Endothelial Progenitor Cell Function in Patients With Coronary Chronic Total Occlusion and its Relationship With Collateral Circulation.

AIM: To evaluate the relationship between endothelial progenitor cell (EPC) count and function and collateral circulation in coronary chronic total occlusions (CTOs). METHODS: A total of 20 consecutive patients with successfully treated CTO lesions were included during a period of 12 months. EPC count and function were evaluated by flow cytometry and colony-forming unit (CFU) analysis at baseline (before percutaneous coronary intervention) and at 1-year follow-up. Patients were classified, according to Rentrop classification at the baseline angiography, as group 1 (Rentrop 3; n = 7) and group 2 (Rentrop <3; n = 13). Differences in EPC count and function were compared between groups. RESULTS: The EPC count did not differ between the 2 groups, either at baseline or at follow-up. CFU was significantly lower at follow-up compared with baseline in the overall population (16.6 10^6/mL (IQR, 10.2-29.4 10^6/mL) vs 7.1 10^6/mL (IQR, 5.3-25.0 10^6/mL); P=.046). Group 1 had both higher basal and follow-up CFU values compared with group 2 (35.4 10^6/mL (IQR, 21.5-41.8 10^6/mL) vs 13.3 10^6/mL (IQR, 6.9-17.5 10^6/mL) and 32.1 10^6/mL (IQR, 13.9-40.5 10^6/mL) vs 5.9 10^6/mL (IQR, 4.4-9.8 10^6/mL), respectively; P=.01 for both). By linear regression analysis, Rentrop grade 3 flow was an independent predictor of both basal and follow-up CFU levels (odds ratio, 3.66; 95% confidence interval, 6.41-29.69; P<.01; and odds ratio, 5.24; 95% confidence interval, 9.78-25.85; P<.01, respectively). CONCLUSION: Patients with Rentrop grade 3 collateral circulation exhibited higher EPC activity at baseline and at 1-year follow-up compared with those who had reduced collateral circulation. The role of this higher EPC activity in determining clinical endpoint should be investigated in a larger study.

Rationale and design of a randomized clinical trial to compare two antithrombotic strategies after left atrial appendage occlusion: double antiplatelet therapy vs. apixaban (ADALA study).

BACKGROUND: Data on antithrombotic therapy after percutaneous left atrial appendage occlusion (LAAO) is scarce and no randomized evaluation has been performed to demonstrate what is the best antithrombotic strategy. Up to date, different antithrombotic regimens with variable durations are currently used. In fact, the use of oral anticoagulation (OAC) or dual antiplatelet therapy (DAPT) with aspirin and clopidogrel during the initial phase (∓ 3 months post-LAAO) has been proposed as valid strategies. However, antiplatelet and OAC therapies have never been compared in a randomized study after left atrial appendage closure (LAAC). The purpose of the present study is to ascertain an optimal antithrombotic strategy after LAAC in terms of safety and efficacy. The study will compare a novel OAC (NOAC) with a highly safety profile like apixaban 5 mg/12 h or 2.5 mg/12 h (after dose adjustment or in high-risk patients) with standard antiplatelet therapy with DAPT. The aim of the study was to compare a strategy of anticoagulation with apixaban 5 mg/2.5 mg bid to the current standard of care (DAPT with aspirin and clopidogrel) after LAAO in patients with non-valvular atrial fibrillation (AF). METHODS: This is a phase IV multicenter randomized, open-label, controlled trial comparing the efficacy and safety of apixaban vs. DAPT after LAAO, both for 3 months. The primary endpoint is a combined endpoint of death, myocardial infarction, stroke, thromboembolic complications, and major or significant bleeding at 3 months of follow-up. Approximately 160 subjects will be enrolled and followed 12 months from randomization. CONCLUSIONS: Considering the high risk of both thromboembolic and hemorrhagic events of patients undergoing LAAO, establishment of an appropriate antithrombotic therapy in terms of efficacy and safety after LAAO is of vital importance. TRIAL REGISTRATION: EudraCT number: 2018-001013-32.

Sex-based differences in chronic total occlusion management and long-term clinical outcomes.

BACKGROUND: Sex differences in coronary artery disease presentation and outcomes have been described. The aim of this study was to compare sex disparities in chronic total occlusion (CTO) management and long-term outcomes. METHODS: All consecutive patients with at least one CTO diagnosed in our center between 2010 and 2014 were included. Demographic and clinical data were registered. All-cause and cardiac mortality were assessed during a median follow-up of 4.03 years (IQR 2.6-4.8). RESULTS: A total of 1248 patients (67.3 ± 10.9 years; 16% female) were identified. Women were older, had a higher prevalence of type 2 DM and a lower ventricle ejection fraction compared to men (p < .05). Although women had major proportion of positive result for severe ischemia-viability test (86% vs. 74%; p = .01), they were more often treated with MT alone compared to male (57% vs 51%; p = .02). During follow-up, 386 patients (31%) died. Women presented a higher rate of all-cause and cardiac mortality, and hospitalizations for heart failure independently of treatment strategy, compared to men (p < .001). In multivariable analysis female sex was associated with higher cardiac mortality [HR 1.67, 95% CI 1.10-2.57; p < .001]. Among women, the independent predictors for all-cause and cardiac mortalities were age, MT of the CTO and ACEF (age, creatinin and ejection fraction) score. CONCLUSIONS: A significant sex gap regarding CTO treatment was observed. Female sex was an independent predictor for cardiac mortality at long-term follow-up. More data are needed to support these findings.

Impact of revascularization versus medical therapy alone for chronic total occlusion management in older patients.

BACKGROUND: Chronic total occlusions (CTOs) are present in more than one third of older patients with myocardial ischemia, but controversy remains about the best therapeutic approach. AIMS: To compare long-term survival after CTO revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) versus medical treatment (MT) alone in patients aged 75 and older. METHODS AND RESULTS: A total of 1,252 consecutive patients with at least one CTO were identified from 2010 to 2014 in our center. Patients were stratified by age (<75 years vs. ≥75 years) in the present analysis. All-cause and cardiac mortality were assessed at a median follow-up of 3.5 years. In the older subgroup (26%), patients were more likely to be treated with MT alone (71% vs. 43% of younger patients; p < 0.001). Patients undergoing revascularization were younger and had higher left ventricular ejection fraction (LVEF) and lower age, creatinine, ejection fraction (ACEF) score (age/LVEF +1 if creatinine >2.0 mg/dL), compared to the MT group (p < 0.05). As compared to MT, revascularization predicted lower rates of cardiac mortality and all-cause mortality in older patients, both in the subgroups treated with CABG (hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.17-0.71; HR 0.39, 95%CI 0.18-0.81) and PCI (HR 0.57, 95%CI 0.33-0.98; HR 0.59, 95%CI 0.28-1.2). No differences in mortality were observed according to type of revascularization procedure. CONCLUSIONS: Among patients aged at least 75 years with a CTO, revascularization (PCI or CABG) rather than MT alone may portend a better outcome in terms of all-cause and cardiac mortality.

Central extracorporeal membrane oxygenation as a bridge to decision in a patient with a ventricular septal rupture complicating a myocardial infarction / Análisis de las medidas de prevención secundaria introducidas en pacientes con historia de síndrome coronario agudo

Abstract In the era of primary percutaneous coronary intervention, mechanical complications after acute myocardial infarction are extremely rare, with an incidence of less than 0.5%. Rupture of the ventricular septum is the least frequent occurrence. Despite early surgical repair, mortality still remains high. Patients who are at high risk of perioperative death include those with cardiogenic shock and multiorgan dysfunction. In this group, a mechanical circulatory support such as an Extracorporeal Membrane Oxygenation circuit could be used as bridge to surgical repair is feasible or heart transplantation, as it provides hemodynamic stability and the potential to correct multiorgan dysfunction. We reported a case pf ECMO device implantation as a bridge to heart transplantation in a patient with post infarction ventricular septal rupture. Unfortunately, while on the waiting list for heart transplantation with maximum priority the patient had massive diffuse alveolar hemorrhage secondary to the anticoagulation required by the equipment and died.

Resumen En la era de la intervención coronaria percutánea primaria, las complicaciones mecánicas tras un infarto de miocardio agudo son extremadamente infrecuentes, con una incidencia de menos del 0,5%. La ruptura del septum ventricular es el caso menos frecuente. A pesar de la reparación quirúrgica, la mortalidad sigue siendo elevada. Los pacientes con alto riesgo de muerte perioperativa incluyen a aquellos con shock cardiógeno y síndrome de disfunción multiorgánica. En este grupo, podría utilizarse soporte circulatorio mecánico, tal como el circuito de oxigenación por membrana extracorpórea, como puente hacia la reparación quirúrgica o trasplante cardiaco, ya que aporta estabilidad dinámica y la posibilidad de corregir el síndrome de disfunción multiorgánica. Se reporta un caso de implantación de dispositivo de membrana extracorpórea, como puente al trasplante cardiaco, en un paciente con ruptura del septum ventricular tras infarto. Lamentablemente, a pesar de estar en lista de espera con prioridad máxima, sufrió una hemorragia alveolar difusa masiva, secundaria a la anticoagulación requerida por el equipo, y falleció.

Un caso inusual de dolor torácico: perforación cardiaca asociada a marcapasos / An unusual cause of thoracic pain: Cardiac perforation associated with a pacemaker

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Muerte súbita secundaria a vasoespasmo coronario multivaso / Sudden cardiac death secondary to severe multivessel coronary spasm

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Lesiones de Janeway, nódulos de Osler y hemorragias en astilla / Janeway lesions, Osler nodes and splinter hemorrhages

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