Response rate in cardiac resynchronization therapy patients implanted with a left ventricular quadripolar lead and the MultiPoint™ pacing feature early activated. QUARTO III.

BACKGROUND: Although cardiac resynchronization therapy (CRT) is beneficial in most heart failure patients, up to 40% do not respond to CRT. It has been suggested that multipoint left ventricle pacing (MPP) would increase the response rate. AIM: To assess the CRT response rate at 6 months in patients implanted with a CRT device with the MPP feature activated early after the implant. METHODS: This was a multicentre, prospective, open-label and non-randomized study. The primary endpoint was response to biventricular pacing defined as >15% relative reduction in left ventricular end-systolic volume (LVESV) comparing echocardiography measurements performed at baseline and 6 months by a core laboratory. Among secondary endpoints the combined endpoint of mortality or all-cause hospitalizations was evaluated. Primary study endpoint and clinical outcomes were compared to a Quarto II control cohort. RESULTS: Totally, 105 patients were included. The response rate was 64.6% (97.5% lower confidence bound 53%). Mean relative reduction in LVESV was 25.3%, and mean absolute increase in LVEF was 9.4%. The subjects with device programmed using anatomical approach showed a trend towards higher responder rate than those using the electrical approach (72% vs. 61.1%, p = 0.32). Finally, the combined incidence of mortality and or all-cause hospitalizations at 6 month was 12.4%. CONCLUSIONS: Early activation of MPP was not associated to an advantage increasing echocardiography responders to CRT at 6 months of follow-up. Nevertheless, patients programmed using widest pacing cathodes had a numerically higher responder rate. Finally, early activation of MPP was associated to a low incidence of clinical endpoints at 6 months of follow-up.

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation.

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

Rendimiento del marcapasos cardiaco Micra en nonagenarios / Performance of the Micra cardiac pacemaker in nonagenarians

INTRODUCCIÓN Y OBJETIVOS: El marcapasos transcatéter Micra presenta una alta efectividad y una tasa de complicaciones más baja que los marcapasos convencionales. Sin embargo, se desconoce su beneficio en la población más anciana (≥ 90 años). El objetivo de este estudio es evaluar la efectividad y la seguridad de Micra en pacientes de edad ≥ 90 años. MÉTODOS: Estudio observacional prospectivo con pacientes consecutivos mayores de 70 años a los que se implantó un marcapasos Micra, divididos en 2 grupos de edad: ≥ 90 y <90 años. RESULTADOS: El Micra se implantó en 129 pacientes, 41 tenían 90 o más años y 88, menos de 90. El implante fue exitoso en 40 pacientes (97,6%) de edad ≥ 90 años y en 87 (98,9%) menores de 90 (p = 0,58). Fueron necesarias 2 o menos reposiciones en el 97,5 y el 91,9% de los pacientes respectivamente (p = 0,32). Los tiempos de procedimiento (26,1±11,6 frente a 30,3±14,2min; p = 0,11) y de fluoroscopia (6,4±4,7 frente a 7,2±4,9min; p = 0,41) fueron similares en ambos grupos. Hubo 3 complicaciones mayores (2,3%), todas en el grupo menor de 90 años: 1 perforación cardiaca, 1 hematoma femoral y 1 seudoaneurisma femoral. Un total de 13 pacientes de edad ≥ 90 años (31,7%) y 16 de los menores de 90 (18,2%) murieron durante unos seguimientos medios de 230±233 y 394±285 días respectivamente. No hubo muertes relacionadas con el dispositivo. No se observaron infección, dislocación o migración de Micra. El rendimiento eléctrico fue óptimo en el seguimiento. CONCLUSIONES: El marcapasos sin cables Micra parece efectivo y seguro en pacientes mayores de 90 años. Podría considerarse una alternativa razonable a la estimulación transvenosa convencional en esta población

INTRODUCTION AND OBJECTIVES: The Micra transcatheter pacing system has shown high effectiveness and a lower complication rate than conventional transvenous pacemakers. However, the benefit of the device is unknown in the very old population (≥ 90 years). The aim of this study was to evaluate the safety and effectiveness of Micra in patients ≥ 90 years. METHODS: We present a prospective observational study with consecutive patients aged >70 years who underwent implantation of a Micra pacemaker system. Patients were divided into 2 groups: ≥ 90 and<90 years. RESULTS: The Micra system was implanted in 129 patients, of whom 41 were aged ≥ 90 years and 88<90 years. The device was successfully implanted in 40 (97.6%) patients ≥ 90 years and in 87 (98.9%) patients<90 years (P=.58). An adequate position was achieved with need for ≤ 2 repositions in 97.5% and 91.9% of patients, respectively (P=.32). Procedure time (26.1 ±11.6 vs 30.3 ±14.2minutes; P=.11) and fluoroscopy time (6.4 ±4.7 vs 7.2 ±4.9minutes; P=0.41) were similar in the 2 groups. There were 3 major complications (2.3%), all in the group aged<90 years: 1 cardiac perforation, 1 femoral hematoma, and 1 femoral pseudoaneurysm. Thirteen patients aged ≥ 90 years (31.7%) and 16 patients aged <90 years (18.2%) died during a mean follow-up of 230±233 days and 394±285 days, respectively. There were no device-related deaths. No infection, dislocation or migration of Micra were observed. The electrical performance was optimal at follow-up. CONCLUSIONS: The Micra leadless pacing system seems to be safe and effective in patients older than 90 years. It may be considered a reasonable alternative to conventional transvenous pacing in this population

Performance of the Micra cardiac pacemaker in nonagenarians.

INTRODUCTION AND OBJECTIVES: The Micra transcatheter pacing system has shown high effectiveness and a lower complication rate than conventional transvenous pacemakers. However, the benefit of the device is unknown in the very old population (≥ 90 years). The aim of this study was to evaluate the safety and effectiveness of Micra in patients ≥ 90 years. METHODS: We present a prospective observational study with consecutive patients aged >70 years who underwent implantation of a Micra pacemaker system. Patients were divided into 2 groups: ≥ 90 and<90 years. RESULTS: The Micra system was implanted in 129 patients, of whom 41 were aged ≥ 90 years and 88<90 years. The device was successfully implanted in 40 (97.6%) patients ≥ 90 years and in 87 (98.9%) patients<90 years (P=.58). An adequate position was achieved with need for ≤ 2 repositions in 97.5% and 91.9% of patients, respectively (P=.32). Procedure time (26.1 ±11.6 vs 30.3 ±14.2minutes; P=.11) and fluoroscopy time (6.4 ±4.7 vs 7.2 ±4.9minutes; P=0.41) were similar in the 2 groups. There were 3 major complications (2.3%), all in the group aged<90 years: 1 cardiac perforation, 1 femoral hematoma, and 1 femoral pseudoaneurysm. Thirteen patients aged ≥ 90 years (31.7%) and 16 patients aged <90 years (18.2%) died during a mean follow-up of 230±233 days and 394±285 days, respectively. There were no device-related deaths. No infection, dislocation or migration of Micra were observed. The electrical performance was optimal at follow-up. CONCLUSIONS: The Micra leadless pacing system seems to be safe and effective in patients older than 90 years. It may be considered a reasonable alternative to conventional transvenous pacing in this population.

Esophageal cooling for protection during left atrial ablation: a systematic review and meta-analysis.

PURPOSE: Thermal damage to the esophagus is a risk from radiofrequency (RF) ablation of the left atrium for the treatment of atrial fibrillation (AF). The most extreme type of thermal injury results in atrio-esophageal fistula (AEF) and a correspondingly high mortality rate. Various strategies for reducing esophageal injury have been developed, including power reduction, esophageal deviation, and esophageal cooling. One method of esophageal cooling involves the direct instillation of cold water or saline into the esophagus during RF ablation. Although this method provides limited heat-extraction capacity, studies of it have suggested potential benefit. We sought to perform a meta-analysis of published studies evaluating the use of esophageal cooling via direct liquid instillation for the reduction of thermal injury during RF ablation. METHODS: We searched PubMed for studies that used esophageal cooling to protect the esophagus from thermal injury during RF ablation. We then performed a meta-analysis using a random effects model to calculate estimated effect size with 95% confidence intervals, with an outcome of esophageal lesions stratified by severity, as determined by post-procedure endoscopy. RESULTS: A total of 9 studies were identified and reviewed. After excluding preclinical and mathematical model studies, 3 were included in the meta-analysis, totaling 494 patients. Esophageal cooling showed a tendency to shift lesion severity downward, such that total lesions did not show a statistically significant change (OR 0.6, 95% CI 0.15 to 2.38). For high-grade lesions, a significant OR of 0.39 (95% CI 0.17 to 0.89) in favor of esophageal cooling was found, suggesting that esophageal cooling, even with a low-capacity thermal extraction technique, reduces the severity of lesions resulting from RF ablation. CONCLUSIONS: Esophageal cooling reduces the severity of the lesions that may result from RF ablation, even when relatively low heat extraction methods are used, such as the direct instillation of small volumes of cold liquid. Further investigation of this approach is warranted, particularly with higher heat extraction capacity techniques.

Resultados en España de la encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) / Spanish results of the Second European Cardiac resynchronization therapy survey (CRT-Survey II)

Introducción y objetivos: Se describen los resultados en España de la segunda encuesta de la Sociedad Europea de Cardiología sobre terapia de resincronización cardiaca (CRT-Survey II) y se comparan con los de los demás países participantes. Métodos: Pacientes a los que se implantó un dispositivo de terapia de resincronización cardiaca entre octubre de 2015 y diciembre de 2016 en 36 centros participantes. Se recogieron datos sobre las características basales de los pacientes y del implante, y un seguimiento a corto plazo hasta el alta hospitalaria. Resultados: La tasa de éxito del implante fue del 95,9%. La mediana [intervalo intercuartílico] de implantes anuales/centro en España fue significativamente menor que en los demás países participantes: 30 [21-50] frente a 55 [33-100] implantes/año (p=0,00003). En los centros españoles hubo una menor proporción de pacientes de edad ≥ 75 años (el 27,9 frente al 32,4%; p=0,0071), una mayor proporción de pacientes en clase funcional II de la New York Heart Association (el 46,9 frente al 36,9%; p <0,00001) y un mayor porcentaje de pacientes con criterios electrocardiográficos de bloqueo de rama izquierda (el 82,9 frente al 74,6%; p <0,00001). La media de la estancia hospitalaria fue menor en los centros españoles (5,8+/-8,5 frente a 6,4+/-11,6; p <0,00001) y una mayor proporción de pacientes recibieron un cable de ventrículo izquierdo cuadripolar (el 74 frente al 56%; p <0,00001) y fueron seguidos a distancia (el 55,8 frente al 27,7%; p <0,00001). Conclusiones: La encuesta CRT-Survey II muestra que en España hay una menor proporción de pacientes de 75 o más años que reciben un dispositivo de terapia de resincronización cardiaca, una mayor proporción de pacientes en clase funcional II de la New York Heart Association, con bloqueo completo de la rama izquierda del haz de His y con seguimiento a distancia, con estancias hospitalarias significativamente menores

Introduction and objectives: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. Methods: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. Results: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in NYHA class II (46.9% vs 36.9%, P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8+/-8.5 days vs 6.4+/-11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%, P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). Conclusions: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring

Spanish Results of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II).

INTRODUCTION AND OBJECTIVES: We describe the results for Spain of the Second European Cardiac Resynchronization Therapy Survey (CRT-Survey II) and compare them with those of the other participating countries. METHODS: We included patients undergoing CRT device implantation between October 2015 and December 2016 in 36 participating Spanish centers. We registered the patients' baseline characteristics, implant procedure data, and short-term follow-up information until hospital discharge. RESULTS: Implant success was achieved in 95.9%. The median [interquartile range] annual implantation rate by center was significantly lower in Spain than in the other participating countries: 30 implants/y [21-50] vs 55 implants/y [33-100]; P=.00003. In Spanish centers, there was a lower proportion of patients ≥ 75 years (27.9% vs 32.4%; P=.0071), a higher proportion in New York Heart Association functional class II (46.9% vs 36.9%; P <.00001), and a higher percentage with electrocardiographic criteria of left bundle branch block (82.9% vs 74.6%; P <.00001). The mean length of hospital stay was significantly lower in Spanish centers (5.8±8.5 days vs 6.4±11.6; P <.00001). Spanish patients were more likely to receive a quadripolar LV lead (74% vs 56%; P <.00001) and to be followed up by remote monitoring (55.8% vs 27.7%; P <.00001). CONCLUSIONS: The CRT-Survey II shows that, compared with other participating countries, fewer patients in Spain aged ≥ 75 years received a CRT device, while more patients were in New York Heart Association functional class II and had left bundle branch block. In addition, the length of hospital stay was shorter, and there was greater use of quadripolar LV leads and remote CRT monitoring.

Use of a novel fragmentation map to identify the substrate for ventricular tachycardia in postinfarction cardiomyopathy.

BACKGROUND: Substrate ablation is commonly performed in patients with postinfarction cardiomyopathy and ventricular tachycardia (VT). Recognition of fragmented and late potentials during sinus rhythm is a tedious process subject to operator fatigue. OBJECTIVE: The purpose of this study was to assess the value of automated analysis to quantify electrogram fragmentation and to determine the relationship of fragmented regions to the VT isthmus. METHODS: Detailed left ventricular (LV) mapping was performed in 2 groups: (1) 14 patients with previous myocardial infarction and tolerated VT and (2) 14 controls with structurally normal hearts. In patients with VT, mid-isthmus sites were identified using entrainment mapping. Sinus rhythm endocardial LV electrograms underwent time- and frequency-domain analysis and were displayed as fragmentation or frequency maps. The region of fractionated electrograms and their relation to the VT isthmus sites were determined. RESULTS: Cutoffs for abnormal electrogram fragmentation were ventricular fractionation index ≥ 7 and fast Fourier transform ratio ≥ 14%, respectively. In the time domain, LV surface area with fractionated electrograms was significantly smaller than the total scar surface area (27.3% ± 7.1% vs 42.1% ± 12.3%, P <.001), yet contained 100% of VT isthmus sites. In the frequency domain, areas of abnormal fractionation occupied 9.7% ± 6.9% of total LV surface area and included only 60% of the VT isthmus sites. CONCLUSION: Automated electrogram fractionation analysis represents an objective tool to rapidly quantify electrogram fragmentation and guide substrate-based ablation of VT. Empiric ablation of these regions may be a new strategy for substrate-guided VT ablation.

¿La clasificación CHA2DS2-VASc selecciona a los pacientes que más van a beneficiarse de la anticoagulación? / Does CHA2DS2-VASc Score Select Patients Who Will Benefit Most From Anticoagulation?

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New unipolar electrogram criteria to identify irreversibility of nonischemic left ventricular cardiomyopathy.

OBJECTIVES: This study sought to assess the value of left ventricular (LV) endocardial unipolar electroanatomical mapping (EAM) in identifying irreversibility of LV systolic dysfunction in patients with left ventricular nonischemic cardiomyopathy (LVCM). BACKGROUND: Identifying irreversibility of LVCM would be helpful but cannot be reliably accomplished by bipolar EAM or cardiac magnetic resonance identification of macroscopic scar. METHODS: Detailed endocardial LV EAM was performed in 3 groups: 1) 24 patients with irreversible LVCM (I-LVCM) but with no or minimal macroscopic scar (<15% LV surface) evidenced on bipolar voltage EAM and/or cardiac magnetic resonance; 2) 14 patients with reversible ventricular premature depolarization-mediated LVCM (R-LVCM); and 3) 17 patients with structurally normal hearts. LV endocardial unipolar electrogram amplitude and area of unipolar amplitude abnormality were defined after excluding macroscopic scar. RESULTS: Unipolar amplitude differed in the 3 groups: median of 7.6 (interquartile range [IQR]: 5.5 to 9.7) mV in I-LVCM group, 13.2 (IQR: 10.4 to 16.2) mV in R-LVCM group, and 16.3 (IQR: 13.6 to 19.8) mV in structurally normal hearts group (p < 0.001). Areas of unipolar abnormality represented a large proportion of total LV surface in I-LVCM, 64.7% (IQR: 47.5% to 75.9%) compared with R-LVCM, 5.2% (IQR: 0.0% to 19.1%) and structurally normal hearts, 0.1% (IQR: 0.0% to 0.9%), groups (p < 0.001). A unipolar abnormality area cutoff of 32% of total LV surface was 96% sensitive and 100% specific in identifying irreversible cardiomyopathy among patients with LV dysfunction (I-LVCM and R-LVCM), p < 0.001. CONCLUSIONS: Detailed unipolar voltage mapping can identify irreversible myocardial dysfunction consistent with fibrosis, even in the absence of bipolar EAM or cardiac magnetic resonance abnormalities, and may serve as valuable prognostic tool in patients presenting with LVCM to facilitate clinical decision making.

Use of a novel endoscopic catheter for direct visualization and ablation in an ovine model of chronic myocardial infarction.

BACKGROUND: Defining the arrhythmogenic substrate is essential for successful ablation of scar-related ventricular tachycardia. The visual characteristics of endocardial ischemic scar have not been described in vivo. The goal of this study was (1) to quantify the visual characteristics of normal tissue, scar border zone, and dense scar in vivo with the use of a novel endoscopic catheter that allows direct endocardial visualization and (2) to correlate visual attributes of myocardial scar with bipolar voltage. METHODS AND RESULTS: Percutaneous transient balloon occlusion (150 minutes) of the mid left anterior descending coronary artery was performed in an ovine model. Animals survived for 41.5±0.7 days. Detailed bipolar voltage maps of the left ventricle were acquired with the use of NavX. Video snapshots of the endocardium were acquired at sites distributed throughout the left ventricle. Visual tissue characteristics of normal (>1.5 mV), border (0.5-1.5 mV), and dense scar (<0.5 mV) were quantified with the use of image processing. Radiofrequency lesions (10-20 W, 30 seconds) were delivered under direct visualization. Mean white-threshold pixel area was lowest in normal tissue (189 969±41 478 pixels(2)), intermediate in scar border zone (255 979±36 016 pixels(2)), and highest in dense scar (324 452±30 152 pixels(2); P<0.0001 for all pairwise comparisons). Tissue whiteness, characteristic of scar, was inversely correlated with bipolar voltage (P<0.0001). During radiofrequency lesions, there was a significant increase in white-thresholded pixel area of the visual field after ablation (average increase, 85 381±52 618 pixels(2); P<0.001). CONCLUSIONS: Visual characteristics of chronic infarct scar in vivo observed with the use of a novel endoscopic catheter correlate with bipolar electrogram voltage. Irrigated radiofrequency lesions in normal endocardial tissue and postinfarction zone can be visualized and quantified with the use of image processing. This technology shows promise for visually based delivery of radiofrequency lesions for the treatment of scar-based ventricular tachycardia.

Comparison of epicardial cryoablation and irrigated radiofrequency ablation in a Swine infarct model.

UNLABELLED: Epicardial Cryoablation in Swine. INTRODUCTION: Cryoablation is an alternative to radiofrequency (RF) energy used in some ablation procedures. Its role and effectiveness compared to irrigated RF in epicardial tissue and epicardial substrates is not yet fully established. METHODS AND RESULTS: Using a swine chronic infarct model, we compared RF lesions produced by an open-irrigated 3.5 mm tip catheter with those produced by an 8 mm tip cryocatheter in epicardial infarct border zone, epicardial normal tissue, and normal endocardium. In the infarct border zone, cryolesions were larger than RF lesions in maximum diameter (9.3 ± 2.9 mm vs 6.2 ± 2 mm, P < 0.001) and volume (171.7 ± 173.1 mm(3) vs 77 ± 53.5 mm(3) , P = 0.021). In normal epicardial tissue, cryolesions were larger in maximum diameter (11.2 ± 4.3 mm vs 7.7 ± 3.1 mm, P = 0.012), depth (5.8 ± 1.6 mm vs 4.7 ± 1.4 mm, P = 0.034), and volume (274.7 ± 242.2 mm(3) vs 112 ± 102.9 mm(3) , P = 0.002). In normal endocardium, no significant differences were found. CONCLUSIONS: Epicardial cryoablation with an 8 mm tip cryocatheter led to larger lesion volume in infarcted myocardium compared to a 3.5 mm irrigated RF catheter. This is likely related to a combination of cryoadherence, more efficient energy delivery with horizontal orientation, and lack of warming by circulating blood. Cryoablation merits further investigation as a modality for treating ventricular tachycardia of epicardial origin in humans. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1016-1023, September 2012).

Ablation of ventricular arrhythmias arising near the anterior epicardial veins from the left sinus of Valsalva region: ECG features, anatomic distance, and outcome.

BACKGROUND: Left ventricular outflow tract tachycardia/premature depolarizations (VT/VPDs) arising near the anterior epicardial veins may be difficult to eliminate through the coronary venous system. OBJECTIVE: To describe the characteristics of an alternative successful ablation strategy targeting the left sinus of Valsalva (LSV) and/or the adjacent left ventricular (LV) endocardium. METHODS: Of 276 patients undergoing mapping/ablation for outflow tract VT/VPDs, 16 consecutive patients (8 men; mean age 52 ± 17 years) had an ablation attempt from the LSV and/or the adjacent LV endocardium for VT/VPDs mapped marginally closer to the distal great cardiac vein (GCV) or anterior interventricular vein (AIV). RESULTS: Successful ablation was achieved in 9 of the 16 patients (56%) targeting the LSV (5 patients), adjacent LV endocardium (2 patients), or both (2 patients). The R-wave amplitude ratio in lead III/II and the Q-wave amplitude ratio in aVL/aVR were smaller in the successful group (1.05 ± 0.13 vs 1.34 ± 0.37 and 1.24 ± 0.42 vs 2.15 ± 1.05, respectively; P = .043 for both). The anatomical distance from the earliest GCV/AIV site to the closest point in the LSV region was shorter for the successful group (11.0 ± 6.5 mm vs 20.4 ± 12.1 mm; P = .048). A Q-wave ratio of <1.45 in aVL/aVR and an anatomical distance of <13.5 mm had sensitivity and specificity of 89%, 75% and 78%, 64%, respectively, for the identification of successful ablation. CONCLUSIONS: VT/VPDs originating near the GCV/AIV can be ablated from the LSV/adjacent LV endocardium. A Q-wave ratio of <1.45 in aVL/aVR and a close anatomical distance of <13.5 mm help identify appropriate candidates.

Diabetes mellitus: a prothrombotic state implications for outcomes after coronary revascularization.

Coronary stent thrombosis is a serious problem in the drug-eluting stent era. Despite aggressive antiplatelet therapy during and after percutaneous coronary intervention (PCI), the incidence of sub-acute stent thrombosis remains approximately 0.5%-2%, which may represent a catastrophic clinical situation. Both procedural factors and discontinuation of antiplatelet therapy are normally associated with this event. We report on simultaneous stent thromboses of two drug-eluting stents implanted in two different vessels, which resulted in a life-threatening clinical condition. Possible contributing factors that led to synergistic thrombotic effects are discussed.