestations, methods of ISR treatment and in-hospital complications of ISR. RESULTS: In-stent restenosis was identified in 432 (3%) of 15,910 patients who underwent PCI. The mean age was 61.6 + or - 15.6 (27-86) years, and 295 (68.3%) patients were men. Risk factor distribution was typical for a Caucasian population. Recurrent clinical episode occurred at a mean of 7 (1-108) months after PCI. Exertional angina was present in 245 (56.7%) patients, UA in 128 (29.6%) patients and MI in 59 (13.7%) patients, including STEMI in 28 (6.5%) and NSTEMI in 31 (7.2%) patients. Overall, ACS was diagnosed in 187 patients or 43.3% of all cases of ISR. Multivariate analysis showed a positive correlation between previous MI and younger age and ACS as the clinical manifestation of ISR, and a negative correlation between more severe restenosis and ACS manifestation. The incidence of clinical complications (MI or death) was higher in patients with ACS as the clinical manifestation of ISR (6.9% vs 1.6%). CONCLUSIONS: In-stent restenosis after BMS implantation is a serious clinical problem. More than 40% of patients with ISR present with ACS, including 13.7% patients with MI, more frequently among younger patients and patients with previous MI. Most patients with ISR are treated with repeated PCI with high success rate (97.7%), although the risk of clinical complications is considerably higher in patients presenting with ACS.

Percutaneous angioplasty of chronically occluded coronary arteries: long-term clinical follow-up.

BACKGROUND: Percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is one of the most demanding procedures in interventional cardiology. In spite of growing experience and technological progress, efficacy of PCI of CTO remains lower than that of standard PCI. AIM: To evaluate long-term clinical results of PCI in patients with stable angina and CTO. METHODS: The study involved 459 consecutive patients who underwent the procedure of CTO recanalisation between 1996 and 2003. All procedures were performed using the standard technique. Follow-up examination was carried out based on a written questionnaire, and the mean follow-up period was 30+/-18 months. RESULTS: The average success rate of intervention was 64.9% and 63.8% of patients underwent successful and uneventful procedures. Clinically significant in-hospital complications were noted in 8 (1.6%) patients including 1 (0.2%) death, 2 (0.4%) cases of myocardial infarction and 4 (1.0%) repeated revascularisations. Long-term survival following either successful or failed recanalisation was similar (97.5% vs 97.3%, NS) as was incidence of acute coronary syndromes (12.5% vs 12.1%, respectively; NS). Patients after successful recanalisation less frequently underwent surgical revascularisation (3.6% vs 8.1%, respectively; p <0.05) and also suffered less frequently from angina (CCS 0/CCS I: 20.4% vs 12.1%, p <0.00005). Otherwise, they were at higher risk of repeated PCI due to restenosis (13.2% vs 6.7%, respectively; p <0.05). CONCLUSIONS: Success rate of PCI in patients with chronically occluded coronary arteries and stable angina is moderately high with relatively low incidence of complications. Late benefits from successful recanalisation of coronary artery depend predominantly on improved coronary reserve and decreased need for surgical myocardial revascularisation. Successful recanalisation does not reduce the risk of death or myocardial infarction but is associated with higher frequency of repeated PCI due to restenosis.

[Isolated right ventricular myocardial infarction in cardiosurgery practice]. / Zawal prawej komory w praktyce kardiochirurgicznej.

Isolated right ventricular myocardial infarction (RVMI) is a very rare complication of ischemic heart disease. Generally it accompanies infero-posterior or antero-septal myocardial infarction cases. Right ventricular myocardial infarction is a strong predictor of acute right ventricular failure, bradyarrythmia, ischemic and mechanical complications and is frequently complicated by cardiogenic shock which often leads to death. Acute right ventricular ischemia (RVI) and RVMI are big problem particularly during and early post-operative cardiosurgery procedures. Atherosclerotic changes and heart blood flow disturbances predispose to RVI or RVMI that occur more often in cardiosurgical patients, especially in early postoperative period. On the other hand early intraoperative diagnosis and longer reperfusion period result in the correction of heart function and better prognosis.

Percutaneous transluminal coronary angioplasty for chronic total coronary occlusion in patients with stable angina. Relationship between lesion anatomy, procedure technique and efficacy.

BACKGROUND: In spite of continuing progress in percutaneous coronary interventions (PCI), recanalisation of chronic total coronary occlusion (CTO) still remains a challenge for invasive cardiologists. AIM: To analyse the results of PCI of CTO and to assess the relationship between lesion anatomy, procedural technique and efficacy of PCI in patients with stable angina. METHODS: The study group consisted of 460 consecutive patients (81% males, age 25-80 years, 68% with a history of myocardial infarction [MI]), who underwent CTO recanalisation in our institution between 1996 and 2003. Duration of CTO ranged between 1 and 3 months in 5.9% of patients, 3-6 months -- in 12.4%, more than 6 months -- in 51.7% and was undefined in 30% of patients. RESULTS: The overall average success rate was 65%; it increased from 60% in 1996 to 75% in 2003. The most frequent (92%) cause of failure was the inability to pass a guide wire through the occlusion. The use of soft or standard guide wire was associated with a 68.7% success rate. In those in whom standard methods failed, the use of special guide wire was associated with the efficacy of 61.2%, and the Magnum system -- of 28.6%. Stents were implanted in 34.5% of patients (from none in 1996 to 55% in 2003). Serious peri-procedural complications included one death (0.2%), MI in one (0.2%) patient, repeated urgent PCI in 5 (1.1%) patients, urgent CABG in one (0.2%) patient, perforation of coronary artery requiring pericardiocentesis in one (0.2%) patient, and complications at the site of artery puncture in 14 (3%) patients. Univariate analysis showed that longer duration of occlusion, TIMI flow grade 0, lengthy occlusion, abrupt vessel stump, small vessel diameter, presence of bridge collaterals, branching off at the site of occlusion, and massive calcifications were the factors adversely affecting the outcome. Multivariate analysis revealed that tapered end of the stump, lack of calcifications and TIMI flow grade 1 were the factors independently associated with a favourable outcome. CONCLUSIONS: The overall average efficacy of PCI of CTO is 75% and the risk of peri-procedural complications is low (1.7%). Clinical factors and the anatomy of lesion should be taken into account when planning the procedure. Special guide wires designed for recanalisation of CTO are effective in more than half of patients in whom standard guide wires failed.

[Non-surgical retrieval of coronary stent from the left ventricle following failed stent deployment in the left anterior descending coronary artery--a case report]. / Usuniecie stentu z lewej komory serca po nieudanej próbie implantacji do galezi miedzykomorowej przedniej lewej tetnicy wiencowej.

A case of a 66-year-old male with acute myocardial infarction (MI) treated with streptokinase is presented. Due to the recurrence of angina six days from the acute phase of MI, the patient underwent coronary angiography which revealed critical stenosis of the left anterior descending coronary artery. During intracoronary intervention, stent was lost and migrated to the left ventricular cavity, being trapped in chordae tendinae of the posterior mitral leaflet. The procedure was stopped. After transferring the patient to our department a few days later, a successful non-surgical retrieval of stent with the use of biopsy forceps was performed. Treatment of dislodged coronary stents is discussed.

[Partial anomalous pulmonary venous drainage with atrial septal defect of the sinus venosus type. Diagnostic role of multi-slice spiral computerised tomography--a case report]. / Nieprawidlowy splyw zyl plucnych do zyly glównej górnej z ubytkiem w przegrodzie miedzyprzedsionkowej typu sinus venosus--rola wielorzedowej spiralnej tomografii komputerowej.

A case of a 53-year-old male with a long-lasting pulmonary hypertension of an unknown cause is presented. Both transthoracic and transesophageal echocardiography as well as cardiac catheterisation failed to document any cardiac defect. Finally, a multi-slice spiral computerised tomography revealed the presence of an anomalous pulmonary vein drainage to the superior vena cava with concomitant inter-atrial septal defect of a sinus venosus type. The patient was selected for surgery.

[Angina pectoris in patients with aortic valvular stenosis]. / Bóle wiencowe u chorych ze zwezeniem lewego ujscia tetniczego.

AIM: The aim of the study was to analyze the factors contributing to the development of anginal pain common in patients with aortic valvular stenosis (SOAS). METHODS: The study included 74 consecutive patients, aged 60,5 (+/- 10,7), with severe acquired valvular aortic stenosis (resting maximum systolic pressure gradient above 50 mm Hg) who were referred for evaluation prior to elective cardiac surgery. The history of angina and its severity according to CCS classification and of common atherosclerosis risk factors including: hypertension, hyperlipidaemia, smoking, diabetes mellitus and family history was taken. The laboratory tests included: lipidogram, white blood count and serum creatinine. The transthoracic echocardiography (TEE) date were collected: LVEDd, IVSDd, LVPWDd, LAd, EF, SF, SV, EDV, ESV, maximum systolic transvalvular pressure gradient and degree of aortic insufficiency. Coronary angiography was then performed. The presence of severe atherosclerosis was defined as more than 50% stenosis of one of three main coronary arteries: right, anterior descending or circumflex artery. Haemodynamic protocol involved LVEDP, PCWP, CO, PASP, aortic pressure gradient and aortic insufficiency evaluation. RESULTS: Patients with severe anginal symptoms (CCS III/IV) were older, had higher LDL cholesterol and triglycerides concentrations, more often had obesity and positive family history of ischemic heart disease than patients with mild (CCS I/II) or without symptoms. They had also higher number of vessels with significant stenosis which most frequently presented in left anterior descending artery. The maximum systolic pressure gradient according to TTE as well as to invasive measurements was also higher in symptomatic patients. The interventricular septum measured using TTE was thicker in patients with severe anginal symptoms. CONCLUSION: The frequency of anginal symptoms in patients with severe aortic valvular stenosis is higher than actual frequency of significant coronary stenosis on angiography. Angina is more common in a subgroup with coronary stenoses than in patients without coronary heart disease and the severity of anginal symptoms correlates with the number of coronary arteries involved. The severity of angina also correlates with the maximum pressure gradient across the aortic valve and the thickness of interventricular septum. In the study group hypercholesterolaemia, obesity and positive family history of IHD were more often found in patients with severe (CCS III/IV) symptoms.

Coronary atherosclerosis in patients with acquired valvular disease.

BACKGROUND: Coronary atherosclerosis often coexists with acquired valvular disorders. There is growing evidence in literature that these two conditions may have common aetiology. AIM: To assess the incidence of coronary atherosclerosis in patients with acquired valvular disorders and to compare clinical parameters as well as the prevalence of risk factors between patients with aortic and mitral valve diseases. METHODS: The study group consisted of 155 patients (101 males, 54 females, mean age 58.2+/-9.7 years) with acquired valvular disorder who between 2000 and 2002 underwent invasive cardiac evaluation in our department prior to planned cardiac surgery. Aortic stenosis was detected in 74 patients, aortic insufficiency -- in 26, mitral stenosis -- in 33, and mitral regurgitation -- in 14 subjects. All patients underwent clinical evaluation, echocardiography, coronary angiography and laboratory tests. RESULTS: Patients with aortic stenosis had similar prevalence of coronary atherosclerosis to patients with aortic insufficiency, and patients with mitral stenosis -- to patients with mitral regurgitation. When the two groups -- patients with aortic valve disease and patients with mitral valve disease were compared, significant coronary lesions were more often detected in patients with aortic valve disease (36% vs 12.8%, p<0.05). Also, patients with aortic valve disorder were older, predominantly of male gender, had more often angina but less often heart failure, and had higher total cholesterol level than patients with mitral valve disease. CONCLUSIONS: Significant coronary lesions are more frequently encountered in patients with aortic valve disorder than in those with mitral valve disease. A high prevalence of atherosclerotic risk factors in patients with aortic valve disease may suggest that this condition has similar aetiology to that of coronary artery disease.