Randomised comparison of provisional side branch stenting versus a two-stent strategy for treatment of true coronary bifurcation lesions involving a large side branch: the Nordic-Baltic Bifurcation Study IV.

Background: It is still uncertain whether coronary bifurcations with lesions involving a large side branch (SB) should be treated by stenting the main vessel and provisional stenting of the SB (simple) or by routine two-stent techniques (complex). We aimed to compare clinical outcome after treatment of lesions in large bifurcations by simple or complex stent implantation. Methods: The study was a randomised, superiority trial. Enrolment required a SB≥2.75 mm, ≥50% diameter stenosis in both vessels, and allowed SB lesion length up to 15 mm. The primary endpoint was a composite of cardiac death, non-procedural myocardial infarction and target lesion revascularisation at 6 months. Two-year clinical follow-up was included in this primary reporting due to lower than expected event rates. Results: A total of 450 patients were assigned to simple stenting (n=221) or complex stenting (n=229) in 14 Nordic and Baltic centres. Two-year follow-up was available in 218 (98.6%) and 228 (99.5%) patients, respectively. The primary endpoint of major adverse cardiac events (MACE) at 6 months was 5.5% vs 2.2% (risk differences 3.2%, 95% CI -0.2 to 6.8, p=0.07) and at 2 years 12.9% vs 8.4% (HR 0.63, 95% CI 0.35 to 1.13, p=0.12) after simple versus complex treatment. In the subgroup treated by newer generation drug-eluting stents, MACE was 12.0% vs 5.6% (HR 0.45, 95% CI 0.17 to 1.17, p=0.10) after simple versus complex treatment. Conclusion: In the treatment of bifurcation lesions involving a large SB with ostial stenosis, routine two-stent techniques did not improve outcome significantly compared with treatment by the simpler main vessel stenting technique after 2 years. Trial registration number: NCT01496638.

Successful extracorporeal membrane oxygenation assisted revascularisation in a high-risk elderly patient refused surgical treatment.

Management of high-risk elderly patients requiring revascularisation remains a clinical challenge. We report a case of extracorporeal membrane oxygenation (ECMO) assisted complex percutaneous coronary intervention in a  high-risk octogenarian. An 83-year-old female with signs of worsening heart failure was admitted to the emergency department of a tertiary care facility. Transthoracic echocardiography revealed a  decreased left ventricular ejection fraction of 20% with severe mitral regurgitation and mild aortic and tricuspid valve insufficiency. Three-vessel disease was found during coronary angiography. Due to the patient's frailty, a high-risk surgery decision to proceed with ECMO assisted percutaneous coronary intervention was made during a heart team meeting. Following initiation of mechanical support, coronary lesions were treated with three drug-eluting stents. After the procedure, the patient was transferred to the ICU on ECMO support, where she was successfully weaned from the device 9 h later. Her ICU stay was four days. She was successfully discharged from the hospital after uneventful recovery. At one-year's follow-up, the patient was clinically stable in an overall state of general well-being and with complete participation in routine activities; she had good exercise tolerance and no signs of ischemia. This report highlights the possibility of use of ECMO during PCI in high-risk elderly patients.

FFR result post PCI is suboptimal in long diffuse coronary artery disease.

AIMS: The aim of this study was to evaluate the functional result immediately post PCI and at nine-month follow-up, and to ascertain how often a functionally optimal result of >0.95 can be achieved in long coronary lesions treated with long second- or newer-generation DES. METHODS AND RESULTS: Patients receiving DES measuring ≥30 mm with FFR value ≤0.8 were included in the study. Stent length was defined as long (30 to 49 mm; L-DES) and ultra-long (≥50 mm; UL-DES). Angiographic and FFR evaluation was performed before and after PCI and at nine-month follow-up. A total of 74 patients each received a mean stent length of 50.72±14.6 mm. Mean FFR post PCI was 0.88±0.06. An optimal post PCI FFR value of >0.95 was achieved in only 9/74 patients (12.2%), and was not achieved in any UL-DES patients. Only 12/74 (16.2%) had FFR post PCI of 0.91 to 0.95; 8/74 (10.8%) patients remained ischaemic (≤0.8). FFR gradient across the stent was higher in UL-DES patients compared to L-DES patients (0.07±0.03 vs. 0.04±0.03; p=0.001). At follow-up, the angiographic restenosis rate was 4.7%, and the functional restenosis rate was 15.1%. CONCLUSIONS: The FFR result post PCI was suboptimal in the majority of patients treated with long DES and was particularly poor when the total stent length exceeded 50 mm.

Successfully treated severe obstetric sepsis and acute respiratory distress syndrome with extracorporeal membrane oxygenation.

We report a unique clinical case about an 18-year-old woman, immediately post-partum after an urgent C-section, who survived severe sepsis, acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) and was successfully treated with 11 different antibiotics, massive blood transfusions and repetitive surgeries and was on extracorporeal membrane oxygenation (ECMO) support for 22 days. Although, ECMO is a time-limited procedure and most manufacturers do not advise more than 14 days of use, the situation for this patient was life-threatening and ECMO, despite the dangerous risks listed above, was the only way to win time for the lungs to recover and for treatment of the underlying disease, while maintaining adequate oxygenation and circulation. Fortunately, the condition of this woman was stabilized and she achieved complete physical recovery, despite minor neurological deficit in the fingers of her right hand.

[Reperfusion therapy in acute myocardial infarction: primary percutaneous transluminal coronary angioplasty or thrombolysis?]. / Uminio miokardo infarkto reperfuzine terapija: perkutanine transliuminaline vainikiniu arteriju angioplastika ar fibrinolize?

Randomized controlled trials that compared primary percutaneous transluminal coronary angioplasty with thrombolysis have shown that primary angioplasty is more effective than intravenous thrombolysis in reducing mortality and morbidity in patients with acute myocardial infarction. Three large myocardial infarction registries - MITI, NRMI-2 and French registry - failed to show an advantage of primary angioplasty compared with thrombolysis. One of the latest trials mentioned in this paper restored the place of primary angioplasty as superior to thrombolysis in acute myocardial infarction. Data of patients treated with primary percutaneous transluminal coronary angioplasty in Clinic of Cardiology of Vilnius University are presented.

Prevalence of activated protein C resistance among women with recurrent miscarriage.

UNLABELLED: Since 1996 activated protein C resistance is closely associated with various obstetric pathologies. The most widely discussed is that of secondary infertility due to recurrent miscarriage. However, there is still widespread discussion about the role of activated protein C resistance in this and other obstetric pathologies. AIM: To investigate whether the activated protein C resistance is a cause of early recurrent miscarriage. MATERIAL AND METHODS: A study was designed as a case-control study. Two study groups were formed. Group I included women who have experienced 2 or more miscarriages (61 patients), and Group II included women who have experienced 3 or more miscarriages (33 patients). We investigated the prevalence and compared it in the control and both study groups. RESULTS: In Group I activated protein C resistance was found for 8 patients (14.7%), in Group II--for 5 patients (16.5%), in the control group--in 4 cases (5%). By comparing different groups the prevalence of activated protein C resistance in Group I was statistically significantly higher than in the control group (p<0.05). The prevalence of activated protein C resistance in Group II and the control group as well as between both study groups was statistically non-significant (p>0.05). CONCLUSION: Activated protein C resistance might be a factor behind spontaneous recurrent miscarriage. There was no statistically significant difference between women who had suffered from 2 or 3 spontaneous abortions.

[Factor V Leiden mutation and pregnancy complications]. / Leideno kresejimo faktoriaus mutacija ir akuserine patologija.

It has become evident in the past few years, that a large number of obstetric pathologies is actually associated with congenital thrombophilias. The most common disorder is Factor V Leiden. Many authors relate this factor with preeclampsia, intrauterine fetal growth retardation, spontaneous abortion, unexplained cases of still birth, placental abruption, and thromboembolic complications during and after parturition. The article discusses the current publications on this topic. Up till now only venous thromboembolism has been statistically proven to be associated with Factor V Leiden. The relationship between Factor V Leiden and the above obstetric pathologies is to be discussed. For this reason, according to the ACCP Consensus strong recommendations only exist for the prophylaxis and treatment of venous thromboembolism.