[Feasibility and safety of right subclavian access for Edwards Sapien 3 balloon-expandable transcatheter aortic valve implantation]. / Fattibilità e sicurezza dell'impianto succlavio destro di valvola aortica transcatetere balloon-expandable Edwards Sapien 3.

Despite the technical advancements in transcatheter aortic valve implantation (TAVI), this procedure in patients with peripheral artery disease remains challenging and requires a patient-tailored management by the Heart Team. In-depth assessment of the patient's vascular anatomy is of utmost importance for the management of TAVI procedures with the aim to use the less invasive approach according to the specific patient characteristics. The trans-subclavian approach should be the preferred option in patients with femoral arterial disease undergoing TAVI; however, self-expandable valves have potential limitations, as in case of ascending aorta dilation and high implantation. We present an elegant solution to overcome this challenging situation with good short- and mid-term outcome. A balloon-expandable Edwards Sapien 3 prosthesis was implanted by right subclavian surgical access using a multistep approach. The imaging controls showed good positioning with trivial paravalvular leak. The right subclavian approach for balloon-expandable TAVI implantation is feasible and safe when performed by skilled operators and can be a valid treatment strategy when no other options are available.

[Hybrid percutaneous coronary intervention with drug-eluting stent in combination with bioresorbable vascular scaffolds for complex coronary lesions]. / Procedura ibrida di rivascolarizzazione coronarica percutanea con impiego combinato di stent medicato e scaffold bioriassorbibile per il trattamento di lesioni coronariche complesse.

Drug-eluting stents (DES) have significantly improved the outcome of percutaneous coronary intervention (PCI); however, several concerns remain regarding late adverse events associated with the presence of a permanent rigid metallic cage that might impair the natural healing process of the coronary vessel wall. Recently, PCI with bioresorbable vascular scaffolds (BVS) has emerged as an interesting alternative with several potential advantages related to the complete resorption process that occurs within 3-5 years. As a consequence, it reduces the trigger for persistent inflammation, enables restoration of normal vessel reactivity and facilitates positive remodeling. However, current BVS have several limitations, including thicker and wider struts, less radial strength, and limited expansion. A hybrid strategy, combining the use of BVS and DES, is a novel approach that could be useful to avoid the limitations of currently available BVS, particularly in case of PCI for complex coronary lesions.We describe a case of hybrid percutaneous intervention with BVS in combination with DES for managing complex lesions unsuitable for pure scaffolding percutaneous coronary intervention.

Patterns and trends of transcatheter aortic valve implantation in Italy: insights from RISPEVA.

AIMS: Clinical trials have shown that transcatheter aortic valve implantation for aortic stenosis compares favorably to surgical replacement in high-risk patients and is superior to medical therapy in those at prohibitive risk. There is uncertainty however on patterns and trends in transcatheter aortic valve implantation, especially focusing on Italy. METHODS: The RISPEVA study is a prospective Italian registry including 21 institutions. Patients have been enrolled since late 2012, and data collection includes several baseline, procedural, in-hospital, and follow-up details. For the present analysis on patterns and trends, we focused on patients enrolled between 2012 and 2015, and as primary variable on the prevalence of high versus prohibitive surgical risk, limiting our scope to procedural outcomes. RESULTS: A total of 1157 patients were included. The temporal breakdown was 376 (33%) patients enrolled in 2013, 408 (35%) in 2014, and 373 (32%) in 2015. Several patient features differed over time, including risk score, peripheral artery disease, end-stage pulmonary disease, and prior valvuloplasty (all P < 0.05). Several procedural features differed significantly over time, including sheath size, use of general anesthesia, Prostar closure device, predilation, antiembolic device, new TAVI device, and multiple prostheses (all P < 0.05). No significant temporal differences were found for major clinical outcomes, whereas the occurrence of moderate or severe postprocedural regurgitation and pacemaker dependency decreased over the years (both P < 0.05). CONCLUSION: According to the RISPEVA results, the Italian uptake of TAVI is steady, with evident trends toward less invasive approaches and fitter patients.

[Percutaneous transcatheter closure of an aorta to left atrium fistula with an Amplatzer septal occluder in a patient with a mitral bioprosthesis]. / Chiusura percutanea transcatetere di una fistola tra aorta e atrio sinistro mediante occlusore settale Amplatzer in un paziente con protesi mitralica biologica.

We describe the case of a patient with a mitral bioprosthetic valve undergoing percutaneous closure with fluoroscopy and echocardiographic guidance of a rare left sinus of Valsalva‒left atrial fistula. The original aspect of this case is that the fistula was located at the level of the left sinus of Valsalva next to the mitral valve bioprosthesis with subsequent risk of prosthesis damage and/or occlusion of the left coronary artery at its origin during the procedure.

Correlation of Left Atrial Strain and Doppler Measurements with Invasive Measurement of Left Ventricular End-Diastolic Pressure in Patients Stratified for Different Values of Ejection Fraction.

BACKGROUND: This study aimed at exploring the correlation of left atrial longitudinal function by speckle tracking echocardiography (left atrial strain) and Doppler measurements (E/E' ratio) with direct measurements of left ventricular (LV) end-diastolic pressure (LVEDP) in patients stratified for different values of ejection fraction. METHODS: The study population was 80 stable patients with sinus rhythm undergoing cardiac catheterization. This population was selected in order to have four groups of 20 patients each with different LV ejection fraction (>55%, 45-54%, 30-44%, and <30%). LVEDP was obtained during cardiac catheterization; peak atrial longitudinal strain (PALS) and mean E/E' ratio were measured in all subjects. RESULTS: Similar correlations with LVEDP of global PALS and E/E' ratio were recorded in patients with preserved (r = -0.79 vs. r = 0.72, respectively; P < 0.0001 for both) or mildly reduced ejection fraction (r = -0.75 vs. r = 0.73, respectively; P < 0.0001 for both). A closer correlation of global PALS compared to E/E' ratio was evident in patients with moderate (r = -0.78 P < 0.0001; vs. r = 0.47 P = 0.01, respectively) and severe reduction (r = -0.74 P < 0.0001; vs. r = 0.19 ns, respectively) of LV ejection fraction. In multivariate analysis of all measurements, global PALS emerged as a determinant of the LVEDP, independent on other confounding factors and, with the cutoff value of 18.0% presented the best diagnostic accuracy to predict a LVDP above 12 mmHg (AUC 0.87). CONCLUSIONS: In patients with preserved or mildly reduced LV ejection fraction, global PALS and mean E/E' ratio presented good correlations with LVEDP. In patients with moderate or severe reduction of ejection fraction, E/E' ratio correlated poorly with invasively obtained LV filling pressures. Global PALS provided an overall better estimation of LV filling pressures.

Spontaneous coronary artery dissection in a middle-age woman: percutaneous treatment guided by intracoronary imaging techniques.

: Angiographic diagnosis and treatment of spontaneous coronary artery dissection is challenging. Complementary use of intracoronary imaging can provide information to guide percutaneous treatments, particularly in these challenging settings. Here we report a case of a 52-year-old woman presenting with an anterior ST-segment elevation myocardial infarction caused by a spontaneous, long, and spiral dissection of the left anterior descending artery. Intracoronary imaging allowed us to visualize the entry port of the coronary dissection which was not sealed by the first angio-guided stenting. This case demonstrates that, beyond merely diagnostic information, the intracoronary imaging is able to provide information to guide percutaneous treatments, particularly in challenging settings in which coronary angiography reveals its limitations.

[Interrupted aortic arch in a 68-year-old female with hypertension]. / Diagnosi ed immagini di arco artico interrotto in una donna ipertesa di 68 anni.

Interrupted aortic arch (IAA) is a rare congenital malformation of the aorta and aortic arch. We report the case of a 68-year-old female with hypertension and poor control of blood pressure levels. She was diagnosed with aortic coarctation by aortography during young age. A double access angiography was performed that showed a type A IAA, a rare condition in adults that may cause hypertension.

Congenital coronary arteriovenous fistulae in a transplanted heart.

We report a very rare case of a heart transplanted man with angiographic documentation of multiple congenital fistulae arising from both coronary arteries and draining into main pulmonary artery. A transthoracic echocardiogram and right heart catheterization were also performed, to assess the functional importance of the shunt. We also carried out a brief review about this rare condition and we reported considerations about its prognosis and treatment.

How should I treat severe symptomatic aortic stenosis with transcatheter aortic valve implantation in a patient with right aortic arch?

BACKGROUND: An 84-year-old man suffering from dyspnoea on mild exertion and a 10-year history of mitral valve replacement with a mechanical prosthesis presented to our department. The patient had an isolated right aortic arch. INVESTIGATION: Transthoracic echocardiography demonstrated severe LV systolic dysfunction (EF 25%), good function of the previously implanted mechanical prosthesis and severe aortic stenosis. Multislice computed tomography confirmed the presence of an isolated right aortic arch with mirror-image branching. DIAGNOSIS: Severe symptomatic aortic stenosis in a patient with right aortic arch at high risk for surgical reintervention. MANAGEMENT: Transcatheter aortic valve implantation using conventional delivery system.

Left atrial remodelling in patients undergoing transcatheter aortic valve implantation: a speckle-tracking prospective, longitudinal study.

Aortic stenosis (AS) results in several left ventricular (LV) disturbances as well as progressive left atrial (LA) enlargement and dysfunction. Transcatheter aortic valve implantation (TAVI) reverses LV remodelling and improves overall systolic function but its effect on LA function remains undetermined. The aim of this prospective, longitudinal study was to investigate the effects of TAVI on LA structure and function. We studied thirty-two patients with severe symptomatic AS who underwent TAVI, using standard and 2-dimensional speckle-tracking echocardiography before, at 40-day and at 3-month follow-up. Following TAVI, mean transvalvular gradient decreased (p < 0.001). Both LA area index and LA volume index decreased at 40-day follow-up (16.2 ± 6.4 vs. 12.5 ± 2.9 cm2/m2, and 47.3 ± 12.0 vs. 42.8 ± 12.5 mL/m2, respectively, p < 0.05) and values remained unchanged at 3 months. The reduction of LA size was accompanied by a significant increase in global peak atrial longitudinal strain (14.4 ± 3.9 vs. 19.1 ± 4.7%, p < 0.001) and in global peak atrial contraction strain (8.4 ± 2.5 vs. 11.0 ± 4.1%, p < 0.05) at 3-month follow-up. LA stiffness measurements significantly decreased 3 months after TAVI (0.93 ± 0.59 vs. 0.65 ± 0.37, respectively, p < 0.001). Trans-aortic mean gradient change and pre-procedural LA volume were identified as predictors of global peak atrial longitudinal strain increase (ß = -0.41, ß = -0.35, respectively, p < 0.0001) while pre-procedural LA volume and trans-aortic mean gradient change as predictor of LA volume index reduction 3 months after TAVI (ß = -0.37, ß = -0.28, respectively, p < 0.0001). TAVI is associated with significant recovery of LA structure and function suggesting a reverse cavity remodelling. Such functional recovery is primarily determined by the severity of pre-procedural valve stenosis.

The impact of gender on fractional flow reserve measurements.

AIMS: Fractional flow reserve (FFR) allows accurate investigation of the functional significance of intermediate coronary stenoses. The present study set out to study the impact of gender on FFR measurements. METHODS AND RESULTS: Three hundred and seventeen intermediate (40-70% at angiography) stenoses were assessed with FFR in 270 patients (mean age 65.8 ± 10.3 years, 84 females). Resting Pd/Pa (the ratio of mean blood pressure measured distal to the stenosis to mean aortic blood pressure in resting conditions), FFR (Pd/Pa during adenosine-induced hyperaemia) and the ΔPd/Pa (calculated as the change in Pd/Pa during hyperaemia) were measured. There was no difference in the location and degree of stenoses between genders (p>0.5). Similarly, there was no difference in age and in the prevalence of cardiovascular risk factors (all p>0.2). Resting Pd/Pa also did not differ between genders (0.92 ± 0.08 vs. 0.93 ± 0.05, p=0.23). In response to adenosine, however, a significantly larger ΔPd/Pa (0.14 ± 0.07 vs. 0.11 ± 0.07, p=0.001) and a significantly lower FFR (0.79 ± 0.12 vs. 0.82 ± 0.10, p=0.008) were observed in males. This difference was maintained in a multivariate regression analysis. CONCLUSIONS: We observed gender-based differences in FFR data in daily routine. Further studies are necessary to test the mechanism of this observation and how these differences impact on the assessment of haemodynamically relevant stenoses.

Optical coherence tomography evidence of endothelial erosion as a cause of ST-segment elevation myocardial infarction.

High-resolution intracoronary imaging provided relevant insights into the field of pathophysiology of acute coronary syndromes (ACS). Human autopsy studies have shown that endothelial erosion may lead to intravascular thrombosis and acute myocardial infarction. We report the case of a 51-year-old woman presenting with ST-segment elevation ACS. In this patient, frequency domain optical coherence tomography (FD-OCT) was performed into the infarct-related artery, showing in-vivo findings suggestive of endothelial erosion, associated with no flow-obstructing luminal thrombus. In this rare case, endothelial erosion, and subsequent thrombosis, in the proximal third of the artery has probably caused embolization and thrombotic occlusion in the mid third. FD-OCT allowed us to obtain a rare in-vivo image of endothelial erosion, providing relevant insights into the setting of ACS.

The role of optical coherence tomography in clarifying the mechanisms for dobutamine stress echocardiography-induced takotsubo cardiomyopathy.

Takotsubo cardiomyopathy is a clinical disorder characterized by a transient dilatation and akynesis or dyskinesis of the left ventricular (LV) apex, mimicking an anterior wall acute myocardial infarction in the absence of significant coronary artery disease (CAD). It typically occurs during an episode of severe emotional or physical stress. Recent reports suggested the potential of dobutamine stress echocardiography (DSE) in inducing the aforementioned syndrome. The transient dysfunction of the LV does not fit any known coronary distribution. Furthermore, there is no obstructive CAD demonstrated at angiography to account for the observed dysfunction. Consequently, the pathophysiology of this syndrome is still undetermined. Here, we report a case of DSE-induced Takotsubo cardiomyopathy in which high-resolution intracoronary imaging was utilized to exclude possible vessel alterations to help provide potential mechanistic explanations for the development of this condition.

Improvement of left ventricular longitudinal systolic function after transcatheter aortic valve implantation: a speckle-tracking prospective study.

Transcatheter aortic valve implantation (TAVI) is able to determine a significant improvement of left ventricular ejection fraction (LVEF). The variations of LV global longitudinal strain (GLS) have not been yet investigated in TAVI patients with reduced LVEF. The aim of this study was to determine the effects of TAVI on LV function by 2D speckle-tracking echocardiography (STE) in patients with reduced LVEF. Eighteen consecutive patients undergoing TAVI in our centre were prospectively enrolled. Echocardiography was performed pre-procedurally the day of TAVI and at 40-day and 3-month follow-up (FU). The mean age of TAVI patients was 79.75 ± 7.68 years. The mean EuroSCORE was 26.59 ± 14.62%. A significant decrease of mean trans-aortic gradient was observed 40 days after TAVI (51.69 ± 18.82 vs. 9.62 ± 3.28 mmHg, p < 0.0001). LV mass index significantly decreased at 40-day FU (165.72 ± 37.75 vs. 145.52 ± 31.32 g/m(2), p < 0.001) with a further reduction at 3-month FU (136.91 ± 26.91 g/m(2), p < 0.05 in comparison with 40-day FU). The mean pre-procedural LVEF was 45.87 ± 7.95%. LVEF significantly increased at 40-day FU (55.20 ± 5.91%, p < 0.05) and remained stable at 3-month FU (55.58 ± 6.14%). Interestingly, an early improvement of LV GLS was observed at 40-day FU (-11.09 ± 3.40 vs. -14.40 ± 3.68%, p < 0.001) with a slight further increase at 3-month FU (-14.71 ± 3.56%). Our results indicate that significant improvements of LVEF and LV GLS can be observed in patients undergoing TAVI with impaired LVEF. Two-dimensional STE was able to detect the reverse remodeling of LV function, adding further insights into the assessment of LV mid-term recovery after TAVI.

Impact of iso-osmolar versus low-osmolar contrast agents on contrast-induced nephropathy and tissue reperfusion in unselected patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (from the Contrast Media and Nephrotoxicity Following Primary Angioplasty for Acute Myocardial Infarction [CONTRAST-AMI] Trial).

Conflicting data have been reported on the effects of low-osmolar and iso-osmolar contrast media on contrast-induced acute kidney injury (CI-AKI). In particular, no clinical trial has yet focused on the effect of contemporary contrast media on CI-AKI, epicardial flow, and microcirculatory function in patients with ST-segment elevation acute myocardial infarction who undergo primary percutaneous coronary intervention. The Contrast Media and Nephrotoxicity Following Coronary Revascularization by Angioplasty for Acute Myocardial Infarction (CONTRAST-AMI) trial is a prospective, randomized, single-blind, parallel-group, noninferiority study aiming to evaluate the effects of the low-osmolar contrast medium iopromide compared to the iso-osmolar agent iodixanol on CI-AKI and tissue-level perfusion in patients with ST-segment elevation acute myocardial infarction. Four hundred seventy-five consecutive, unselected patients who underwent primary percutaneous coronary intervention were randomized to iopromide (n = 239) or iodixanol (n = 236). All patients received high-dose N-acetylcysteine and hydration. The primary end point was the proportion of patients with serum creatinine (sCr) increases ≥25% from baseline to 72 hours. Secondary end points were Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion grade, increase in sCr ≥50%, increase in sCr ≥0.5 or ≥1 mg/dl, and 1-month major adverse cardiac events. The primary end point occurred in 10% of the iopromide group and in 13% of the iodixanol group (95% confidence interval -9% to 3%, p for noninferiority = 0.0002). A TIMI myocardial perfusion grade of 0 or 1 was present in 14% of patients in the 2 groups. No differences between the 2 groups were found in any of the secondary analyses of sCr increase. No significant difference in 1-month major adverse cardiac events was found (8% vs 6%, p = 0.37). In conclusion, in a population of unselected patients with ST-segment elevation acute myocardial infarction who underwent primary percutaneous coronary intervention, iopromide was not inferior to iodixanol in the occurrence of CI-AKI; no significant differences were found in terms of tissue-level reperfusion and major adverse cardiac events between the 2 contrast agents.

B-type natriuretic peptide as an independent predictor of coronary disease extension in non-ST elevation coronary syndromes with preserved systolic function.

OBJECTIVE: B-type natriuretic peptide (BNP) has been employed as a risk marker in patients with coronary artery disease (CAD) with ST elevation and non-ST elevation. It is not yet established if early BNP measurements provide additional information to troponin and electrocardiographic analysis in patients without ventricular enlargement and systolic dysfunction. DESIGN: This study compared BNP levels in patients with stable angina (SA) and acute coronary syndromes with non-ST elevation in relation to angiographic lesions (NSTEMI-ACS). Moreover, the diagnostic utility of BNP was determined using the receiver operating characteristic curve. PATIENTS: 280 patients with CAD without ST elevation and preserved systolic function were studied. BNP samples were measured in all recruited patients within 24 hours of hospitalization. RESULTS: BNP values increased progressively with the severity of diagnosis: SA (n = 85; 50.4 ± 50 pg/ml) NSTEMI-ACS (n = 195; 283 ± 269 pg/ml; p < 0.0001). The analysis of BNP in relation to the number of involved vessels demonstrated significantly increased levels in patients with multivessel disease compared to patients with 1- or 2-vessel disease (p < 0.001 and p < 0.003). Values of BNP >80 pg/ml were shown to be able to predict CAD severity and coronary vessel involvement (AUC = 0.80; p = 0.0001) with a sensitivity of 78% and a specificity of 72%. In multivariate analysis, BNP levels >80 pg/ml, CAD history, and ST deviation >2 mm were confirmed as independent predictors of CAD severity. CONCLUSIONS: Circulating BNP levels appear elevated in NSTEMI-ACS, without left ventricular systolic dysfunction. A BNP cut-off value of 80 pg/ml is a good predictor of CAD extension.