Can Pharmacogenetic Variants in TPMT, MTHFR and SLCO1B1 Genes Be Used as Potential Markers of Outcome Prediction in Systemic Sclerosis Patients?

Systemic sclerosis (SSc) is a rare connective tissue disorder with highest morbidity and mortality among rheumatologic diseases. Disease progression is highly heterogeneous between patients, implying a strong need for individualization of therapy. Four pharmacogenetic variants, namely TPMT rs1800460, TPMT rs1142345, MTHFR rs1801133 and SLCO1B1 rs4149056 were tested for association with severe disease outcomes in 102 patients with SSc from Serbia treated either with immunosuppressants azathioprine (AZA) and methotrexate (MTX) or with other types of medications. Genotyping was performed using PCR-RFLP and direct Sanger sequencing. R software was used for statistical analysis and development of polygenic risk score (PRS) model. Association was found between MTHFR rs1801133 and higher risk for elevated systolic pressure in all patients except those prescribed with MTX, and higher risk for kidney insufficiency in patients prescribed with other types of drugs. In patients treated with MTX, variant SLCO1B1 rs4149056 was protective against kidney insufficiency. For patients receiving MTX a trend was shown for having a higher PRS rank and elevated systolic pressure. Our results open a door wide for more extensive research on pharmacogenomics markers in patients with SSc. Altogether, pharmacogenomics markers could predict the outcome of patients with SSc and help in prevention of adverse drug reactions.

Optical coherence tomography evaluation of late strut coverage patterns between first-generation drug-eluting stents and everolimus-eluting stent.

OBJECTIVES: To compare strut coverage patterns between everolimus-eluting stent (EES) and first-generation drug-eluting stents (DES) at more than 12 months after successful implantation, using optical coherence tomography (OCT). BACKGROUND: No sufficient OCT data has been reported comparing late strut coverage patterns between EES and first-generation DES. The favorable late results after EES implantation could be related to lower rates of uncovered and malapposed struts. METHODS: A total of 66 DES (21 EES, 23 SES, and 22 PES) that were implanted at least 1 year in advance in 40 patients and met good late angiographic results were evaluated by OCT. The percentage of uncovered and malapposed struts, calculated as the ratio of uncovered or malapposed struts to total struts in all cross-sectional images per stent, was compared among the three groups. RESULTS: A total of 35,061 struts were analyzed: 11,967 from EES, 11,855 from SES, and 11m239 from PES. The average tissue coverage thickness of the struts per stent was greater in EES than in SES and PES (109 ± 40 µm vs. 72 ± 27 µm and 83 ± 26 µm, respectively; P = 0.001). The percentage of uncovered struts (1.9 ± 4.1% in EES vs. 11.6 ± 12.7% in SES, P = 0.01 and vs. 7.1 ± 5.2% in PES, P < 0.001) and malapposed struts (0.1 ± 0.3% in EES vs. 1.8 ± 3.5% in SES, P = 0.01 and vs. 3.5 ± 5.1% in PES, P = 0.02) was much lower in EES than in first-generation DES, with no significant differences between SES and PES. CONCLUSIONS: Late strut coverage patterns are not similar between EES and first-generation DES. EES showed a lower percentage of uncovered and malapposed struts.

Long-term outcome of patients with isolated thin discrete subaortic stenosis treated by balloon dilation: a 25-year study.

BACKGROUND: Transluminal balloon tearing of the membrane in a thin discrete subaortic stenosis is an alternative to membrane surgical resection. However, the long-term outcome of patients with isolated thin discrete subaortic stenosis treated by transluminal balloon tearing remains unknown. METHODS AND RESULTS: This 25-year study describes findings from 76 patients with isolated thin discrete subaortic stenosis who underwent percutaneous transluminal balloon tearing of the membrane and were followed up for a mean period of 16±6 years. The age at presentation had a wide range (2-67 years). The mean age at treatment was 19±16 years. Immediately after treatment, the subvalvular gradient decreased from 70±27 to 18±12 mm Hg (P<0.001). No significant postprocedural aortic regurgitation was observed. After a mean follow-up time of 16±6 years, 11 patients (15%) developed restenosis, 3 patients (4%) progressed to muscular obstructive disease, and 1 patient (1.3%) developed a new distant obstructive membrane. Twelve patients (16%) were redilated at a mean of 5±3 years after their first treatment, and 4 patients (5%) underwent surgery at a mean of 3±2 years after their first treatment. Fifty-eight patients (77%) remained alive and free of redilation or surgery at follow-up. Larger annulus diameter and thinner membranes were independent factors associated with better long-term results. CONCLUSIONS: Most patients (77%) with isolated thin discrete subaortic stenosis treated with transluminal balloon tearing of the membrane had sustained relief at subsequent follow-ups without restenosis, the need for surgery, progression to muscular obstructive disease, or an increase in the degree of aortic regurgitation.

Diagnostic and Therapeutic Implications of Long Non-Coding RNAs in Leukemia.

Leukemia is a heterogenous group of hematological malignancies categorized in four main types (acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML) and chronic lymphocytic leukemia (CLL). Several cytogenetic and molecular markers have become a part of routine analysis for leukemia patients. These markers have been used in diagnosis, risk-stratification and targeted therapy application. Recent studies have indicated that numerous regulatory RNAs, such as long non-coding RNAs (lncRNAs), have a role in tumor initiation and progression. When it comes to leukemia, data for lncRNA involvement in its etiology, progression, diagnosis, treatment and prognosis is limited. The aim of this review is to summarize research data on lncRNAs in different types of leukemia, on their expression pattern, their role in leukemic transformation and disease progression. The usefulness of this information in the clinical setting, i.e., for diagnostic and prognostic purposes, will be emphasized. Finally, how particular lncRNAs could be used as potential targets for the application of targeted therapy will be considered.

Expression Profiles of Long Non-Coding RNA GAS5 and MicroRNA-222 in Younger AML Patients.

Acute myeloid leukemia (AML) is a heterogeneous malignant disease both on clinical and genetic levels. AML has poor prognosis and, therefore, there is a constant need to find new prognostic markers, as well as markers that can be used as targets for innovative therapeutics. Recently, the search for new biomarkers has turned researchers' attention towards non-coding RNAs, especially long non-coding RNAs (lncRNAs) and micro RNAs (miRNAs). We investigated the expression level of growth arrest-specific transcript 5 (GAS5) lncRNA in 94 younger AML patients, and also the expression level of miR-222 in a cohort of 39 AML patients with normal karyotype (AML-NK), in order to examine their prognostic potential. Our results showed that GAS5 expression level in AML patients was lower compared to healthy controls. Lower GAS5 expression on diagnosis was related to an adverse prognosis. In the AML-NK group patients had higher expression of miR-222 compared to healthy controls. A synergistic effect of GAS5low/miR-222high status on disease prognosis was not established. This is the first study focused on examining the GAS5 and miR-222 expression pattern in AML patients. Its initial findings indicate the need for further investigation of these two non-coding RNAs, their potential roles in leukemogenesis, and the prognosis of AML patients.

Somatostatin receptor scintigraphy in the follow up of neuroendocrine neoplasms of appendix.

BACKGROUND: Neuroendocrine tumors of appendix (ANETs) known as carcinoids, are rare endocrine neoplasms originated from enterochromaffin cells of gastrointestinal tract. ANETs are the third most frequent (16.7%) gastrointestinal neuroendocrine tumors, with the incidence of 0.08-0.2 cases/100000 during one year. Incidental ANETs occur in 0.2%-0.7% of emergency surgical resections because of suspected appendicitis which is usually the first manifestation of ANET. Although there are a lot of papers about application of somatostatin receptor scintigraphy in gastrointestinal neuroendocrine tumors, there are very rare sporadic cases described about ANETs particularly. AIM: To establish the role of somatostatin receptor scintigraphy (SRS) in the management of patients with neuroendocrine tumors of appendix (ANET). METHODS: The total of 35 patients was investigated, 23 females and 12 males, average age (43.7 ± 17.3 years). All patients had histological diagnosis of ANET (34 carcinoids of appendix and one tubular carcinoid). Majority of tumors have been found incidentally during surgery of: Acute appendicitis (n = 15), perforated appendicitis (n = 2), ileus (n = 3), hysterectomy (n = 3), ruptured ovarian cyst (n = 2), caecal volvulus (n = 1), while 9 patients had diagnosis of appendiceal tumor before the surgery. Seventeen patients had tumor grade (G) G1, 12 G2 and 6 G3. The right hemicolectomy was performed in 13, while the rest of the patients had appendectomy only. SRS was done early (2 h) and late (24 h) after i.v. application of 740 MBq technetium-99m ethylenediamine-N, N'-diacetic acid Hydrazinonicotinyl-Tyr3-Octreotide (technetium-99m-Tektrotyd, Polatom, Poland). SRS was performed for restaging in all the patients after surgery. RESULTS: There were 12 true positive (TP), 19 true negative, 3 false positive and 1 false negative SRS result. Sensitivity of the method was 92.31%, specificity was 86.36%, positive predictive value was 80.00%, negative predictive value was 95.00% and accuracy 88.57%. Receiver operating characteristics analysis showed that SRS scintigraphy is a good test for detection TP cases [area under the curve of 0.850, 95% confidence interval (CI): 0.710-0.990, P < 001]. Single photon emission computed tomography contributed diagnosis in 7 TP findings. In 10 patients Krenning score was 4 and in 2 was 3. In 8 patients SRS significantly changed the management of the patients (in two surgery was repeated, in 4 somatostatin analogues and in two peptide receptor radionuclide therapy). Median progression-free survival in SRS positive patients was 52 months (95%CI: 39.7-117.3 mo) while in SRS negative patients it was 60 months (95%CI: 42.8-77.1 mo), without statistically significant difference between the two groups (P = 0.434). CONCLUSION: In conclusion, our results confirmed the value of SRS in the follow-up of the patients with ANET after surgery, if recurrences or metastases are suspected.

Drug-eluting stents for the treatment of bifurcation lesions: a randomized comparison between paclitaxel and sirolimus stents.

BACKGROUND: Drug-eluting stents have been shown to reduce restenosis in many types of lesions. The purpose of this article is to assess the efficacy of sirolimus- and paclitaxel-eluting stents in patients with bifurcation lesions. METHODS: Between June 2003 and October 2004, 205 patients were enrolled in a prospective randomized trial; 103 patients were assigned to sirolimus stents and 102 patients to paclitaxel stents. All patients were treated by provisional T-stenting. RESULTS: There were no differences between groups in terms of age, risk factors, clinical condition, location of the bifurcation lesion, or other technical factors. Angiographic data and immediate results were also similar in both groups. Three patients developed inhospital non-Q-wave acute myocardial infarction (2 from the sirolimus group and 1 from the paclitaxel group). Follow-up angiography was obtained in 109 patients (53%). In the sirolimus group, 5 patients developed restenosis (9%): 1 at the main vessel, 2 at the side branch, and 2 in both branches. In contrast, 16 patients from the paclitaxel group had restenosis (29%): 6 at the main vessel, 5 at the side branch, and 5 in both branches. Target lesion revascularization at 24 +/- 5 months post stenting occurred in 4 patients from the sirolimus group (4%) and in 13 from the paclitaxel group (13%) (P < .05). Late loss at the main vessel in the sirolimus group patients was 0.31 +/- 0.59 versus 0.60 +/- 0.77 mm in patients from the paclitaxel group (P < .05). CONCLUSIONS: Patients with bifurcation lesions treated by sirolimus showed significantly lower rates of late loss, restenosis and target lesion revascularization than patients treated with paclitaxel-eluting stents.

Atrioventricular Conduction Changes After CoreValve Transcatheter Aortic Valve Implantation.

INTRODUCTION AND OBJECTIVES: Conduction disturbances often occur after CoreValve transcatheter aortic valve implantation. The aim was to analyze which cardiac conduction changes occur in patients with aortic stenosis treated with this type of prosthesis. METHODS: A total of 181 patients with severe aortic stenosis treated with this prosthesis and studied by electrocardiography between April 2008 and December 2013 were selected. A subgroup of 137 (75.7%) consecutive patients was studied by intracardiac electrocardiogram before and after prosthesis implantation. The primary endpoint of the study was the need for a permanent pacemaker within 72 hours after prosthesis implantation. Numerous variables to predict this possibility were analyzed. RESULTS: Following implantation, PR and QRS intervals were increased from 173±47 ms to 190±52ms (P < .01) and from 98±22ms to 129±24 ms (P < .01), whereas the A-H and H-V intervals were prolonged from 95±39ms to 108±41ms (P < .01) and from 54±10ms to 66±23ms (P < .01). A total of 89 (49%) patients had new-onset left bundle-branch block, and 33 (25%) required a pacemaker within the first 72hours. The independent predictors for a pacemaker were baseline right bundle-branch block and prosthetic depth. Intracardiac intervals had no predictive value. In addition, 13 patients required a pacemaker after 72 hours. CONCLUSIONS: CoreValve prosthesis implantation has a high incidence of conduction disturbance, with left bundle-branch block being the most common. A total of 25% of patients required a permanent pacemaker. The need for a pacemaker was related to baseline right bundle-branch block and prosthetic depth.

Effect of New-Onset Left Bundle Branch Block After Transcatheter Aortic Valve Implantation (CoreValve) on Mortality, Frequency of Re-Hospitalization, and Need for Pacemaker.

New-onset conduction disturbances are common after transcatheter aortic valve implantation (TAVI). The most common complication is left bundle branch block (LBBB). The clinical impact of new-onset LBBB after TAVI remains controversial. The aim of this study was to analyze the clinical impact of new-onset LBBB in terms of mortality and morbidity (need for pacemakers and admissions for heart failure) at long-term follow-up. From April 2008 to December 2014, 220 patients who had severe aortic stenosis were treated with the implantation of a CoreValve prosthesis. Sixty-seven of these patients were excluded from the analysis, including 22 patients with pre-existing LBBB and 45 with a permanent pacemaker, implanted previously or within 72 hours of implantation. The remaining 153 patients were divided into 2 groups: group 1 (n = 80), those with persistent new-onset LBBB, and group 2 (n = 73), those without conduction disturbances after treatment. Both groups were followed up at 1 month, 6 months, 12 months, and yearly thereafter. Persistent new-onset LBBB occurred in 80 patients (36%) immediately after TAVI; 73 patients (33%) did not develop conduction disturbances. The mean follow-up time of both groups was 32 ± 22 months (range 3 to 82 months), and there were no differences in time between the groups. There were no differences in mortality between the groups (39% vs 48%, p = 0.58). No differences were observed between the groups in re-hospitalizations for heart failure (11% vs 16%, p = 0.55). Group 1 did not require pacemaker implantation more often at follow-up (10% vs 13%, p = 0.38) than group 2. In conclusion, new-onset LBBB was not associated with a higher incidence of late need for a permanent pacemaker after CoreValve implantation. In addition, it was not associated with a higher risk of late mortality or re-hospitalization.

Sirolimus-eluting stents for treatment of in-stent restenosis: immediate and late results.

We analyzed the clinical, angiographic, and late intravascular ultrasonographic findings from 140 patients whose in-stent restenosis was treated with sirolimus-eluting stents. In-stent restenosis remains the main limitation to percutaneous coronary revascularization and has a high recurrence rate after bare stent implantation. From May 2002 through July 2003, we studied 140 patients with clinical restenosis after bare-stent treatment. In 107 patients, in-stent restenosis occurred de novo; in 28 patients, this was the 2nd restenosis; and in another 5, it was the 3rd occurrence. A sirolimus-eluting stent was implanted directly after angiographic evaluation of the in-stent restenosis in 79 patients and after pre-dilation in 61 patients. All patients were given the following antithrombotic regimen: low-molecular-weight heparin, ticlopidine, and aspirin for 1 month, followed by clopidogrel and aspirin for 1 year. Primary success was achieved in 137 patients. Three patients had a non-Q wave myocardial infarction. At the 1-month evaluation, 2 patients had died: 1 due to subacute stent thrombosis and another due to acute mesenteric ischemia. After a mean follow-up of 16 +/- 4 months, the major adverse cardiac events were acute myocardial infarction due to late stent thrombosis in 2 patients and the need for target lesion revascularization in 15 patients. Late angiographic evaluation was performed in 97 patients (69%), 16 of whom had new restenosis: 14 of the restenoses were intrastent, and 2 were at the edges of the stent. Our results suggest that sirolimus-eluting stents are effective in the prevention of in-stent restenosis and, therefore, may become the leading treatment alternative for patients with in-stent restenosis.

[Effects of stem-cell mobilization with recombinant human granulocyte colony stimulating factor in patients with percutaneously revascularized acute anterior myocardial infarction]. / Efectos de la movilización de células madre mediante el uso de factor estimulante de colonias granulocíticas en pacientes con infarto agudo de miocardio anterior revascularizado percutáneamente.

INTRODUCTION AND OBJECTIVES: This study reports the findings in a group of 13 patients aged 53+/-8 years with anterior wall acute myocardial infarction who were revascularized with stents and treated with recombinant human granulocyte colony stimulating factor (G-CSF). PATIENTS AND METHOD: Patients were initially treated with intravenous thrombolytics. The first cardiac catheterization was performed between days 0 and 5 after acute myocardial infarction, when the left anterior descending artery was stented. A 10-day course of 10 .g/kg/day G-CSF was started 5 days after acute myocardial infarction. Blood cell counts and immunophenotyping were done to assess the total number of circulating CD34+ cells and their subpopulations in serial fashion. At 3-month follow-up, cardiac catheterization was repeated. Functional recovery was defined as an increase in ejection fraction. RESULTS: All patients did well initially, but 1 had spontaneous spleen rupture on day 8 of G-CSF administration, which required emergency splenectomy. The gain in ejection fraction varied among patients from -22 to +18 (mean, 6.2%+/-12%), and correlated directly with the total number of circulating CD34+ CD38- cells/microL on the fifth day of G-CSF treatment (r=0.78; P<.003). The gain in ejection fraction correlated inversely with peak MB fraction creatine kinase (r=-0.82; P<.002). CONCLUSION: Stem-cell mobilization with G-CSF is a feasible and safe treatment for patients with revascularized acute myocardial infarction. However, because of the possibility of acute splenitis induced by massive cell mobilization, future studies should be designed with due caution to take this eventuality into account.

[Interventional cardiology. Where are we and where are we going from here?]. / Intervencionismo percutáneo. Dónde estamos y adónde vamos?

This article summarizes 20 years of percutaneous interventional cardiology for coronary angioplasty. During this period, interventional cardiology has evolved faster than any other type of treatment in the field of cardiovascular diseases. We describe the early results of interventional cardiology, the increase in primary success rates and the reduction in complication rates for percutaneous techniques during this period, which coincided with the introduction of technological advances. In the early 1990s, primary success rates for the treatment of coronary lesions stood at 86%-88%, with a restenosis rate of 30%-40% at 6-month follow-up. Current primary success rates have risen to over 95% with a restenosis rate of under 10%, even for many types of lesions classically considered complex. Currently the main limitations in interventional cardiology remain coronary segments that cannot be accessed due to chronic total occlusion, or severe proximal tortuosity or calcification. Rapid improvements have led to broader clinical indications for percutaneous revascularization procedures, and have made frequent updates of clinical practice guidelines necessary. Meanwhile, comparative studies involving other modes of surgical revascularization have become extremely difficult because percutaneous methods used in long-term studies begun 5 to 10 years have become obsolete.

[Six-month intravascular ultrasound follow-up of coronary bifurcation lesions treated with rapamycin-eluting stents: technical considerations]. / Ecografía intracoronaria durante el seguimiento en la valoración de stents liberadores de rapamicina para el tratamiento de las lesiones en bifurcación: implicaciones técnicas.

INTRODUCTION AND OBJECTIVES: In vitro studies show that stents deform when dilated laterally to access a side branch. This phenomenon may be avoided by use of a kissing balloon at the end of the procedure. However, to date, no in vivo data are available. Our objectives were to investigate the main vessel stent using intravascular ultrasound (IVUS) at six-month follow-up in 55 patients with bifurcation lesions treated using rapamycin-eluting stents and to examine the effect of technical factors. PATIENTS AND METHOD: All patients were treated using provisional or T stents. At 6 months, IVUS measurements were made in the main vessel at both proximal and distal ends of the stent, in reference segments, immediately below the side branch ostium, and at the points where the lumen was smallest and where stent expansion was greatest. RESULTS: The lumen area immediately below the side branch ostium was significantly smaller than that at the point of maximum stent expansion (6.7 [1.8] vs 5.1 [1.3] mm2; P<.05). Underexpansion was not influenced by use of a kissing balloon (stent area immediately under the side branch ostium: 5.5 [0.9] vs 5.6 [1.6] mm2; P=NS) and only one patient experienced restenosis at this point. The lumen areas at the proximal and distal edges of the stent were almost identical in patients who did or did not undergo balloon dilation beyond the ends of the stent. CONCLUSIONS: Stent underexpansion below the side branch ostium was frequently found following provisional or T stenting of bifurcation lesions. This minor stent deformity was not prevented by use of a kissing balloon nor by any specific side branch treatment and had no significant impact on the restenosis rate.

Stent Repair for Complex Coarctation of Aorta.

OBJECTIVES: This study sought to determine whether several anatomic or evolving characteristics of the coarctation may create challenging conditions for treatment. BACKGROUND: Stent repair of coarctation of aorta is an alternative to surgical correction. METHODS: We analyzed our 21-year experience in the percutaneous treatment of complex coarctation of aorta. Adverse conditions for treatment were as follow: 1) complete interruption of the aortic arch (n = 11); 2) associated aneurysm (n = 18); 3) complex stenosis (n = 30); and 4) the need for re-expansion and/or restenting (n = 21). Twenty patients (33%) belonged to more than 1 group. Ten interruptions were type A and 1 was type B. The mean length of the interrupted aorta was 9 ± 11 mm. The associated aneurysms were native in 8 patients and after previous intervention in 10 patients. Aneurysm shapes were fusiform in 8 patients and saccular in 10. The following characteristics defined complex stenosis as long diffuse stenosis, very tortuous coarctation, or stenosis involving a main branch or an unusual location. Patients previously stented at an early age, required re-expansion and/or restenting after reaching 16 ± 5 years of age. RESULTS: Two patients had died by 1-month follow-up. The remaining 58 patients did well and were followed-up for a mean period of 10 ± 6 years. Late adverse events occurred in 3 patients (5%). All remaining patients are symptom-free, with normal baseline blood pressure. Imaging techniques revealed good patency at follow-up without associated aneurysm or restenosis. The actuarial survival free probability of all complex patients at 15 years was 92%. CONCLUSIONS: Stent repair of complex coarctation of aorta is feasible and safe. Initial results are maintained at later follow-up.

Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy.

BACKGROUND: Rapamycin-eluting stents (RES) have been shown to reduce restenosis in many types of lesions. However, the ideal strategy for the treatment of coronary bifurcated lesions has not been established to date. This randomized study compares 2 strategies for the RES treatment of bifurcation lesions: a simple approach (stenting the main vessel and balloon dilatation for the side branch [SB]) versus a complex approach (stents for both vessels). METHODS: To compare both strategies, a randomized study was conducted in 91 patients with true coronary bifurcation lesions. All patients received an RES at the main vessel, covering the SB. Patients from group A (n = 47) were assigned to balloon dilation of the involved SB (simple strategy); patients in group B (n = 44) were randomized to receive a second stent at the SB origin (complex strategy). There were no differences between groups regarding baseline clinical and angiographic data. RESULTS: Major adverse cardiac events occurred in 3 patients from group A (2 non-Q-wave myocardial infarctions and 1 target lesion revascularization). Six-month angiographic reevaluation was obtained in 80 patients (88%). Restenosis of the main vessel was observed in 1 (2%) patient from group A and in 4 (10%) from group B. Restenosis of the SB appeared in 2 (5%) patients from group A and in 6 (15%) from group B. CONCLUSIONS: Both strategies are effective in reducing the restenosis rate, with no differences in terms of clinical outcome. Elective SB stenting seems to provide no advantages over the simpler stent jail followed by SB balloon dilation.

Rapamycin-eluting stents for the treatment of unprotected left main coronary disease.

BACKGROUND: Conventional bare stents have been used to treat unprotected left main (LM) coronary artery stenosis. However, restenosis remains the main limitation. Since rapamycin-eluting stents (RES) appear to inhibit neointimal proliferation, their application to this specific site seems promising. METHODS: Since May 2002, we have studied a series of 52 patients with LM lesions treated with RES. Forty-seven patients presented with de novo stenoses, and 5 had in-stent restenosis; 19 patients required combined stent treatment for other remote lesions in the coronary tree, 6 of them at the level of proximal right coronary artery. The RES was implanted directly at the LM in 39 patients; 13 others needed predilation. Once deployed, the RES was overexpanded with short balloons adjusted to the LM length in 44 patients. Quantitative coronary angiograms were analyzed in the same view before and immediately after treatment and at follow-up. Patients were followed-up closely and new cardiac catheterization was scheduled at 6-month evaluation or earlier in the presence of symptoms. At follow-up study, quantitative coronary angiography and motorized intravascular ultrasound analyses were performed in 35 (67%) patients. RESULTS: Primary success was obtained in 50 patients (96%). Two patients (4%) developed a non-Q-wave myocardial infarction. All patients were symptom-free at discharge. After a mean follow-up of 12 +/- 4 months, 50 patients (96%) remain asymptomatic. No late death or acute thrombosis have been recorded. Two patients became symptomatic 2 and 4 months after treatment, respectively. One had restenosis at a remote site, while the other had in-segment restenosis. None of the remaining 33 angiographically evaluated patients developed restenosis at any site. Target lesion revascularization was 1/52 (2%). CONCLUSIONS: Although longer-term follow-up studies are needed, the tailored treatment of coronary lesions located at the LM by overexpanded RES is feasible and safe. Midterm results seem promising, which might help to shift the orientation of patient management from surgical to percutaneous revascularization.

Effectiveness of percutaneous device occlusion for atrial septal defect in adult patients with pulmonary hypertension.

BACKGROUND: Adult patients with atrial septal defect (ASD) and pulmonary hypertension have a more advanced degree of disease, frequently having functional class deterioration and atrial arrhythmias when they are aged >40 years. Surgery at this age prolongs life expectancy and limits functional deterioration. Although percutaneous ASD device occlusion is an accepted alternative to surgery, there is limited information on the immediate and long-term effects of device occlusion in middle-aged and elderly patients with ASD and pulmonary hypertension. METHODS: From a total of 101 patients with secundum ASD who were receiving treatment with percutaneous device occlusion, we selected for analysis 29 adult patients (mean age 56 +/- 14 years) with a baseline peak pulmonary pressure of >40 mm Hg (mean 65 +/- 23 mm Hg). Three of the patients had suprasystemic pulmonary pressure and a bidirectional shunt. Six patients were asymptomatic at treatment. The remaining 23 had different degrees of dyspnea; 14 of them had an advanced New York Heart Association functional class (III-IV). Twelve patients had chronic atrial fibrillation. At cardiac catheterization, the mean ratio of pulmonary to systemic flow was 1.8 +/- 0.5, and the pulmonary-to-systemic pressure ratio was 0.66 +/- 0.22. The mean diameter of the defect, as evaluated by the stretching balloon method, was 26 +/- 7 mm. All patients received an Amplatzer septal occluder (Golden Valley, Minn). Seven patients had combined therapeutic procedures for associated anomalies before the implant: mitral balloon valvuloplasty (n = 1), stent coronary revascularization (n = 1), stent in pulmonary vein stenosis (n = 1), and internal catheter defibrillation (n = 4). After treatment, patients were followed up by clinical and echocardiographic Doppler studies every 6 months. RESULTS: Immediately after the implantation, the peak systolic pulmonary pressure significantly decreased to 54 +/- 21 mm Hg (P <.001). A clear improvement in functional status was observed after the treatment in all symptomatic patients, especially in those with refractory heart failure. There were no major complications. Six patients who had atrial fibrillation at baseline study recovered to a stable sinus rhythm after treatment, and it was maintained at discharge. Complete ASD occlusion by echocardiographic Doppler at discharge was observed in 28 patients (97%). After a mean follow up of 21 +/- 14 months, clinical improvement persisted in all previously symptomatic patients, and the peak systolic pulmonary pressure, obtained by echocardiographic Doppler, further decreased to 31 +/- 11 mm Hg (P <.001) compared with baseline and immediately after hemodynamic measurements. CONCLUSIONS: Our findings suggest that percutaneous device occlusion of ASD in adult patients with pulmonary hypertension is safe and effective and provides significant and prolonged relief.

[Percutaneous closure of large atrial septal defects]. / Cierre percutáneo de comunicaciones interauriculares grandes.

BACKGROUND: Percutaneous occlusion of secundum type atrial septal defect with an Amplatzer device is an effective treatment alternative. However, there is little information about the use of this treatment for large defects. PATIENTS AND METHOD: We retrospectively analyzed the initial and follow-up findings in 31 patients aged 41 18 years who had large atrial septal defects (>= 30 mm diameter). Mean defect diameter evaluated by the balloon occlusion method was 33.4 3.4 mm (range, 30-40 mm). In all patients we attempted the implantation of an Amplatzer septal occluder. RESULTS: The implant was successful in 23 patients (74%); 3 of whom had a double orifice. The size of the device was 34 3 mm diameter (range, 30-38 mm). Combined associated procedures were balloon pulmonary valvuloplasty in 3 patients and coronary stent implantation in 1. In 4 out of 8 patients where we failed, the implant was attempted but the device was unstable so we decided to retrieve it; in the remaining 4 patients, balloon measurement alone contraindicated the procedure. All patients did well, but one had cardiac tamponade during the procedure that was resolved in the catheterization laboratory. After 15 12 months of follow-up all 31 patients were alive and those who had functional limitation before treatment remained stable, with significant clinical improvement. CONCLUSIONS: Percutaneous device occlusion of large atrial septal defects is feasible and effective in most patients.

[Late recovery of coronary flow reserve in patients successfully treated with a percutaneous procedure]. / Recuperación tardía de la reserva coronaria en pacientes tratados con éxito mediante revascularización peructánea.

INTRODUCTION AND OBJECTIVES: Coronary angiograms are of limited value for the assessment of the results of percutaneous interventions. Intracoronary Doppler studies have been used to overcome these difficulties. The achievement of a coronary flow reserve (CFR) > 2-2.5 after the procedure is considered a good result and further optimization is generally not required. However, coronary flow reserve may not recover immediately, despite optimal procedural results. The aim of this study is to assess the temporal course of the recovery of coronary flow reserve after successful revascularization. PATIENTS AND METHOD: We studied 34 patients with coronary heart disease who were successfully treated by balloon angioplasty (n = 8) or stent implantation (n = 26). In all patients, serial observations were made by quantitative angiography and intracoronary Doppler (0.014 = flow-wire). Patients were studied: a) before treatment; b) immediately after, and c) 8 3 months later. RESULTS: The baseline coronary flow reserve was 1.3 0.4 and increased to 2.4 0.8 after the procedure (p < 0.01). At 8 months follow-up there was a significant increase (3 0.8; p < 0.01). This late improvement in coronary flow reserve was associated with a decline in average peak velocity at follow-up. Patients with impaired CFR immediately after treatment had a greater increase in CFR during followup than those with CFR > 2 after treatment (1.4 0.9 vs 0.4 0.6; p < 0.01). CONCLUSIONS: After a successful coronary intervention, CFR increases immediately, but some patients may experience additional improvement during follow-up. This increase was greater in patients who showed less improvement in coronary flow reserve immediately after treatment. Our findings suggest that the use of Doppler parameters in the immediate assessment of percutaneous coronary intervention results have limitations.

Immediate results and long-term clinical outcome of patients with unprotected distal left main restenosis: the CORPAL registry (Córdoba and Las Palmas).

OBJECTIVES: The goal of this study was to assess the immediate and long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) in an unprotected distal left main coronary artery (UDLM). BACKGROUND: PCI for UDLM-ISR can be complex. Limited information is available on procedural and clinical outcomes. METHODS: Between May 2002 and February 2011, UDLM-ISR after drug-eluting stent implantation was observed in 79 of 1,102 patients (7%). Seventy-five were treated by repeat PCI using a simple approach (balloon/in-stent implantation) or a complex strategy (additional stent/double-stenting technique). A diagnosis of mild or severe restenosis was considered depending on the number of bifurcation segments affected (1 vs. >1). Major adverse cardiac events (MACE) were defined as cardiac death, target lesion revascularization, and myocardial infarction. RESULTS: ISR treatment was performed using a simple approach in 44 (58%) patients, and using a complex strategy in 31 (42%). After 46 ± 26 months, the MACE rate was 22%. Patients treated with a simple approach had a lower incidence of MACE at follow-up compared with patients treated with a complex strategy, regardless of the restenosis extent (mild restenosis: 93% vs. 67%, p < 0.05; severe: 70% vs. 23%, p < 0.05). On Cox regression analysis, diabetes was the only predictor of MACE (hazard ratio [HR]: 4.94; 95% confidence interval [CI]: 1.03 to 23.70; p < 0.05), whereas a simple strategy for ISR treatment was associated with lower risk (HR: 0.25; 95% CI: 0.08 to 0.79; p = 0.02). CONCLUSIONS: PCI for UDLM-ISR is safe and feasible, with a high rate of procedural success and an acceptable long-term MACE rate. A simple strategy, when applicable, appears to be a good treatment option, associated with a lower event rate at follow-up.