Anxious/Depressive Symptoms Alter the Subjective Perception of Heart Failure Severity in Transthyretin Cardiac Amyloidosis.

The subjective perception of cardiac symptom severity is considered a main treatment target in the management of transthyretin-related cardiac amyloidosis (CA), as opposed to objective prognostic markers such as N-terminal pro b-type natriuretic peptide (NT-proBNP), which objectively reflects the severity of heart disease. Nevertheless, anxious and depressive symptoms in patients with CA might affect subjects perceptions of disease, creating a potential gap between objective and subjective parameters. We assess the impact of such bias in consecutive patients with CA. A total of 60 patients aged 62 to 88 years with CA were recruited. The level of anxiety and depression was measured by the Hospital Anxiety and Depression Scale and the subjective perception of symptoms severity by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Finally, NT-proBNP plasma levels at rest and glomerular filtration rate were measured. Nearly 1/2 of the patients (48%) reported clinically relevant levels of psychologic symptoms. Higher levels of anxious and depressive symptoms were significantly linked to lower KCCQ scores. Furthermore, the relation between NT-proBNP and KCCQ was significant only when anxious and depressive symptoms were low (ß = -0.86, p = 0.002; ß = -0.86, p = 0.002, respectively) and medium (ß = -0.49, p = 0.004; ß = -0.45, p = 0.004, respectively) but was otherwise lost. Depression and anxiety in patients with transthyretin-related CA required assessment and management. In conclusion, patients with depression/anxiety have a clear disconnect between their personal assessment and objective measures of cardiac symptoms, with a major influence on the patients' wellbeing and on their subjective response to treatments in clinical trials.

Frequency of Lipid-Rich Coronary Plaques in Stable Angina Pectoris versus Acute Coronary Syndrome (from the Lipid Rich Plaque Study).

The multicenter prospective Lipid Rich Plaque (LRP) registry showed that nonculprit (NC) lipid-rich plaques identified by near-infrared spectroscopy (maxLCBI4mm >400) with an intravascular ultrasound plaque burden (PB) >70% and/or minimum lumen area (MLA) <4 mm2 within the maxLCBI4mm segment were more frequently associated with major adverse cardiac events (MACE) within 2 years. The aim of this sub-study was to report the relationship between initial clinical presentation and subsequent NC-MACE. Patients enrolled in the LRP study were stratified post hoc as having a stable angina pectoris or silent ischemia presentation versus acute coronary syndrome, excluding patients presenting with acute ST-elevation myocardial infarction. Among the 1552 patients, 717 presented with stable angina pectoris or silent ischemia. Patients presenting with acute coronary syndrome were more likely to be younger and Black, current smokers, and have less chronic kidney disease. Of the scanned nonculprit vessels, there was no difference between the 2 clinical presentation groups regarding lipidic content, and the rate of lipid-rich plaques (maxLCBI4mm >400) was 31.9% in both groups. Finally, there was no difference in NC-MACE at 2 years' follow-up, although within each group (stable versus acute coronary syndrome), the NC-MACE rate associated with maxLCBI4mm >400 was significantly higher than maxLCBI4mm ≤400 (stable 13.8% vs 6.5%; acute patients 11.6% vs 6.3%, respectively). In conclusion, in patient groups that present with stable angina pectoris or silent ischemia versus acute coronary syndrome, the NC lipidic content was similar, as was NC-MACE, through 2 years of follow-up.

The DESolve® novolimus bioresorbable scaffold.

A longtime aspiration of interventional cardiologists remains to improve the long-term impact of stent permanence in coronaries to restore original vessel patency and physiological endothelium response. Bioresorbable vascular scaffolds were considered revolutionary in coronary devices, but several trials were disappointing; thus, the challenge in this field remains. DESolve is a novolimus-eluting poly-L-lactide-based polymer scaffold that dissolves through a bio-reabsorption mechanism, vanishing completely in 2 years. Its ability to supply the necessary radial strength to support the vessel for the critical early months after delivery is an important feature showing a unique self-correction property, which reduces incomplete stent apposition. Overexpansion has a good, safe margin with DESolve. This review aims to provide an overview of this controversial topic.

Incidence of Adverse Events at 3 Months Versus at 12 Months After Dual Antiplatelet Therapy Cessation in Patients Treated With Thin Stents With Unprotected Left Main or Coronary Bifurcations.

Incidence and predictors of adverse events after dual antiplatelet therapy (DAPT) cessation in patients treated with thin stents (<100 microns) in unprotected left main (ULM) or coronary bifurcation remain undefined. All consecutive patients presenting with a critical lesion of an ULM or involving a main coronary bifurcation who were treated with very thin strut stents were included. MACE (a composite end point of cardiovascular death, myocardial infarction [MI], target lesion revascularization [TLR], and stent thrombosis [ST]) was the primary endpoint, whereas target vessel revascularization (TVR) was the secondary endpoint, with particular attention to type and occurrence of ST and occurrence of ST, CV death, and MI during DAPT or after DAPT discontinuation. All analyses were performed according to length of DAPT dividing the patients in 3 groups: Short DAPT (3-months), intermediate DAPT (3 to 12 months), and long DAPT (12-months). A total of 117 patients were discharged with an indication for DAPT ≤3 months (median 1: 1 to 2.5), 200 for DAPT between 3 and 12 months (median 8: 7 to 10), and 1,958 with 12 months DAPT. After 12.8 months (8 to 20), MACE was significantly higher in the 3-month group compared with 3 to 12 and 12-month groups (9.4% vs 4.0% vs 7.2%, p ≤0.001), mainly driven by MI (4.4% vs 1.5% vs 3%, p ≤0.001) and overall ST (4.3% vs 1.5% vs 1.8%, p ≤0.001). Independent predictors of MACE were low GFR and a 2 stent strategy. Independent predictors of ST were DAPT duration <3 months and the use of a 2-stent strategy. In conclusion, even stents with very thin strut when implanted in real-life ULM or coronary bifurcation patients discharged with short DAPT have a relevant risk of ST, which remains high although not significant after DAPT cessation.

Impact of Final Kissing Balloon and of Imaging on Patients Treated on Unprotected Left Main Coronary Artery With Thin-Strut Stents (From the RAIN-CARDIOGROUP VII Study).

Few data are available about the impact on outcomes of procedural strategies for percutaneous coronary intervention with thin-struts stents on unprotected left main (ULM): 792 patients with an ULM stenosis treated with percutaneous coronary intervention with thin-strut stents were enrolled in the present multicenter registry. Target lesion revascularization (TLR) was the primary end point. MACE (a composite of all-cause death, myocardial infarction, TLR, and stent thrombosis) and its single components, along with target vessel revascularization were the secondary end points. Subgroup analyses were performed according to complex versus noncomplex bifurcation lesions. After 16 months, 5.5% of patients experienced a TLR. At multivariate analysis, provisional stenting (odds ratio [OR] 0.46: 0.85 to 0.23, p = 0.006), use of imaging (OR 0.45: 0.23 to 0.98, p = 0.003) and final kissing balloon (FKB) (OR 0.41: 0.83 to 0.21, p = 0.001) reduced risk of TLR. FKB reduced risk of overall TLR only for 2 stents-strategy (6.2% vs 32.4%, p <0.05), but not for provisional strategy (3.8% vs 3.7%, p = 0.67). Intracoronary imaging reduced risk of overall TLR both for provisional (2.2% vs 5.4%) and for 2-stents strategy (7.3% vs 14.1% p <0.05 for both, all confidence interval 95%). In conclusion, TLR for ULM patients treated with thin-strut stents is infrequent. Provisional stenting was noninferior compared with 2-stents apart from complex lesions. Benefit from intracoronary imaging is consistent for different strategies, whereas that from FKB persists only for 2-stents.

Outcome after percutaneous edge-to-edge mitral repair for functional and degenerative mitral regurgitation: a systematic review and meta-analysis.

OBJECTIVES: Differences in terms of safety and efficacy of percutaneous edge-to-edge mitral repair between patients with functional and degenerative mitral regurgitation (MR) are not well established. We performed a systematic review and meta-analysis to clarify these differences. METHODS: PubMed, EMBASE, Google scholar database and international meeting abstracts were searched for all studies about MitraClip. Studies with <25 patients or where 1-year results were not delineated between MR aetiology were excluded. This study is registered with PROSPERO. RESULTS: A total of nine studies investigating the mid-term outcome of percutaneous edge-to-edge repair in patients with functional versus degenerative MR were included in the meta-analysis (n=2615). At 1 year, there were not significant differences among groups in terms of patients with MR grade≤2 (719/1304 vs 295/504; 58% vs 54%; risk ratio (RR) 1.12; 95% CI: 0.86 to 1.47; p=0.40), while there was a significantly lower rate of mitral valve re-intervention in patients with functional MR compared with those with degenerative MR (77/1770 vs 80/818; 4% vs 10%; RR 0.60; 95% CI: 0.38 to 0.97; p=0.04). One-year mortality rate was 16% (408/2498) and similar among groups (RR 1.26; 95% CI: 0.90 to 1.77; p=0.18). Functional MR group showed significantly higher percentage of patients in New York Heart Association class III/IV (234/1480 vs 49/583; 16% vs 8%; p<0.01) and re-hospitalisation for heart failure (137/605 vs 31/220; 23% vs 14%; p=0.03). No differences were found in terms of single leaflet device attachment (25/969 vs 20/464; 3% vs 4%; p=0.81) and device embolisation (no events reported in both groups) at 1 year. CONCLUSIONS: This meta-analysis suggests that percutaneous edge-to-edge repair is likely to be an efficacious and safe option in patients with both functional and degenerative MR. Large, randomised studies are ongoing and awaited to fully assess the clinical impact of the procedure in these two different MR aetiologies.

Risk Stratification Using the CHA2DS2-VASc Score in Takotsubo Syndrome: Data From the Takotsubo Italian Network.

BACKGROUND: The CHA2DS2-VASc score predicts stroke in patients with atrial fibrillation and has been reported to have a prognostic role even in acute coronary syndrome patients. The Takotsubo syndrome is a condition that mimics acute coronary syndrome and may present several complications including stroke. We sought to assess the ability of CHA2DS2-VASc score to predict adverse events in Takotsubo syndrome patients. METHODS AND RESULTS: Overall, 371 Takotsubo syndrome patients were enrolled in a prospective registry. Patients were divided into 3 groups according to the CHA2DS2-VASc score: Group A (≤1), B (2-3), and C (≥4). The median CHA2DS2-VASc score was 3 (interquartile range: 2-4). Overall, 9%, 42%, and 49% were included in Group A, B, and C, respectively. Follow-up length was 26±20 months. The mortality rate was 6%, 7%, and 17% in Group A, B, and C, respectively (P=0.011). The stroke rate was 3% and not different among the 3 groups. Estimated major adverse cardiac and cerebrovascular events (the composite of death, myocardial infarction, and stroke) rates in the 3 groups were 6%, 9%, and 17% in Group A, B, and C, respectively (P=0.033). The CHA2DS2-VASc score resulted as a predictor of major adverse cardiac and cerebrovascular events (odds ratio 2.1, 95% confidence interval, 1.2-3.6; P=0.01) and all-cause mortality (odds ratio 1.5, 95% confidence interval, 1.2-1.9; P=0.001). CONCLUSIONS: In Takotsubo syndrome, the CHA2DS2-VASc score allows prediction of cardiovascular events and mortality at long-term follow-up.

Catheter-based intervention for symptomatic patient with severe mitral regurgitation and very poor left ventricular systolic function - Safe but no room for complacency.

Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation (MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous MitraClip(®) can be used safely to reduce the severity of MR even in patients with advanced heart failure and is associated with improved symptoms, quality of life and exercise tolerance. However, a few patients with very poor left ventricular systolic function may experience significant haemodynamic disturbance in the peri-procedural period. We present three such patients, highlighting some of the potential problems encountered and discuss their possible pathophysiological mechanisms and safety measures.

Chronic total occlusion successfully treated with a bioresorbable everolimus-eluting vascular scaffold.

Fully bioresorbable vascular scaffolds (BVS) are a new approach to the percutaneous treatment of coronary artery disease. The BVS have not yet been fully tested in complex lesions, including chronic total occlusion (CTO). We report a CTO case successfully treated with a second-generation bioabsorbable drug-eluting scaffold.

Transcatheter aortic valve implantation without balloon predilatation: not always feasible.

Balloon predilatation has been regarded as an essential step before implanting the self-expandable prosthesis during transcatheter aortic valve implantation (TAVI). Recent evidence showed that without balloon predilatation, an implantation success rate of >95% could be achieved. We report two cases in which balloon predilatation was not performed initially during TAVI but eventually required it to facilitate device crossing and implantation. They illustrated the importance of case selection and alerted us the potential limitation in performing TAVI without balloon predilatation.

Estrategia simple o compleja para lesiones de bifurcaciones coronarias: evaluación inmediata de la aposición de los struts del stent mediante tomografía de coherencia óptica / Simple versus complex approaches to treating coronary bifurcation lesions: direct assessment of stent strut apposition by optical coherence tomography

Introducción y objetivos. La implantación de stents en lesiones de bifurcaciones coronarias comporta un riesgo elevado de deformación y mala aposición del stent. Las observaciones anatomopatológicas han atribuido a la mala aposición de los struts un papel causal en la elevada tasa de trombosis de los stents que se observa en las bifurcaciones. Métodos. Se evaluó la aposición de los struts en las lesiones de bifurcaciones tratadas con una técnica simple de implantación de stent solo en el vaso principal o con una técnica compleja (de culotte) mediante el empleo de tomografía de coherencia óptica (OCT). La mala aposición de un strut se definió por el hecho de que la distancia entre su superficie intraluminal y la pared vascular fuera superior a su grosor más un margen de error de resolución de la OCT de 15 μm. Resultados. En 17 pacientes se utilizó la estrategia simple y en 14, la técnica compleja (de culotte). Los struts con mala aposición fueron significativamente más frecuentes y la distancia entre el strut y la pared vascular en los casos de mala aposición fue mayor en la mitad de la bifurcación situada hacia la rama lateral (RL) (46,1% [35,3-62,5]) en comparación con la mitad del lado opuesto (9,1% [2,2-21,6]), el segmento distal (7,5% [2,3-20,2]) y el segmento proximal (12,6% [7,8-23,1]; p < 0,0001) (distancias, 98 μm [37-297] frente a 31 μm [13-74], 49 μm [20-100] y 38 μm [17-90], respectivamente; p < 0,0001). El empleo de la técnica compleja no afectó a la prevalencia de struts con mala aposición en los 4 segmentos en comparación con la estrategia simple (p = 0,31) y se asoció a una menor distancia strut-pared en el segmento proximal (47 frente a 60 mm; p = 0,0008). Conclusiones. En las lesiones de bifurcaciones coronarias, la mala aposición de los struts se produce con mayor frecuencia y es más importante en la zona de origen de la RL. El empleo de la técnica de culotte no aumenta de manera significativa la prevalencia de la mala aposición de los struts en comparación con una estrategia simple (AU)

Introduction and objectives. Stenting of coronary bifurcation lesions carries an increased risk of stent deformation and malapposition. Anatomical and pathological observations indicate that the high stent thrombosis rate in bifurcations is due to malapposition of stent struts. Methods. Strut apposition was assessed with optical coherence tomography (OCT) in bifurcation lesions treated either using the simple technique of stent implantation in the main vessel only or a complex technique (i.e. Culotte’s). A strut was regarded as malapposed if the gap between its endoluminal surface and the vessel wall was greater than its thickness plus an OCT resolution error margin of 15 µm. Results. Simple and complex (i.e. Culotte’s) approaches were used in 17 and 14 patients, respectively. Strut malapposition was significantly more frequent for the half of the bifurcation on same side as the vessel side branch (median, 46.1%; interquartile range [IQR], 35.3–62.5%) than for the half opposite the side branch (9.1%; IQR, 2.2–21.6%), the distal segment (7.5%; IQR, 2.3–20.2%) or the proximal segment (12.6%; IQR, 7.8–23.1%; P<.0001); the gap between strut and vessel wall in malapposed struts was significantly greater in the first segment than the others: 98 µm (IQR, 37–297 µm) vs. 31 µm (IQR, 13–74 µm), 49 µm (IQR, 20–100 µm) and 38 µm (IQR, 17–90 µm), respectively (P<.0001). Using the complex technique had no effect on the prevalence of strut malapposition in the four segments relative to the simple technique (P=.31) but was associated with a smaller gap in the proximal segment (47 µm vs. 60 µm; P=.0008). Conclusions. In coronary bifurcation lesions, strut malapposition occurred most frequently and was most significant close to the side branch ostium. The use of Culotte’s technique did not significantly increase the prevalence of strut malapposition compared with a simple technique (AU)

A new quantitative analysis system for the evaluation of coronary bifurcation lesions: comparison with current conventional methods.

BACKGROUND: Objective conventional quantitative angiographic systems are designed to automatically follow the contours of straight vascular segments and not of bifurcations. Recently a new analysis method was specifically developed for bifurcation lesions, able to automatically divide the lesion into three separate segments. In this study, we aimed to assess whether the smaller interaction required by the analyst could reduce the analysis time and inter and intra observer variability when compared with a conventional analysis. METHOD: We used a dedicated system (QVA-CMS V. 6.0 with the Bifurcation Module, MEDIS, Leiden, The Netherlands) applying a minimum cost algorithm tuned to detect the contours of the proximal main vessel (PMV), distal main vessel (DMV), and side-branch (SB). We assessed the intra- and the interobserver agreement in measurements of minimal lumen diameter (MLD) and percentage diameter stenosis (%DS) of the PMV and DMV, as well as of the SB ostium in 30 angiograms of patients before and after percutaneous coronary angioplasty with stenting of both branches. The consensus between measurements by two observers and by the same observer was analyzed using the intra- and interclass correlation coefficient and the reliability coefficients for all measurements. Bland-Altman plots before and after PCI were also generated to assess the relationship between variability and absolute measurements. RESULTS: Before PCI, intra- and interobserver variabilities were consistently lower for the new QVA system, with a significant difference for lesion length in the SB. Post-PCI data showed a greater variability in the assessment of diameter stenosis with both techniques. The time for analysis was significantly lower both before and after PCI for QVA compared with quantitative coronary angiography (QCA) (4.7 +/- 1.1 min versus 6.2 +/- 1.3 min, P < 0.0001). CONCLUSION: Our results demonstrate that this new quantitative bifurcation analysis system can be consistently applied to the analysis of bifurcation lesions before and after angioplasty, with an intra- and interobserver reproducibility equal to or better than the conventional analysis system with a significantly shorter analysis time.