Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures.

Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for "frail patients", in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.

Antiplatelet Therapy for Non-ST-Segment Elevation Myocardial Infarction in Complex "Real" Clinical Scenarios: A Consensus Document of the "Campania NSTEMI Study Group".

The incidence of ST-segment elevation myocardial infarction (STEMI) has significantly decreased. Conversely, the rate of non-STEMI (NSTEMI) has increased. Patients with NSTEMI have lower short-term mortality compared to patients with STEMI, whereas at long-term follow-up, the mortality becomes comparable. This might be due to the differences in baseline characteristics, including older age and a greater prevalence of comorbidities in the NSTEMI population. Although antithrombotic strategies used in patients with NSTEMI have been well studied in clinical trials and updated guidelines are available, patterns of use and outcomes in clinical practice are less well described. Thus, a panel of Italian cardiology experts assembled under the auspices of the "Campania NSTEMI Study Group" for comprehensive discussion and consensus development to provide practical recommendations, for both clinical and interventional cardiologists, regarding optimal management of antithrombotic therapy in patients with NSTEMI. This position article presents and discusses various clinical scenarios in patients with NSTEMI or unstable angina, including special subsets (eg, patients aged ≥85 years, patients with chronic renal disease or previous cerebrovascular events, and patients requiring triple therapy or long-term antithrombotic therapy), with the panel recommendations being provided for each scenario.

Everolimus-Eluting Bioresorbable Vascular Scaffold System in the Treatment of Cardiac Allograft Vasculopathy: the CART (Cardiac Allograft Reparative Therapy) Prospective Multicenter Pilot Study.

Cardiac allograft vasculopathy (CAV) is a form of accelerated atherosclerosis, which represents the leading cause of late morbidity and mortality after heart transplantation. The recent bioresorbable vascular scaffold (BVS) technology represents a potential novel therapeutic tool, in the context of CAV, by allowing transient scaffolding and concomitant vessel healing. Eligible subjects will be treated by using the Absorb Everolimus-Eluting BVS (Abbott Vascular, Santa Clara, CA, USA), and evaluated at pre-determined time points, up to 3 years since the index procedure. Both clinical and imaging data will be collected in dedicated case report forms (CRF). All imaging data will be analyzed in an independent core laboratory. The primary aim of the study is to evaluate the angiographic performance at 1 year of second-generation Absorb BVS, in heart transplant recipients affected by CAV.

Effects of transcatheter aortic valve implantation on left ventricular and left atrial morphology and function.

AIMS: Transcatheter aortic valve implantation (TAVI) is an alternative treatment in surgically high-risk or inoperable patients with severe aortic stenosis (AS). The objective of this study was to analyze the effects of TAVI on left ventricular (LV) and left atrial (LA) longitudinal function assessed by speckle tracking echocardiography (2DSTE) in patients with AS. METHODS: In our prospectively conducted study, a total of 55 symptomatic (New York Heart Association class II or higher) patients with severe AS, considered to be at increased risk for undergoing surgical aortic valve replacement, were recruited (age: 78.6 ± 7.4 year). Patients underwent a complete clinical and laboratory evaluation, in addition to standard echocardiography and 2DSTE. Echocardiographic analysis was performed before and 6 months after TAVI. 2DSTE measured segmental and global longitudinal strain (GLS) and radial strain. RESULTS: All the patients received the CoreValve self-expanding prosthesis. Six months after TAVI, patients showed a significant reduction in mean transaortic gradient (52.1 ± 15.8 vs. 11.2 ± 3.3 mmHg, P < 0.0001), LV mass, LA volume index, and an improvement of ejection fraction (P < 0.0001). In addition, LV GLS (-11.8 ± 3.2 vs. -16.3 ± 4.2%; P < 0.0001) and LA longitudinal strain (14.2 ± 5.4 vs. 26.6 ± 10.8%, P < 0.0001) significantly increased after TAVI. In a stepwise forward multiple logistic regression analysis, LV mass before TAVI (P < 0.001) and peak CK MB mass after TAVI (P < 0.0001) were powerful independent predictors of lower improvement of LV GLS. Moreover, LV mass index (P < 0.001) and LV GLS strain (P < 0.001) before TAVI were powerful independent predictor of LA longitudinal strain after TAVI CONCLUSIONS: TAVI in patients with AS resulted in geometric changes known as "reverse remodelling," and improved LV and LA function assessed by 2DSTE.

Preoperative evaluation before MitraClip®: present and future perspective.

Mitral regurgitation (MR) is the second most common heart valve disease worldwide. Currently, the management of MR is based on medical therapy (including biventricular pacing), surgery (mitral valve replacement or repair) and percutaneous therapy. However, in spite of guideline recommendations, 50% of individuals assessed in the Euro Heart Survey were not referred to surgical intervention due to comorbidities or real or perceived high risks for cardiac surgery; thus, in recent years, the focus of research has shifted to the development of percutaneous approaches to treat severe MR in order to restore valve function in a minimally invasive fashion. Among these techniques, the percutaneous mitral valve repair procedure using the MitraClip(®) system (Abbott Vascular, IL, USA) is one of the most promising. Usually, patient selection for MitraClip implantation is based on careful echocardiographic assessment of valve disease; however, although definitive data are lacking, evidence is mounting for a multiparametric approach including the evaluation of the functional status of patients.

Drug-eluting stent implantation in patients with acute coronary syndrome - the Activity of Platelets after Inhibition and Cardiovascular Events: Optical Coherence Tomography (APICE OCT) study.

AIMS: To our knowledge, no randomised study has compared rates of uncovered stent struts in everolimus (EES) vs. new-generation zotarolimus-eluting (ZES-R) stents in acute coronary syndrome (ACS). The aim of our study was to evaluate the completeness of neointimal coverage with optical coherence tomography (OCT) in ACS patients treated with drug-eluting stents (DES) comparing EES versus new-generation ZES-R. METHODS AND RESULTS: All eligible ACS patients admitted to four Italian centres with a clinical indication for culprit lesion intervention were randomised 1:1 to EES or ZES-R. The primary study endpoint was the percentage of uncovered stent struts evaluated by optical coherence tomography (OCT) at six months. Secondary endpoints were the percentage of malapposed stent struts, percent neointimal hyperplasia cross-sectional area (CSA) and major adverse cardiac events (MACE) at six months. A total of 60 patients were randomised to EES (n=29) or ZES-R (n=31). No differences were observed in baseline characteristics between the two groups. Overall, 31.7% presented with STEMI, of which 68.4% were anterior. The other patients comprised 41.7% NSTEMI and 26.7% troponin-negative ACS. A mean of 1.3±0.6 lesions were treated per patient, with a mean of 1.3±0.5 stents per lesion. At 30 days there was one sudden death. Six-month OCT analysis was performed in 25 lesions in the EES group and in 24 lesions in the ZES-R group. There was no difference in the primary endpoint of uncovered stent struts between groups (EES 6.42% [3.27, 9.57] vs. ZES-R 7.07% [3.22, 10.92]; p=0.80). Furthermore, there were no differences between groups in the percentage of malapposed stent struts, either with (EES 1.19% [0.34, 2.04] vs. ZES-R 0.85% [0.40, 1.30]; p=0.49) or without coverage (EES 1.06% [0.12, 2.01] vs. ZES-R 0.24% [0.05, 0.44]; p=0.09). Percent neointima CSA was similar in both groups (EES 37.0% [18.6, 55.3] vs. ZES-R 26.6% [18.4, 34.8]; p=0.31). At six-month clinical follow-up, no additional patients died or suffered MI. There were four MACE in the EES group and one in the ZES-R group. CONCLUSIONS: In our study, in patients presenting with ACS, both EES and ZES-R had low percentages of malapposed and uncovered stent struts at six-month OCT analysis.

Colecistectomía mínimamente invasiva: los primeros 100 casos no seleccionados / Minimal invasive cholecistectomy: the first 100 nonselected cases

Durante años usamos en casos seleccionados incisiones pequeñas para colecistectomías, pero manteniendo la técnica tradicional de exéresis, lo que definimos como colecistectomía a través de minilaparotomía. Tratando de minimizar el trauma quirúrgico, llegamos a definir una técnica enteramente diferente que eventualmente adoptamos como el procedimiento de elección para todos los casos sin obstrucción de la vía biliar principal. Definimos como colecistectomía mínimamente invasiva a una modalidad técnica que implica una completa redefinición del protocolo operatorio, más alla del simple empleo de una minilaparotomía. Presentamos 100 casos consecutivos seleccionados sólo por la ausencia de evidencias de litiasis de la vía biliar principal y operados con esta técnica. El 26% tenía un proceso agudo. No hubo complicaciones yatrogénicas ni reoperaciones precoces y la estadía postoperatoria promedio fue de 1,3 días. La laparotomía tuvo una extensión de 25 a 45 mm en 93 casos y fue menor de 9 cm en los 7 casos restantes. En base a nuestra experiencia con colecistectomías convencionales, minilaparotomías, el procedimiento que describimos y datos de la literatura, se intenta establecer el rol de la colecistectomía mínimamente invasiva en la cirugía biliar contemporánea

Anestesia peridural con bupivacaína en cirugía general / Peridural anesthesia with bupivacaine in general surgery

Se presentan 193 adolescentes o adultos de ambos sexos, consecutivamente operados por el mismo equipo por patología abdominal extraperitoneal, perineal y de las extremidades inferiores bajo anestesia peridural con bupivacaína al 0,5%, desde junio de 1987 hasta junio de 1990 en la Clínica Lautaro, procedimiento adoptado en forma rutinaria en estos casos después de un estudio secuencial que demostrara significativamente las ventajas de esta técnica en comparación con la anestesia general en cuanto a la magnitud del dolor postoperatorio, empleo de analgésicos postoperatorios y costo. No hubo punciones fallidas. En cuatro casos se perforó la duramadre pero pudo completarse el procedimiento repitiendo la punción en un espacio adyacente. Se observaron dos fracasos (excitación incontrolable y efecto anestésico insuficiente) y tres complicaciones (depresión respiratoria profunda, bloqueo cardíaco con Stokes-Adams y retención urinaria rebelde) fácilmente tratables. El 97,5% de los pacientes no presentó incidentes y se manifestó muy complacido por los resultados anestésicos. Los pacientes se realimentaron precozmente y sólo necesitaron analgésicos postoperatorios de bajo costo en el 80% de los casos. El peligro potencial de la anestesia peridural con bupivacaína es probablemente menor que otras alternativas, sus resultados son más satisfactorios para todas las personas involucradas en el acto quirúrgico, sus costos son cuatro a cinco veces menores que los de la anestesia general y en consecuencia se estima procedente promover su empleo en centros bien dotados y como una alternativa menos mala en nosocomios modestos no atendisos por personal especializado

Comparación del efecto analgésico de la aspirina inyectable y del ketoprofeno en el postoperatorio inmediato / Comparisson of analgesic effect among inyectable aspirin and ketoprofene in the early postoperatory time

Se estudió en forma prospectiva y azarizada a un universo de 60 pacientes sometidos a cirugía mayor por uno de los autores, dividido en dos grupos según el analgésico utilizado por vía parenteral en el postoperatorio inmediato (acetil salicilato de lisina o ketoprofeno). La magnitud del dolor fue determinada por los mismos pacientes, en términos de fracción remanente del dolor experimentado antes de la inyección, consignándose dicho valor en intervalos de dos horas. Se establecieron normas rígidas para autorizar una nueva dosis del analgésico. El ketoprofeno mostró mayor eficacia en cuanto a magnitud y duración del efecto analgésico (p<0,05). Es posible que los analgésicos no narcóticos sean más convenientes que la morfina y similares para el dolor postoperatorio. Sin embargo, dada la característica variabilidad de sus efectos en dolores de diferentes causas, es necesario determinar mediante ensayos de este tipo cúal de las alternativas presenta más ventajas