Prolactin Inhibition to Treat Postpartum Arrhythmic Storm.

Postpartum electrical storm due to torsade de pointes is a rare but life-threatening condition. The uniqueness of this case lies in the use of cabergoline to suppress postpartum ventricular arrhythmias in absence of heart disease. Timely multidisciplinary management is crucial to achieve final diagnosis, deliver proper treatment and improve prognosis.

How to deal with vessel diameter mismatch in left main bifurcation stenting.

Left main coronary artery percutaneous coronary intervention is particularly complex when stenting across the distal bifurcation is required in the presence of a diameter mismatch between the proximal main and distal branches. A suboptimal procedural result increases the risk of thrombosis and restenosis. Considering the paucity of data published on this topic, our objective was to provide technical solutions to deal with this complex anatomy. We described four cases showing the use of devices and techniques which allowed us to overcome a diameter discrepancy between adjacent coronary segments: (1) self-expanding nitinol stent; (2) stent platform with noteworthy expansion capacity; (3) the 'extended skirt' technique; (4) the 'trouser-leg' technique. In conclusion, the use of specific strategies and devices allows a safe and effective approach to be used to perform treatment that respects the coronary anatomy, and to optimize percutaneous coronary intervention results in complex scenarios.

Immediate coronary angiography and systematic targeted temperature management are associated with improved outcome in comatose survivors of cardiac arrest.

Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short- and long-term outcome of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. All consecutive comatose CA survivors without obvious extra-cardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST elevation on electrocardiogram, and good neurological recovery. We enrolled 107 patients with a median age of 64.9 (57.7-73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty-six (61.7%) patients underwent PCI. In-hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in-hospital survival. Long-term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log-rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non-shockable) and ST deviation (elevation vs no-elevation), and improved the long-term survival of patients discharged with good neurological recovery. Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST deviation in the post-ROSC electrocardiogram. The benefit was sustained at long-term particularly in those with neurological recovery.

Balloon aortic valvuloplasty: current status and future prospects.

INTRODUCTION: Balloon aortic valvuloplasty (BAV) improves hemodynamic and clinical status of patients with severe aortic stenosis (AS) for a limited period of 6-12 months. However, there is a high number of procedures performed worldwide and an upward trend over the last decades. AREAS COVERED: Epidemiology of AS and the advent of transcatheter aortic valve implantation (TAVI) contribute to the extensive referral of patients. The expansion of recommendations for TAVI has occasionally led to financial reimbursement-related problems that do not exist for BAV. BAV is indicated as a bridge to valve replacement, to decision in complex cases, and to extracardiac surgery. BAV may play a role in preparing for TAVI and optimizing procedural results. The minimalist approach and reduced complication rate make it applicable in fragile patients. EXPERT OPINION: In the near future, BAV will continue to be a useful asset in managing patients with AS given the multiple indications, broad applicability, safety profile, low cost, and repeatability. Specific studies are necessary to explore technical solutions, stronger indications, the finest technique, and to standardize the procedural result. Pending the development of potential competitive devices, the role that BAV plays will remain closely intertwined with the one played by TAVI.

[The shockwave: an ace in the hole?] / Lo shockwave: un asso nella manica?

In patients with severe calcified coronary lesions, angioplasty procedures are associated with significant technical problems and a higher rate of complications. Nowadays, intravascular lithotripsy represents a safe and effective system for the treatment of calcified coronary stenosis before stent deployment. In this article, we report three complex clinical or angiographic cases in which the use of coronary lithotripsy is not yet codified. Specifically, we discuss a case of stent underexpansion after primary angioplasty, a case of acute myocardial infarction due to left main subocclusive stenosis complicated by cardiogenic shock and a case of severely calcified plaque in a venous bypass graft. In these three cases, the use of shockwave was essential to ensure an optimal procedural result, in the absence of significant adverse clinical events.

Medial-to-lateral plantar loop technique for retrograde transcollateral recanalization of the lateral plantar artery in patients with type 3 plantar arch.

A 89-year-old male presented with severe untreatable pain and ischemic non-healing ulcer in the left forefoot. The pre-procedural angiograms showed multiple stenosis of the superficial femoral and popliteal arteries, occlusion of anterior tibial artery, tibio-peroneal trunk (TTP) and distal posterior tibial artery (PTA), stenosis of the peroneal artery, and the patency of the medial plantar artery (MPA) as a single pedal artery, with very poor perfusion of the lateral aspect of the forefoot. The TTP and PTA were recanalized, and balloon angioplasty of superficial femoral artery and popliteal artery and peroneal artery was carried out. After unsuccessful antegrade attempts, the lateral plantar artery (LPA) was retrogradely recanalized performing the medial-to-lateral plantar loop, navigating from the deep branch of MPA to the plantar arch and reentering back in the common plantar artery through the LPA. Balloon angioplasty of LPA was performed though the retrograde and antegrade route. When the MPA is the single pedal artery, and the antegrade recanalization of the dorsalis pedis artery (DPA) and the LPA is not possible, the medial-to-lateral plantar loop is a feasible technique to recanalize the LPA retrogradely through the plantar arch.

Contemporary balloon aortic valvuloplasty: Changing indications and refined technique.

Even if un to improve long-term prognosis, balloon aortic valvuloplasty (BAV) may be useful in selected patients with symptomatic severe aortic stenosis either as a bridge to surgical or transcatheter valve replacement (aortic valve replacement [AVR] or transcatheter aortic valve implantation [TAVI]) or as a triage strategy for patients with uncertain indications. International guidelines recommend BAV as: a "bridge" to AVR/TAVI, a "trial" in patients with undetermined symptoms, or a "bridge-to-decision" in case of comorbidities. However, in clinical practice, BAV is also used as a palliative measure to improve hemodynamics and quality of life in many patients who are excluded from AVR/TAVI. Finally, BAV is often performed during TAVI to facilitate prosthesis delivery, optimize frame expansion, or for bioprosthetic valve fracture in selected valve-in-valve procedures. Technical innovations, which allow for a mini-invasive approach via transradial access and pacing delivered through the wire, have led to a decrease in complications over time. This review focuses on contemporary BAV with a specific emphasis on new indications, innovative techniques, and specific complex patient subgroups.

[Delirium in cardiology: an old problem, a new emergency]. / Il delirium in cardiologia: un vecchio problema, una nuova emergenza.

Delirium is a common cognitive behavioral disorder, with acute onset, frequent in elderly hospitalized patients. This condition has long been the subject of research in the critical area, with the development of targeted prevention and management protocols. In the cardiology field, however, awareness of delirium is poor. The problem of delirium has recently begun to involve practitioners since the publication of first studies showing the increase of adverse events in patients with this condition. The pathophysiology of delirium is unclear and the risk factors are based on clinical conditions and factors related to patient's care itself that need to be readily identified. Thus, delirium is a clinical manifestation that can easily be confused with other conditions. Notwithstanding, delirium can be prevented and treated when clinically evident, with a number of non-pharmacological interventions based on a multidisciplinary approach. Pharmacological therapy, due to its unclear effectiveness, should be reserved to patients with severe agitation or at risk of injuring themselves and others. The purpose of this review is to increase the awareness in healthcare professionals about the recent data on etiology, prevention, treatment and prognosis of delirium and to put the basis for a protocol that could be used in Cardiology departments.

Multimodality Imaging of Purulent Pericarditis: Hints to Speed up Diagnosis and Promote Healing.

Purulent pericarditis is rare and usually associated with pneumonia, bacteremia, immunosuppression, and thoracic surgery. A timely diagnostic pericardiocentesis with dedicated maneuvers to improve the effectiveness of drainage and pericardial fibrinolytic rinsing can improve prognosis and prevent a surgical pericardiectomy. Imaging offers useful clues for a more aggressive approach.

No-Reflow Complicating Chronic Total Occlusion Coronary Revascularization.

OBJECTIVES: To assess the incidence of no-reflow in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI), analyze possible causes and differential diagnoses, and identify useful management approaches. METHODS: In this multicenter observational study, all CTO-PCIs performed between January 2018 and April 2019 were reviewed to collect no-reflow complications, defined as Thrombolysis in Myocardial Infarction (TIMI) flow ≤1 in a patent epicardial artery. Patient clinical, anatomical, and procedural characteristics were analyzed. RESULTS: Out of 461 PCIs, two (0.43%) were complicated by no-reflow. In 1 case, PCI was performed on a long segment of the right coronary artery, after use of a dissection-re-entry technique by knuckle wiring. In the second patient, no-reflow developed after proximal left anterior descending coronary artery stenting, with a short subintimal tracking. Intravascular ultrasound was used to exclude complications in the epicardial vessel in both cases. Distal embolization seems the most plausible cause, and intracoronary adenosine effectively improved flow. Both patients had a type 4a myocardial infarction, asymptomatic in the first case, and associated with chest pain, electrocardiographic changes, and new regional wall-motion abnormality at echocardiography in the second case. CONCLUSIONS: No-reflow in CTO recanalization is rare, but associated with a high risk of periprocedural myocardial infarction, with incomplete protection from ischemia offered by the pre-existing collateral network.

Arteriovenous Fistula of the Peroneal Artery Complicating a Retrograde Access: Successful Endovascular Treatment with Covered Stent Implantation.

An 80-year-old woman developed a recurrent chronic limb-threatening ischemia of the right lower limb after a popliteal artery (PA) recanalization with retrograde puncture of the peroneal artery (PR). The angiography showed the PA restenosis and an arteriovenous fistula (AVF) at the previous peroneal retrograde access site. After the PA angioplasty, the AVF was identified through selective contrast injections in multiple projections. A coronary balloon-expandable covered stent was deployed at the AVF site with complete resolution of the AVF. The final angiography demonstrated the patency of PA and PR with complete resolution of the AVF. The patient was discharged without complications, with regression of rest pain. The foot lesion healed within 2 months.

Drug-Eluting Balloon Versus Drug-Eluting Stent for Complex Femoropopliteal Arterial Lesions: The DRASTICO Study.

BACKGROUND: Drug-eluting technologies improve 12-month angiographic results of femoropopliteal (FP) interventions, but few data on the comparison between drug-coated balloons (DCBs) and drug-eluting stents (DES) are available. OBJECTIVES: The aim of this study was to compare, after balloon pre-dilation, a strategy of DCB followed by provisional self-expanding nitinol bare-metal stent implantation with a strategy of systematic DES implantation in patients at high risk for FP restenosis. METHODS: Patients presenting with either intermittent claudication or critical limb ischemia undergoing FP intervention were randomly assigned 1:1 to DCB or DES after successful target lesion pre-dilation. The primary endpoint was 12-month target lesion binary restenosis, assessed using Doppler ultrasound. Secondary endpoints were freedom from target lesion revascularization and from major amputation. RESULTS: A total of 192 patients, 96 in the DCB group and 96 in the DES group, with 240 lesions in 225 limbs, were included. Diabetes and critical limb ischemia were present in >50% in both groups. Mean lesion length was 14 cm, and baseline target lesion occlusion reached about 60% of cases in both groups. The systematic DES strategy yielded larger post-procedural minimal luminal diameter and a lower incidence of residual dissection compared to DCB, in which nitinol stents were used in only 21% of the lesions. Twelve-month target lesion restenosis was observed in 22% of DCB-treated versus 21% of DES-treated patients (p = 0.90). Clinically driven target lesion revascularization was necessary in 14% of DCB patients versus 17% of DES patients (p = 0.50). CONCLUSIONS: DCB was not superior to DES in the treatment of complex FP lesions in a high-risk population, yielding similar rate of restenosis and clinically driven target lesion revascularization. (Paclitaxel-Eluting Balloon Angioplasty With Provisional Use of Nitinol Stent Versus Systematic Implantation of Paclitaxel-Eluting Stent for the Treatment of Femoropopliteal De Novo Lesions; NCT01969630).

Cardiac Arrest in a 31-Year-Old Man With Noonan Syndrome.

A 31-year-old man with Noonan syndrome who suffered an out-of-hospital cardiac arrest presented at our institution with severe postanoxic coma (Glasgow coma scale 3), but normalized electrocardiogram and stable hemodynamics. Coronary angiography documented a giant right coronary artery supplying collateral flow to the left coronary artery, which presented a left main functional occlusion.

[Rescue thrombolytic therapy for the treatment of ST-elevation myocardial infarction after unsuccessful primary percutaneous coronary intervention in a patient with coronary artery aneurysm]. / Infarto miocardico acuto trattato con trombolisi di salvataggio dopo inefficace angioplastica coronarica primaria in paziente con aneurismi coronarici.

The recommended treatment for ST-segment elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (pPCI). However, in a non-negligible proportion of patients, pPCI is ineffective and the cardiologist must face the decision of how to achieve optimal myocardial reperfusion. Although the possibility of a rescue fibrinolytic strategy has not been evaluated yet in this clinical setting, it is a viable alternative to emergency cardiac surgery. We here report the case of a 60-year-old STEMI patient presenting with a coronary anatomy unsuitable for percutaneous mechanical revascularization, characterized by marked dilation and tortuosity of the proximal and middle epicardial segments. After pPCI failure, the administration of recombinant tissue-type plasminogen activator allowed us to obtain reperfusion as shown by clinical outcome, ST-segment resolution and subsequent angiographic study. No indication was given to further percutaneous or surgical revascularization. The long-term pharmacological management of these patients represents a challenge for the clinician, also considering the available data on the use of new antiplatelet and anticoagulant molecules and their possible associations.