[Myocardial viability: when and how to look for it, its prognostic impact and interaction with benefits of revascularization]. / Vitalità miocardica: quando cercarla, in che modo e quale valore prognostico ai fini della rivascolarizzazione.

Ischemic left ventricular dysfunction results from the combination of scar and areas of dysfunctional but viable myocardium that may improve contractile function with revascularization. The traditional paradigm states that an improvement in function after revascularization leads to improved health outcomes and that assessment of myocardial viability has a key role in predicting the benefit of revascularization and, therefore, is a prerequisite for the selection of patients to undergo this treatment option. A range of retrospective observational studies supported this "viability hypothesis". However, randomized prospective trials have not confirmed the interaction between myocardial viability and the treatment effect of revascularization, challenging the recovery of left ventricular function as the principal mechanism by which surgical revascularization improves prognosis. A conceptual shift from the traditional paradigm centered on the assessment of viability as a dichotomous variable to a more comprehensive approach founded on an alternative concept that the main goal of revascularization is to prevent further damage by protecting the residual viable myocardium from subsequent acute coronary events and ventricular arrhythmias is required.

Myocardial viability on trial.

The concept of myocardial viability is usually referred to areas of the myocardium, which show contractile dysfunction at rest and in which contractility is expected to improve after revascularization. The traditional paradigm states that an improvement in function after revascularization leads to improved health outcomes and that assessment of myocardial viability in patients with ischaemic left ventricular dysfunction (ILVD) is a prerequisite for clinical decisions regarding treatment. A range of retrospective observational studies supported this 'viability hypothesis'. However, data from prospective trials have diverged from earlier retrospective studies and challenge this hypothesis. Traditional binary viability assessment may oversimplify ILVD's complexity and the nuances of revascularization benefits. A conceptual shift from the traditional paradigm centred on the assessment of viability as a dichotomous variable to a more comprehensive approach encompassing a thorough understanding of ILVD's complex pathophysiology and the salutary effect of revascularization in the prevention of myocardial infarction and ventricular arrhythmias is required.

[Ischemic burden or anatomic burden: which non-invasive testing in stable patients with suspected coronary artery disease?] / Valutazione anatomica o ricerca di ischemia: quale esame non invasivo preferire?

Guidance on the diagnostic approach to coronary artery disease has diverged as the increasing complexity of atherosclerotic clinicopathologic correlations has been revealed. Foundational concepts linking stenosis, the ischaemic cascade and prognosis have been re-evaluated in light of the underwhelming results from the percutaneous revascularization of stenotic vessels. These studies have revealed ischaemia to be an important marker for cardiovascular outcomes, but likely separate from the causal pathway of hard clinical events. Instead, observations from non-invasive anatomical imaging have redefined risk, shifting the focus away from discrete lesions towards total atherosclerotic burden, and with it elevating the role of computed tomography in contemporary diagnostic pathways. As it currently stands, functional and anatomical approaches provide complementary information; stress testing continues to provide guidance for potential revascularization in current guidelines, yet anatomical testing may additionally identify individuals likely to benefit from preventive therapy. While guidelines attempt to keep pace with the advancing technology and expanding literature, clinicians are left to apply clinical acumen to decide on a vast and confusing array of investigative options. This review will deal with strenghts and limitations of the current approach to the diagnosis of coronary artery disease, providing the rationale for both functional and anatomical approaches.

Long-term follow-up after invasive or conservative management of stable coronary disease: the ISCHEMIA-EXTEND study.

The ISCHEMIA trial found no statistical difference in the primary endpoint between initial invasive and conservative management of patients with chronic coronary disease and moderate-to-severe ischaemia on stress testing. However, an invasive strategy increased peri-procedural myocardial infarction (MI) but decreased spontaneous MI with continued separation of curves over time. Thus, in order to assess the long-term effect of invasive management strategy on mortality, the ISCHEMIA-EXTEND observational study was planned including surviving participants from the initial phase of the ISCHEMIA trial with a projected median follow-up of nearly 10 years. Recently, an interim report of 7-year all-cause, cardiovascular (CV), and non-CV mortality rates has been published showing no difference in all-cause mortality between the two strategies, but with a lower risk of CV mortality and higher risk of non-CV mortality with an initial invasive strategy over a median follow-up of 5.7 years. The trade-offs in CV and non-CV mortality observed in ISCHEMIA-EXTEND raise many important questions regarding the heterogeneity of treatment effect, the drivers of mortality, and the relative importance and reliability of CV vs. all-cause mortality. Overall, findings from ISCHEMIA and ISCHEMIA-EXTEND trials might help physicians in shared decision-making as to whether to add invasive management to guideline-directed medical management in selected patients with chronic coronary artery disease and moderate or severe ischaemia.

Computed tomography to replace invasive coronary angiography? The DISCHARGE trial.

Ongoing advancements of coronary computed tomographic angiography (CTA) continue to challenge the role of invasive coronary angiography (ICA) as the gold standard for the evaluation of coronary artery disease (CAD). To investigate the comparative effectiveness of ICA when compared with CTA as an initial diagnostic imaging strategy the DISCHARGE Trial enrolled 3561 patients with stable chest pain and an intermediate pre-test probability of obstructive CAD. The study showed no difference between CTA and ICA in the incidence of the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke during 3.5 years of follow up. As with many trials that advance a field, this trial raises several additional questions of interest that will be discussed. Furthermore, recent studies focused on the discrepancies of CTA vs. ICA indicate that the status of CTA remains unchanged in its ability to rule out disease but at present cannot be considered a substitute for ICA when coronary lesions are documented. Thus, a change in clinical practice patterns likely requires evidence from clinical studies demonstrating equivalence of CT to ICA for guiding medical management. Developments, however, are swift, and CT technology is catching up on its invasive counterpart.

Drug-Eluting Balloon for Below the Knee Angioplasty: Five-Year Outcome of the DEBATE-BTK Randomized Clinical Trial.

BACKGROUND: The aim of this study is to evaluate the 5-year clinical outcome of the DEBATE-BTK (Drug-eluting balloon for below-the-knee angioplasty evaluation) trial. METHODS: The DEBATE-BTK was a single-center, randomized trial that enrolled 132 diabetic patients with critical limb ischemia. Subjects were randomized 1:1 to DCB or plain old balloon angioplasty (POBA). Major clinical endpoints were, freedom from all-cause death, freedom from clinically driven target lesion revascularization (CDTLR) and the occurrence of major amputation. Additional analysis were conducted to assess overall survival in patients treated with DCB compared to those treated with only POBA in the entire 5-years period and to test the correlation between paclitaxel dose exposure (in terciles) and overall survival. RESULTS: Freedom from all-cause death at 5 years was 63.1% (41/65) in DCB vs. 53.7%(35/67) POBA patients (p = 0.4). Freedom from CDTLR was 82% in DCB and 63% in POBA patients (p = 0.002) at 1 year and 63 versus 54% at 5 years respectively P = 0.07. One patient in DCB and 2 patients in POBA underwent a major amputation of the target limb. During the 5-year follow-up, 24 patients originally randomized to POBA received DCB treatment for additional limb revascularization. According to DCB treatment in all the 5 years period, overall survival was 66.3.% (30/89) in DCB versus 40%(26/43) in POBA patients, p = 0.003. CONCLUSIONS: Overall survival at 5-year was similar in DCB treated patients compared to POBA. Moreover, survival was higher in patients that received DCB angioplasty at any time of the 5 years period. LEVEL OF EVIDENCE: Level 1b, Individual inception cohort study with > 80% follow-up.

Long-term mortality in patients undergoing lower-limb revascularization with Paclitaxel eluting devices.

BACKGROUND: Paclitaxel-eluting devices (PED) reduce restenosis and target lesion revascularization (TLR) in femoropopliteal intervention. Recent data suggest a two-fold increased long-term mortality in patients treated with PED. The aim of our study is to evaluate if endovascular therapy (EVT) with PED increases mortality risk in patients with symptomatic lower limb peripheral artery disease (PAD) compared to non-eluting devices (NED). METHODS: The study is a retrospective, single-center registry on patients undergoing EVT for PAD from January 2009 to June 2018. Propensity score analysis on logistic regression model for independent predictors of long-term mortality was used to match PED and NED patients. Mortality was assessed at 2, 5 and 7 years in the entired matched population and in a sub-group of patients ≤75 years. RESULTS: During the study period, 1294 patients, 718 NED and 576 PED, met the inclusion/exclusion criteria and entered in the study. Propensity score matching analysis identified 854 matched patients, 414 PED and 440 NED. The population was mainly characterized by diabetic patients with CLI (80%) and high prevalence of CAD (30%), heart failure (15%) and renal insufficiency (20%). Mean follow-up length was 58 ± 34 months, (median 52.5). Mortality was 18% in NED vs 12% in PED patients at two years (p = 0.01), 36% vs 30% at 5 years (p = 0.03) and 41% vs 39% at seven years (p = 0.2) respectively. In patients ≤75 years, mortality at 7-year was 28% in PED vs 36% in NED, p = 0.07. CONCLUSION: These results suggest a reduced mortality at 2 and 5 years with PED as compare to NED treatment in a real-world CLI scenario. At 7-year follow-up, the advantage was numerically evident only in patients ≤75 years.

Randomized Controlled Trial of Acotec Drug-Eluting Balloon Versus Plain Balloon for Below-the-Knee Angioplasty.

OBJECTIVES: The aim of this study was to investigate the efficacy and safety of the Litos drug-coated balloon (DCB) versus plain old balloon angioplasty (POBA) for reduction of late lumen loss (LLL) in patients with critical limb ischemia undergoing below-the-knee (BTK) intervention. BACKGROUND: Restenosis after balloon angioplasty of BTK arteries approximates 70%. Previous studies of DCBs in BTK arteries produced conflicting results. METHODS: ACOART-BTK (Evaluation of the Use of ACOTEC Drug-Eluting Balloon Litos® in Below-the-Knee Arteries to Treat Critical Limb Ischemia) is a randomized controlled single-center study. Inclusion criteria were critical limb ischemia (Rutherford class ≥4) and significant stenosis or occlusion >40 mm of at least 1 BTK vessel with distal runoff successfully treated with angioplasty. Six-month angiographic LLL was the primary endpoint. Occlusive restenosis at 6 months and clinically driven target lesion revascularization at 12 months were secondary endpoints. RESULTS: From January 2016 through January 2019, 105 patients with 129 BTK lesions were enrolled in the study. Mean lesion length was 168 ± 109 mm in the DCB group and 187 ± 113 mm in the POBA group (p = 0.30). Almost 70% of lesions were occluded at baseline in both groups. On 6-month angiography, mean LLL was 0.51 ± 0.60 mm in the DCB group and 1.31 ± 0.72 mm in the POBA group (p < 0.001); rates of occlusive restenosis were 8.6% and 48.4%, respectively (p < 0.001). Twelve-month clinically driven target lesion revascularization occurred in 6 of 62 DCB-treated lesions (10%) versus 27 of 66 POBA-treated lesions (41%) (p < 0.001). Complete healing at 12 months was observed in 42 of 47 DCB-treated limbs (89.4) versus 35 of 47 POBA-treated limbs (74.5%) (p = 0.05); no major amputations occurred. CONCLUSIONS: Litos DCBs strikingly reduced LLL, vessel reocclusion, and clinically driven target lesion revascularization compared with POBA in BTK angioplasty.

Predictors of in-hospital and long-term mortality in unselected patients admitted to a modern coronary care unit.

AIMS: Objective data on epidemiology, management and outcome of patients with acute cardiac illness are still scarce, and producing evidence-based guidelines remains an issue. In order to define the clinical characteristics and the potential predictors of in-hospital and long-term mortality, we performed a retrospective, observational study, in a tertiary cardiac centre in Italy. METHODS: One thousand one hundred and sixty-five consecutive patients, admitted to our intensive cardiac care unit (ICCU) during the year 2016, were included in the study. The data were collected from the hospital discharge summary and the electronic chart records. RESULTS: Global in-hospital mortality was 7.2%. Predictors of in-hospital mortality were age [odds ratio (OR): 2.0; P = 0.011], female sex (OR: 2.18; P = 0.003), cardiac arrest (OR: 12.21; P = 0.000), heart failure/cardiogenic shock (OR: 9.99; P = 0.000), sepsis/septic shock (OR: 5.54; P = 0.000), acute kidney injury (OR: 3.25; P = 0.021) and a primary diagnosis of acute heart failure or a condition other than acute heart failure and acute coronary syndrome. During a mean follow-up period of 17.4 ± 4.8 months, 96 all-cause deaths occurred in patients who were still alive at discharge. One-year mortality rate was 8.2%. Predictors of long-term mortality were age (hazard ratio: 1.08; P = 0.000), female sex (hazard ratio: 0.59; P = 0.022), comorbidity at least 3 (hazard ratio: 1,60; P = 0.047), acute kidney injury (hazard ratio: 3.15; P = 0.001), inotropic treatment (hazard ratio: 2.54; P = 0.002) and a primary diagnosis of acute heart failure. CONCLUSION: In our Level-2 ICCU, predictors of in-hospital and long-term mortality are similar to those commonly found in a Level-3 ICU. These data strongly suggest that ICUs dealing with acute cardiovascular patients should be reorganized with a necessary upgrading of competences and resources for medical and nursing staff.

Bailout surgical explantation of a transcatheter valve-in-valve for subacute thrombosis: When there is no time for anticoagulation: Case report and literature review.

Trancatheter heart valve (THV) thrombosis is effectively treated with anticoagulation but alternative therapies are required when a faster gradient reduction is needed. Open heart surgery has been rarely performed due to the high perioperative mortality and only five cases have been described so far. Here we describe a case of emergent surgical explantation for THV thrombosis after a valve-in-valve. A 67years old man underwent transcatheter aortic valve implantation for a failed surgical bioprosthesis Epic 21mm (St. Jude Medical; St. Paul, Minnesota, US). A CoreValve 23mm (Medtronic, Minneapolis, Minnesota, US) was implanted through femoral access under conscious sedation without complications. Mean transvalvular gradient was effectively reduced (33mmHg vs 16mmHg) with no more than mild residual aortic regurgitation. After 8days the patient was discharged on dual antiplatelet therapy but was readmitted to the intensive care unit for pulmonary oedema 13days later. Echocardiography showed a raised transvalvular mean gradient (mean gradient change from discharge=15mmHg) without aortic regurgitation. Heart Team decided for emergent open heart surgery for the hemodynamic instability. On direct inspection THV was well positioned inside the surgical bioprosthesis but two cusps were covered by thrombus which markedly restricted their mobility. The THV and the former surgical valve were explanted and a new larger stented bioprosthesis was implanted. Thrombosis of the THV was confirmed on microscopic examination which showed no signs of inflammation or degeneration. The patient was discharged after 1month and the 3month follow up showed stable transvalvular gradients.

What Ultrasounds, Sometimes, Cannot See: A Case of Posterior Pericardial Cyst.

Pericardial cysts (PCs) are very rare, often congenital, mediastinal masses. Usually, they are located in the right cardiophrenic angle and only in 8% of cases in the anterior or posterior mediastinum. Computed tomography and/or magnetic resonance imaging are accurate tools for the diagnosis and characterization of mediastinal masses. However, echocardiography is, in many cases, a good screening technique. If asymptomatic, they do not require surgical excision. The authors describe a case of posterior mediastinum PC; in these cases, echocardiography cannot see the mass and three-dimensional imaging techniques are required. The clinical management of this case is discussed.