A Five-Year Follow-up of Left Main Coronary Artery Stenting 8 Years After Arterial Switch Operation.

The fate of coronary artery stenting in children several years after implantation is unknown. We previously reported the case of an 8-year-old child undergoing stent implantation for a total left main coronary artery occlusion after arterial switch operation. Six months later, she needed another stent implantation for in-stent restenosis. Here we report the angiographic, intravascular ultrasound and optical coherence tomography findings at 5-year follow-up. Despite nongrowth of the left main coronary artery inherent to the stents, luminal patency, adequate struts apposition, and the absence of in situ complications were confirmed.

On ne sait rien de ce qu'il advient des endoprothèses coronariennes plusieurs années après l'implantation chez les enfants. Nous avons déjà présenté le cas d'une fillette de huit ans chez qui une endoprothèse a été implantée pour corriger une occlusion totale de l'artère coronaire principale gauche après une intervention de détransposition artérielle. Six mois plus tard, la patiente avait besoin d'une autre endoprothèse en raison d'une resténose de l'endoprothèse. Nous rapportons ici les observations effectuées à l'angiographie, à l'échographie intravasculaire et à la tomographie par cohérence optique à l'évaluation de suivi à cinq ans. Malgré l'absence de croissance de l'artère coronaire principale gauche en raison de la présence des endoprothèses, la perméabilité luminale, l'apposition adéquate des entretoises et l'absence de complications in situ ont été confirmées.

Optical coherence tomography for characterization of cardiac allograft vasculopathy in late survivors of pediatric heart transplantation.

BACKGROUND: Optical coherence tomography (OCT) has been shown to reliably detect cardiac allograft vasculopathy (CAV). In recent studies performed in adult heart transplant (HTx) recipients, OCT revealed the presence of vulnerable plaques and complicated coronary artery lesions, thus challenging the current concept that CAV disease is a diffuse concentric and fibrosing vasculopathy. The aim of our study was to characterize CAV by OCT in a young population of HTx recipients. METHODS: We prospectively enrolled 21 young HTx recipients (mean age 27 years, range 22 to 38 years) to undergo OCT of the left anterior descending coronary artery (LAD) in addition to annual CAV screening by coronary angiography and virtual histology intravascular ultrasound (VH-IVUS). Quantitative OCT analysis was performed at the site of maximal intimal thickness (MIT) for each LAD segment. RESULTS: Patients were 27 years old with a mean time from cardiac transplantation of 14.7 ± 6.8 years. All patients exhibited intimal hyperplasia with an abnormal (>1) intima-to-media ratio. The median (interquartile range) MIT values by OCT were 0.37 (0.22 to 0.54) mm, 0.46 (0.29 to 0.54) mm and 0.34 (0.25 to 0.49) mm in the distal, middle and proximal LAD segments, respectively. Qualitative OCT analysis rarely showed features of vulnerable plaque or complicated lesions. Consistently, at VH-IVUS, the prevalent component at the site of MIT per vessel assessed by OCT was fibrous tissue. CONCLUSIONS: Unlike recent evidence in adult HTx recipients, OCT findings of vulnerable plaque and complicated coronary lesions were found to be rare among late survivors of pediatric HTx.

Percutaneous recanalization of a chronic total left main coronary artery occlusion in an 8-year-old child after arterial switch surgery.

How and when to treat patients with coronary occlusion after arterial switch surgery is still under debate. We report the case of a child who underwent arterial switch surgery a few weeks after birth. At the age of 8 years, coronary angiography showed a total occlusion of the left main coronary artery, successfully treated using percutaneous coronary intervention. Percutaneous coronary recanalization of chronic total occlusions might be considered the first treatment strategy in children who undergo complex surgical procedures.

One-year outcome from an all-comers population of patients with ST-segment elevation myocardial infarction treated with biolimus-eluting stent with biodegradable polymer.

OBJECTIVES: To evaluate the performance of biolimus-eluting stent (BES) in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) in a real world clinical scenario. BACKGROUND: Randomized studies suggest that the BES with biodegradable polymer is more effective and safe than early generation coronary stents in patients with STEMI. METHODS: We included all consecutive STEMI patients undergoing PCI in this prospective, multicenter registry. The primary endpoint of the study was the rate of major adverse cardiac events (MACE), a composite of cardiac death, recurrent myocardial infarction and ischemia-driven target vessel revascularization at 1-year follow-up. RESULTS: Between June and December 2012 we enrolled 311 STEMI patients. The primary endpoint occurred in 3.2% (95% confidence interval: 1.6-5.8) of patients: cardiac death, re-infarction, and ischemia-driven TVR occurred in 2.3%, 1.3%, and 0.6% of patients, respectively. One-year MACE-free survival was 96.8% ± 1.0%. CONCLUSIONS: In a real-world cohort of STEMI patients undergoing PCI, the use of BES is associated with good 1-year clinical outcome. These results confirm and expand previous findings showing the efficacy and safety of BES in the setting of randomized trials.

A prospective registry on carotid artery revascularisation selected by consensus of a cardiovascular team.

AIMS: This prospective registry was designed to evaluate the early and long-term incidence of clinical events in patients with carotid obstructive disease (COD), after carotid artery revascularisation selected by consensus of a cardiovascular team. METHODS AND RESULTS: 403 consecutive patients with COD scheduled for carotid revascularisation were included: 130 were treated with carotid endarterectomy (CEA) and 273 with carotid artery stenting (CAS). Propensity score matching was performed to assemble a cohort of patients in whom all baseline covariates would be well balanced. The occurrence of major adverse cardiac and cerebrovascular events (MACCE), including any death, non-fatal myocardial infarction or stroke, was assessed at 30 days and at long-term follow-up. The incidence of MACCE at 30 days was 4.0% (95% confidence interval: 2.1 to 6.0), without any significant difference between the CAS and CEA groups in unmatched and matched populations. The cumulative freedom from MACCE at two-year follow-up was 80.5%±0.94%, with no statistically significant differences between the CAS and CEA groups, both in the total population and in the matched cohort. CONCLUSIONS: In this registry of patients undergoing carotid artery revascularisation selected by consensus of a cardiovascular team, the early and long-term incidence of clinical events is up to standard.

Open-label, randomized, placebo-controlled evaluation of intracoronary adenosine or nitroprusside after thrombus aspiration during primary percutaneous coronary intervention for the prevention of microvascular obstruction in acute myocardial infarction: the REOPEN-AMI study (Intracoronary Nitroprusside Versus Adenosine in Acute Myocardial Infarction).

OBJECTIVES: This study sought to assess whether intracoronary adenosine or nitroprusside following thrombus aspiration (TA) is superior to TA alone for the prevention of microvascular obstruction (MVO) in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: MVO, due to its multifactorial pathogenesis, still occurs after TA in a sizeable portion of patients. METHODS: We performed a placebo-controlled, randomized, open-label, blind-examination, multicenter trial. A total of 240 STEMI patients with Thrombolysis In Myocardial Infarction (TIMI) flow grade 0/1 were randomly allocated 1:1:1 to receive adenosine (n = 80), nitroprusside (n = 80), or saline (n = 80) given distal to the occluded site after TA. The primary endpoint was the incidence of ST-segment resolution (STR) >70% on surface electrocardiogram at 90 min after PCI. Secondary endpoints were angiographic MVO incidence (TIMI flow grade ≤2 or 3 with a myocardial blush grade <2) and major adverse cardiac event (MACE) rate at 30 days as a composite of cardiac death, myocardial infarction, target lesion revascularization, and heart failure requiring hospitalization. RESULTS: STR >70% occurred in in 71% of adenosine-treated patients, in 54% of nitroprusside-treated patients, and in 51% of saline-treated patients (p = 0.009 and p = 0.75, respectively, vs. saline). Angiographic MVO occurred in 18% of adenosine-treated patients, in 24% of nitroprusside-treated patients, and in 30% of saline-treated patients (p = 0.06 and p = 0.37, respectively, vs. saline). MACE occurred in 10%, 14%, and 20% of patients, respectively (p = 0.08 and p = 0.29 vs. saline). CONCLUSIONS: In STEMI patients treated by PCI and TA, the additional intracoronary administration of adenosine, but not that of nitroprusside, results in a significant improvement of MVO, as assessed by STR.

Effect of pre-infarction angina on platelet reactivity in acute myocardial infarction.

BACKGROUND: Previous studies demonstrated that patients with PIA have a smaller infarct and better in-hospital outcome after acute myocardial infarction, than those without angina. This protective effects has been attributed to ischemic preconditioning (PC), to earlier reperfusion after fibrinolysis or its better collateral circulation development. In this study we aimed at assessing platelet reactivity in patients with history of pre-infarction angina (PIA) in the acute phase of ST segment elevation myocardial infarction (STEMI) and 1 month later. METHODS: 85 consecutive patients (63 ± 10.5 years, 60 male) with a first STEMI treated by primary percutaneous coronary intervention (PCI) were studied at admission and 1 month later. Platelet reactivity was evaluated by flow cytometry with and without adenosine diphosphate (ADP) stimulation, by measuring monocyte-platelet aggregates (MPAs) and glycoprotein IIb/IIIa (CD41) expression in the MPA gate, and CD41 and fibrinogen receptor (PAC-1) expression in the platelet gate. RESULTS: MPAs and expression of platelet receptors CD41 and PAC-1 were significantly lower in patients with than patients without PIA, both with and without ADP stimulation. After 1 month, all cytometry variables both with and without ADP stimulation were similar in the two groups. CONCLUSIONS: This study shows, for the first time, that patients with a first STEMI who experience PIA show a lower platelet reactivity as compared with those without history of PIA.

Long-term outcome of provisional side-branch T-stenting for the treatment of unprotected distal left main coronary artery disease.

Percutaneous coronary intervention (PCI) on distal left main (LM) remains an independent predictor of poor outcome. The strategy of implanting one stent on the main branch (MB), with provisional stenting on the side-branch (SB) only when required (provisional T-stenting), has become the default approach to most bifurcation lesions. This prospective registry sought to investigate the long-term safety and efficacy of provisional SB T-stenting for the treatment of unprotected distal LM disease in patients undergoing PCI. From January 2006 to May 2009, 107 consecutive patients affected by unprotected distal LM disease underwent PCI at our center with the intent to use a provisional SB-stenting technique. We evaluated the rate of major adverse cardiac events (MACE) at long-term follow-up (up to 12-41 months). Procedural success was obtained in 98% of patients. A final kissing balloon inflation was performed in 95% and intravascular ultrasound in 83% of patients. Additional stenting on the SB after provisional stenting on MB was required in 29% of lesions. Long-term follow-up (3.5 years; 25-75th percentile and 1.1-4.5 years) was completed in 97% of patients. The cumulative incidence of MACE was 32.7%: all-cause death was 15.8%, nonfatal myocardial infarction 8.4%, and target vessel revascularization 21.5%. At multivariable analysis, age (hazard ratio, 2.08; 95% confidence interval: 2.01-3.32, P = 0.03), European System for Cardiac Operative Risk Evaluation (HR 1.20, 95% CI: 1.04-1.33, P = 0.02), and diabetes mellitus (HR 3.48, 95% CI: 1.12-6.87, P = 0.01) were identified as independent predictors of MACE. In patients with unprotected distal LM disease undergoing PCI, a provisional strategy of stenting the MB only is associated with good long-term clinical outcomes.

[Feasibility and safety of immediately returning patients transferred for percutaneous coronary intervention in a large metropolitan area]. / Fattibilità e sicurezza dell'immediato reinvio al centro di provenienza dei pazienti sottoposti ad angioplastica coronarica in una vasta area metropolitana.

BACKGROUND: Hospitals without percutaneous coronary intervention (PCI) capabilities are used to transfer patients who need coronary angiography and/or PCI to other centers. In order to optimize economic resources and hospital bed management, PCIs might be performed with an in-service organization, with re-transfer to the community hospital immediately after the procedure. The aim of our study was to evaluate the safety of a consecutive, unselected series of in-service PCIs compared to PCIs performed in patients admitted to hospitals with cath-lab capabilities. METHODS: During 2008, 1030 PCI procedures were performed at the European Hospital and Aurelia Hospital: 905 in patients admitted to a hospital with PCI capabilities (Group I) and 125 (12%) with an in-service strategy (Group II) referring from the Città di Roma Hospital. All treatment protocols were preventively uniformed and standardized. RESULTS: The two groups were statistically comparable in terms of baseline clinical characteristics and/or procedural findings, with the exception for older age (66 +/- 10 vs 70 +/- 10 years, p = 0.004) and a higher prevalence of acute coronary syndromes (56 vs 88%, p < 0.001) and femoral vascular access (94 vs 98%, p = 0.03) in Group II. The rate of left ventricular ejection fraction < or = 35% (20 vs 13%, p = 0.06), multivessel PCI (23 vs 19%, p = 0.4), and glycoprotein IIb/IIIa inhibitor use (15 vs 13%, p = 0.5) was similar between the two groups. Among patients treated with an in-service strategy, 2 (1.6%) were not transferred to the community hospital, because of hemodynamic instability. The in-hospital rate of major clinical events (death for cardiovascular causes, cerebrovascular events, urgent revascularization, stent thrombosis) was 0.75% and 0.8% (p = 0.8), 1.8% and 1% (p = 0.4) for periprocedural myocardial infarction, 1.7% and 1.9% (p = 0.5) for major bleeding, 1.1% and 1.6% (p = 0.6) for vascular complications, in Group I and II, respectively. Left ventricular dysfunction was the only independent predictor of major clinical events (p = 0.003). CONCLUSIONS: A strategy of in-service organization for PCI presents a similar rate of in-hospital clinical events and complications compared to an overnight stay into a hospital with PCI capabilities. Such a strategy may be utilized in order to optimize economic resources and hospital bed management.

The RESTART project: high-dose atorvastatin helps control RESTenosis AfteR sTenting procedures at high risk for restenosis. Results from a prospective study and a matched control group comparison.

AIMS: The long-term results of bare stenting in complex procedures are troubled by a high incidence of restenosis. The use of drug-eluting stents lead to excellent long-term angiographic results, but require, long-term antithrombotic treatment to prevent stent thrombosis. We evaluated the efficacy of high-dose atorvastatin as an adjuvant in limiting clinical and angiographic restenosis after bare stenting procedures which carry an high risk of restenosis. METHODS AND RESULTS: Between November 2003 and February 2004, 91 consecutive patients (with 152 target lesions) underwent successful interventional procedures with bare stents (158 stents; 1.7 stent/patient). The patients were included in the study in the presence of at least one of the following criteria: diabetes mellitus (14.6%); acute myocardial infarction (8.8%); lesion length >15 mm (27.5%); lesion in vessels with a reference diameter of <2.5 mm (24.2%); >2 treated lesions (58.2%); side-branch lesions (3.3%). All patients were started on atorvastatin (80 mg/day) on the day of the procedure, and continued receiving it for at least nine months.Six of the 91 patients (6.5%) experienced a clinical restenosis and underwent target lesion revascularisation; a further two underwent re-PTCA due to progressive atherosclerosis in untreated sites. Seventy-one patients (78.0%; 125 stents) were followed up with angiography after a mean 8.5 months (7-10 months): binary angiographic restenosis was observed in 18/71 patients (25.3%) (in-stent restenosis 21.1%; in-segment restenosis 4.2%), and 17/125 stents (13.6%).We matched 122 lesions (125 stents) from the present population with a reference group of 600 consecutive lesions treated at the Ospedale Maggiore della Carità in Novara during the same period of time, but without high-dose statin treatment: 88 lesions (94 stents) were successfully matched on the basis of the clinical and angiographic variables of diabetes, acute myocardial infarction, treated vessel, reference diameter and lesion length. The incidence of late loss was significantly lower in the atorvastatin group (p=0.027). CONCLUSIONS: The RESTART prospective study showed that the adjunct of atorvastatin 80 mg leads to excellent clinical and angiographic outcomes. These results were confirmed in a matched lesion comparison.

Use of abciximab prevents microcirculatory impairment in patients treated with coronary angioplasty for unstable angina: results of a prospective randomized study.

The use of abciximab during percutaneous coronary angioplasty (PTCA) in patients with unstable angina (UA) prevents the postintervention enzyme surge and improves clinical outcomes, possibly by improving microcirculatory function. The aim of this quantitative myocardial blush grade (MBG) study was to verify whether abciximab improves postintervention microcirculation in patients with UA. This prospective randomized open-label study involved 140 UA patients scheduled to undergo PTCA of the target coronary lesion: 140 patients were randomized to receive either abciximab during PTCA (group 1, 70 patients) or conventional treatment without GP IIb/IIIa inhibitor (group 2, 70 patients). The exclusion criteria included above normal CK-MB levels. MBG was calculated by means of quantitative software that evaluates video intensity in a given region of interest: assuming that greater peak video intensity reflects a larger myocardial blood volume, a perfusion scale of 1-6 points (poor to optimal) was devised. The groups were homogeneous in terms of their demographic, procedural, and angiographic characteristics. Stents were used in 98% of the patients in both groups. The MBG score significantly increased in group 1 from 3.04 +/- 2.17 to 3.71 +/- 2.02 (P = 0.045) and slightly decreased in group 2 from 3.13 +/- 2.07 to 2.93 +/- 2.03 (P = 0.42). Consequently, group 1 showed a significantly greater postintervention MBG score (3.71 +/- 2.02 vs. 2.93 +/- 2.03; P = 0.022) and had a significantly greater MBG score change (P = 0.025). The results of this randomized study show that the administration of abciximab prevents microcirculatory impairment in patients undergoing angioplasty for acute coronary syndromes.