Results of percutaneous drug-eluting stent implantation for unprotected left main coronary disease according to left ventricular systolic function.

OBJECTIVES: We aimed to appraise the early and long-term outcome after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in patients with unprotected left main disease (ULM) and left ventricular systolic dysfunction (LVD). BACKGROUND: PCI with DES has being performed with increasing frequency in subjects with ULM and LVD, but few specific data are available. SETTING AND PATIENTS: We identified patients undergoing PCI with DES for ULM at our Center and distinguished those with ejection fraction (EF) >50% from those with 40% 50%, 32.0% with 40% 50%, 41.6% in those with 40%

Early and long-term results of percutaneous coronary intervention for unprotected left main trifurcation disease.

OBJECTIVES: We aimed to conduct a retrospective cohort study focusing on our 5-year experience in the percutaneous treatment of unprotected left main (ULM) trifurcation disease. BACKGROUND: Percutaneous treatment of ULM trifurcation remains a challenging and rare procedure for most interventional cardiologists. Moreover, data on long-term outcomes are lacking. METHODS: We retrieved all patients with ULM trifurcation disease treated percutaneously at our Institution since 2002, and adjudicated baseline, procedural, and outcome data. The primary end point was the long-term rate of major adverse cardiovascular events (MACE, i.e., cardiac death, myocardial infarction, bypass surgery, or target vessel revascularization). RESULTS: A total of 27 patients underwent percutaneous coronary intervention with stent implantation for ULM trifurcation disease, with 14 (52%) cases of true trifurcations, i.e., with concomitant significant stenoses of the distal ULM/ostial left anterior descending plus ostial ramus intermedius and ostial circumflex. Bare-metal stents were implanted in 8 (29%) patients and drug-eluting stents (DES) in 26 (96%), with a main branch stent only strategy in 11 (40%), T stenting in 9 (33%), and V stenting in 6 (27%). Procedural and clinical success occurred in 26 (96%), with one postprocedural death. Angiographic follow-up was obtained in 22 patients (81%), and clinical follow-up was completed in all subjects after a median of 28 +/- 17 months, showing overall MACE in 9 (33%), with cardiac death in 4 (15%), myocardial infarction in 1 (4%), coronary artery bypass grafting (CABG) in 4 (15%), and percutaneous target vessel revascularization in 5 (19%). Definite stent thrombosis was adjudicated in 1 (3%) patient. Treatment of a true trifurcation lesion and recurrence of angina during follow-up were significantly associated with an increased risk of MACE (P = 0.029 and P = 0.050, respectively). CONCLUSIONS: Percutaneous treatment of ULM trifurcation disease is feasible, associated with favorable mid-term results, and may be considered given its low invasiveness in patients at high surgical risk or with multiple comorbidities.

Very long-term results comparing a simple versus a complex stenting strategy in the treatment of coronary bifurcation lesions.

BACKGROUND: The optimal stenting strategy for coronary bifurcation lesions has not yet been defined, especially given the lack of very long-term data (>24 months). We compared our long-term results of a simple vs complex stenting strategy in patients with bifurcation lesions. METHODS: We retrospectively selected subjects undergoing percutaneous coronary intervention (PCI) with stenting in a bifurcation lesion between June 2002 and December 2005, comparing those treated with a simple technique vs those treated with a complex one. The primary end-point was the rate of major adverse cardiac events (MACE) at >24 months of follow-up. RESULTS: A total of 326 patients were included, 64.7% treated with a simple technique (Group A) and 35.3% with a complex strategy (Group B). Drug-eluting stents were used in 82.0% and 73.0%, respectively (P = 0.059), final kissing balloon in 47.9% and 53.0% (P = 0.37), and procedural success obtained in 99.5% and 99.1% (P = 0.66). After a median of 34 months, MACE occurred in 52 (26.5%) in Group A and in 32 (31.4%) in Group B (P = 0.37), cardiac death in six (3.1%) vs four (3.9%, P = 0.70), myocardial infarction in 13 (6.6%) vs 6 (5.9%, P = 0.80), target vessel revascularization in 36 (18.4%) vs 29 (28.4%, P = 0.04), and bypass in five (2.6%) vs two (2%, P = 0.74). Definite stent thrombosis was adjudicated in two (1%) vs one (0.9%, P = 0.98). CONCLUSIONS: This study, comparing simple and complex stenting strategies for the treatment of coronary bifurcation lesions, shows that both techniques are associated with favorable clinical results and low adverse events rates at long-term follow-up.

Update on dedicated bifurcation stents.

Coronary bifurcation lesions represent an area of ongoing challenge in interventional cardiology. Contemporary studies using drug-eluting stents report a reduction in main vessel (MV) restenosis; however, residual stenosis and restenosis at side-branch ostium remain an issue. Multiple two-stent bifurcation strategies exist, including T-stenting, V-stenting, simultaneous kissing stenting, culotte stenting, and crush stenting technique. Each strategy has its own advantages and disadvantages, but on the basis of results of numerous randomized trials, the provisional approach of implanting one stent on the main branch has became the default approach to most bifurcation lesions. Dedicated bifurcation stents have been designed to specifically address some of the shortcomings of the conventional percutaneous approach to bifurcation intervention. The majority of the devices are aimed at facilitating the provisional approach. Dedicated bifurcation stents should enable all operators to treat the side-branch ostium simultaneously with the main branch, preserving a safe, permanent access to side branch during the procedure. In the future, the use of these new devices will probably enhance the interaction between adequate mechanical scaffolding and accurate delivery of the appropriate dosage of any new antirestenosis drugs. There are currently 11 devices available that either have completed or are undergoing first-in-man trials. The development of further drug-eluting platforms and larger controlled studies should demonstrate their clinical applicability, efficacy, and safety before they are widely incorporated into daily practice.

A long-term comparison of drug-eluting versus bare metal stents for the percutaneous treatment of coronary bifurcation lesions.

BACKGROUND: After the first exciting results on drug-eluting stents (DES), many concerns have been raised on their potential risk for late stent thrombosis. Whereas DES appear beneficial at early and mid-term for coronary bifurcation lesions, no data are available on their long-term safety in this setting in comparison to bare metal stents (BMS). We thus aimed to appraise the long-term (> 2 years) outcomes of patients with bifurcation lesions treated with DES vs. BMS. METHODS: We abstracted baseline, procedural and follow-up data on all patients with bifurcation coronary lesions (both branches with reference vessel diameter > 2.0 mm) treated with stent implantation at our centre. The primary end-point was the long-term (> 2 years) rate of major adverse cardiac events (MACE, i.e. cardiac death, myocardial infarction, coronary artery bypass grafting and target vessel revascularization). RESULTS: A total of 315 patients and 334 lesions were included, 84.4% treated with DES, and 15.6% treated with BMS. The side branch was stented in 108 cases, according to a provisional T in 76 (22.7%), crushing in 15 (4.5%),V in 14 (4.2%), and culottes in 1 (0.3%). In-hospital MACE occurred in 4 (1.5%) patients of the DES group and 2 (4.1%) of the BMS group (P = 0.22). After 35.8 +/- 12.9 months, MACE were 72 (27.1%) vs. 24 (49%), respectively (P = 0.002), with cardiac death in 7 (2.6%) patients vs. 3 (6.1%, P = 0.20), myocardial infarction in 12 (4.5%) vs. 6 (12.2%, P = 0.42), coronary artery bypass grafting in 5 (1.9%) vs. 1 (2%, P = 0.93), target lesion revascularization in 30 (11.3%) vs. 13 (26.5%, P = 0.0042), and target vessel revascularization in 48 (18%) vs. 13 (26.5%, P = 0.16). Definite stent thrombosis occurred in 2 (0.75%) patients in the DES group vs. 1 (2%, P = 0.93) in the BMS group, whereas probable stent thrombosis was adjudicated in 5 (1.9%) vs. 2 (4%, P = 0.93). CONCLUSION: This cohort study, reporting for the first time on the long-term outlook of patients treated with DES vs. BMS for coronary bifurcation lesions, supports the overall safety and efficacy of DES in comparison to BMS. Specifically, even after several years of follow-up, repeat revascularizations appeared significantly lower with DES, and stent thromboses occurred with equivalent frequency in both DES and BMS groups.

Systematic review and meta-analysis of randomized clinical trials appraising the impact of cilostazol after percutaneous coronary intervention.

BACKGROUND: Drug-eluting stents reduce the risk of restenosis after percutaneous coronary intervention (PCI) but may pose a risk of thrombosis. Cilostazol, an oral antiplatelet agent with pleiotropic effects including inhibition of neointimal hyperplasia, could hold the promise of preventing both restenosis and thrombosis. We systematically reviewed randomized clinical trials (RCTs) on the angiographic and clinical impact of cilostazol after PCI. METHODS: We searched RCT in BioMedCentral, CENTRAL, clinicaltrials.gov, EMBASE, and PubMed (November 2007). Coprimary end points were binary angiographic restenosis and repeat revascularization, abstracted and pooled by means of random-effect relative risks (RRs). Small study/publication bias was appraised with multiple methods. RESULTS: A total of 23 RCTs were included (5428 patients), with median follow-up of 6 months. Pooled analysis showed that cilostazol was associated with statistically significant reductions in binary angiographic restenosis (RR = 0.60 [0.49-0.73], P < .001) and repeat revascularization (RR = 0.69 [0.55-0.86], P = .001). Cilostazol appeared also safe, with no significant increase in the risk of stent thrombosis (RR = 1.35 [0.71-2.57], P = .36) or bleeding (RR = 0.71 [0.43-1.16], P = .17). However, small study bias was evident for both binary restenosis (P < .001) and repeat revascularization (P < .001), suggesting that at least part of the apparent benefits of cilostazol could be due to this type of confounding effect. CONCLUSIONS: Cilostazol appears effective and safe in reducing the risk of restenosis and repeat revascularization after PCI, but available evidence is limited by small study effects. Awaiting larger RCTs, this inexpensive treatment can be envisaged in selected patients in which drug-eluting stents are contraindicated or when there is a need for neointimal hyperplasia inhibition.

A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease.

BACKGROUND: Cardiac surgery is the standard treatment for unprotected left main disease (ULM). Drug-eluting stent (DES) implantation has been recently reported in patients with ULM but with unclear results. We systematically reviewed outcomes of percutaneous DES implantation in ULM. METHODS: Several databases were searched for clinical studies reporting on > or = 20 patients and > or = 6-month follow-up. The primary end point was major adverse cardiovascular events (MACEs; ie, death, myocardial infarction, or target vessel revascularization [TVR]) at the longest follow-up. Incidence and adjusted risk estimates were pooled with generic inverse variance random-effect methods (95% CIs). RESULTS: From 823 initial citations, 16 studies were included (1278 patients, median follow-up 10 months). Eight were uncontrolled registries, 5 nonrandomized comparisons between DES and bare-metal stents and 3 nonrandomized comparisons between DES and CABG, with no properly randomized trial. Meta-analysis for DES-based PCI showed, at the longest follow-up, rates of 16.5% (11.7%-21.3%) MACE, 5.5% (3.4%-7.7%) death, and 6.5% (3.7%-9.2%) TVR. Comparison of DES versus bare-metal stent disclosed adjusted odds ratios for MACE of 0.34 (0.16-0.71), and DES versus CABG showed adjusted odds ratios for MACE plus stroke of 0.46 (0.24-0.90). Meta-regression showed that disease location predicted MACE (P = .001) and TVR (P = .020), whereas high-risk features predicted death (P = .027). CONCLUSIONS: Clinical studies report apparently favorable early and midterm results in selected patients with ULM. However, given their limitations in validity and the inherent risk for DES thrombosis, results from randomized trials are still needed to definitely establish the role of DES implantation instead of the reference treatment, surgery.

[Management of heart failure in Piedmont Region]. / La gestione ambulatoriale dello scompenso cardiaco cronico nella Regione Piemonte.

BACKGROUND: Congestive heart failure (CHF) represents an emerging problem in industrialized countries: it continues to be diagnosed at high rates and has an decreased survival time, raising new problems, such as the need of an adequate medical service organization and resource expenditure. Aim of this analysis was a quantitative evaluation of diagnostic and therapeutic resource use for CHF in outpatient departments in Piedmont, Italy. METHODS: We performed a cross-sectional observational study, based on a two-month data collection in 12 outpatient departments dedicated to congestive heart failure. Information was obtained on each patient using a specific anonymous data collection form. RESULTS: We obtained and analyzed for the study 547forms. Mean patient age was 66.1 years, mean ejection fraction was 36.6%. Coronary artery disease accounted for 34.6% of congestive heart failure cases, followed by idiopathic etiology (26.4%). Main comorbidities were diabetes (22.3%) and chronic obstructive pulmonary disease (17.7%). Sixty-nine% of patients received a medical treatment with angiotensin-converting enzyme (ACE) inhibitors, 72.6% with beta-blockers, 48.8% with aldosterone antagonists. As far as diagnostic resource use during a six-month period preceeding observation, 46.8% of patients underwent echocardiographic examination, 9.9% Holter ECG, 6.0% coronary angiography. Therapy was more often increased in patients who underwent an instrumental evaluation during the preceeding six-month period. CONCLUSIONS: Data suggests that in Piedmont outpatients with chronic heart failure receive a high drug prescription level and a small number of instrumental evaluations, as suggested in main international guidelines.

Long-term clinical and angiographic outcomes of treatment of unprotected left main coronary artery stenosis with sirolimus-eluting stents.

Favorable early results of percutaneous drug-eluting stents in unprotected left main (LM) disease are available, but outcome data beyond 6 to 10 months are lacking. We evaluated the long-term results of sirolimus-eluting stents (SESs) in patients with LM disease. From November 2002 to December 2004, consecutive patients with LM disease, without contraindications to double antiplatelet therapy and undergoing SES implantation, were enrolled prospectively. The primary end point of the study was occurrence of major adverse cardiovascular events. In total 85 patients were treated with 118 SES and followed for 595 +/- 230 days. Event-free survival rates at 1 year and 2 years were 85.5% and 78.6%, respectively. Only 2 deaths occurred overall (2.4%), the first in-hospital in a very high-risk patient according to the European System for Cardiac Operative Risk Evaluation and the second in a patient with severe systolic dysfunction already at the index procedure). Myocardial infarction was adjudicated in 3 patients (3.6%), 2 occurring periprocedurally and 1 during follow-up for a de novo nontarget lesion. There were 7 (10.8%) target lesion revascularizations at 24 months, with all but 1 percutaneous and in a subject with bifurcation LM disease at baseline. At 9-month angiography, late loss was 0.15 +/- 0.81 mm and restenosis rate was 8.2%. An increased incidence of adverse events was noted in patients undergoing SES after dilation with extremely oversized balloons. No case of stent thrombosis was reported. In conclusion, this single-center experience suggests that percutaneous use of SESs to treat LM disease in unselected high-risk patients is safe and effective even 1 year after implantation.

Renin-angiotensin-aldosterone system polymorphisms: a role or a hole in occurrence and long-term prognosis of acute myocardial infarction at young age.

BACKGROUND: The renin-angiotensin-aldosterone system (RAAS) is involved in the cardiovascular homeostasis as shown by previous studies reporting a positive association between specific RAAS genotypes and an increased risk of myocardial infarction. Anyhow the prognostic role in a long-term follow-up has not been yet investigated. Aim of the study was to evaluate the influence of the most studied RAAS genetic Single Nucleotide Polymorphisms (SNPs) on the occurrence and the long-term prognosis of acute myocardial infarction (AMI) at young age in an Italian population. METHODS: The study population consisted of 201 patients and 201 controls, matched for age and sex (mean age 40 +/- 4 years; 90.5% males). The most frequent conventional risk factors were smoke (p < 0.001), family history for coronary artery diseases (p < 0.001), hypercholesterolemia (p = 0.001) and hypertension (p = 0.002). The tested genetic polymorphisms were angiotensin converting enzyme insertion/deletion (ACE I/D), angiotensin II type 1 receptor (AGTR1) A1166C and aldosterone synthase (CYP11B2) C-344T. Considering a long-term follow-up (9 +/- 4 years) we compared genetic polymorphisms of patients with and without events (cardiac death, myocardial infarction, revascularization procedures). RESULTS: We found a borderline significant association of occurrence of AMI with the ACE D/I polymorphism (DD genotype, 42% in cases vs 31% in controls; p = 0.056). DD genotype remained statistically involved in the incidence of AMI also after adjustment for clinical confounders. On the other hand, during the 9-year follow-up (65 events, including 13 deaths) we found a role concerning the AGTR1: the AC heterozygous resulted more represented in the event group (p = 0.016) even if not independent from clinical confounders. Anyhow the Kaplan-Meier event free curves seem to confirm the unfavourable role of this polymorphism. CONCLUSION: Polymorphisms in RAAS genes can be important in the onset of a first AMI in young patients (ACE, CYP11B2 polymorphisms), but not in the disease progression after a long follow-up period. Larger collaborative studies are needed to confirm these results.

Myocardial viability after primary coronary angioplasty: low-dose dobutamine stress echocardiography versus myocardial contrast echocardiography.

BACKGROUND: Successful reperfusion therapy in patients with acute myocardial infarction (AMI) improves survival. Indeed, after AMI myocardial dysfunction may be reversible (hibernating or stunned myocardium). Low-dose dobutamine stress echocardiography (LDDSE) provides us with the possibility of evaluating viable myocardial segments, while myocardial contrast echocardiography (MCE) allows the study of the microcirculation in the same myocardial areas. The aim of our study was to compare LDDSE and MCE, in the prediction of the recovery of segments in patients with AMI who were submitted to primary coronary angioplasty (PTCA). METHODS: We studied 14 patients with AMI. Both LDDSE and MCE with Levovist were performed after primary PTCA. The viability gold standard was a recovery of contractility detected at echocardiography 2 months later. RESULTS: For LDDSE, the sensitivity was 91%, the specificity 71% and the positive and negative predictive values were 93 and 64% respectively. For MCE, the sensitivity was 94%, the specificity 44%, the positive predictive value 89%, and the negative predictive value 59%. Two tests agreed in 81% of the cases. Stress echocardiography and contrast echocardiography agreed in 81% of cases. CONCLUSIONS: LDDSE has a very good positive accuracy, it has an acceptable negative predictive value and is relatively cheap. On the other hand, MCE has a good positive accuracy, but a low negative accuracy and carries a high cost. The integration of these two tests, which are too expensive in clinical practice, could improve our comprehension of the post-PTCA pathophysiology.

Myocardial infarction with normal coronary arteries: ten-year follow-up.

BACKGROUND: Patients with myocardial infarction without angiographically significant coronary artery lesions are considered, as a whole, to have a better prognosis. Different degrees of coronary involvement, within this wide group, may portend different degrees of risk. The aim of this study was to assess which clinical and angiographic covariates are more useful in defining the individual prognosis. METHLODS: We prospectively followed 53 consecutive patients admitted to our coronary care unit between 1985-1990 with myocardial infarction and a culprit lesion causing < or = 50% angiographic luminal narrowing. RESULTS: Patients with normal angiograms (group A) were compared to those with minor parietal irregularities (group B) or discrete (< or = 50%) stenosis (group C). Group A patients were younger, had a lower peak creatine kinase release, and a higher ejection fraction. After a median follow up of 125 +/- 32 months, group A patients had a 100% 10-year survival compared to 77 and 58% for group B and group C patients respectively (p = 0.01). At univariate analysis, ischemic events correlated with the severity of coronary lesions (while group A patients had no ischemic events at follow-up, events occurred in 46 and 50% of group B and C patients respectively; p = 0.003) and with ejection fraction, that was lower in patients with events (56.0 +/- 17 vs 67 +/- 11%, p = 0.006). Cardiac death, too, correlated with the type of coronary lesions (p = 0.03) and with lower ejection fraction (p = 0.004). By means of multivariate analysis, on the contrary, only the vessel morphology was predictive of ischemic events at follow-up (p = 0.02), while the only significant predictor of death was ejection fraction (p = 0.0012). CONCLUSIONS: Patients with myocardial infarction and strictly normal vessels have very few ischemic events at follow-up, and may be distinguished from both patients with non-significant lesions as well as those with minor angiographic irregularities. On the other hand, cardiac mortality correlates strongly and independently with a depressed ventricular function.

The future of new aortic valve replacement approaches.

Aortic valve disease is a growing cause of mortality and morbidity, especially in developed countries. Whereas medical therapy is associated with an ominous prognosis, since the 1970s, surgical valve replacement has represented a standard therapy for fit patients. Indeed, this approach is safe and feasible in younger patients without comorbidities. However, in unfit patients, surgery may be associated with a very high risk. The advent of transcatheter valve replacement techniques, by means of percutaneous or transapical approaches, has been recently introduced into mainstream clinical practice and is likely to radically change the treatment of aortic valve disease. At present, further data are needed to thoroughly appraise the long-term risk-benefit balance of transcatheter valve replacement techniques. For this reason, it can only be considered for high surgical risk patients, but early results are so promising that in the future, transcatheter aortic valve implantation could became the first therapeutic choice, even for low-risk patients.

Altered nitric oxide/cGMP platelet signaling pathway in platelets from patients with acute coronary syndromes.

This study was aimed at evaluating whether the nitric oxide (NO)/cyclic GMP (cGMP) signaling pathway is altered in platelets from patients with an acute coronary syndrome (unstable angina and acute myocardial infarction). We investigated 10 patients with unstable angina (UA), 14 with acute myocardial infarction (AMI) and 14 age and sex-matched healthy subjects. The serum markers of platelet activation (sP-selectin), inflammation (TNF-alpha and erythrocyte sedimentation rate), thrombotic state (fibrinogen) and plaque disruption were significantly higher in both UA and AMI patients compared to the healthy controls. In their platelets we assessed the cGMP levels in basal conditions and after stimulation with sodium nitroprusside (SNP), and performed Western blot analysis of homogenates to measure the expression of soluble guanylate cyclase isoforms. Basal levels of cGMP (pmol/10(10) platelets) were significantly higher in platelets from UA patients (1,097 +/- 111; p < 0.0001) and AMI (1,122 +/- 77; p < 0.0001) compared to those collected from healthy controls (497 +/- 80). The platelets of AMI patients exhibited a lack of cGMP increase after SNP stimulation in comparison with UA patients. The phosphorylation of upstream (Akt1 protein kinase alpha and endothelial NO synthase) and downstream (vasodilator-stimulated phosphoprotein, VASP) signaling proteins of the NO/cGMP pathway was investigated: serine phosphorylation in Akt1, eNOS and VASP was enhanced in platelets from UA and AMI patients when compared to controls. Furthermore, in AMI patients the inhibitors of guanylate cyclase and cGMP-dependent protein kinase did not revert the VASP phosphorylation. These data suggest that platelets from AMI patients are more resistant to SNP stimulation, not only as cGMP production, but also in terms of VASP activation. From these ex vivo results we hypothesize that the increased inflammatory state which often accompanies patients with cardiovascular diseases might promote a platelet preactivation resulting in their reduced sensitivity to NO.

Impact of routine angiographic follow-up after percutaneous coronary drug-eluting stenting for unprotected left main disease: the Turin Registry.

BACKGROUND: Most cardiologists performing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main disease (ULM) mandate mid-term angiographic follow-up, yet there are few data supporting this approach. We aimed to retrospectively compare the outcome of patients with ULM treated with DES according to their follow-up management strategy. METHODS: Patients with ULM stenosis undergoing PCI with DES and surviving up to 6 months were retrospectively identified from our ongoing database. We distinguished those undergoing clinical follow-up only, those with clinically driven angiographic follow-up, and those with routine angiographic follow-up. The primary end-point was the long-term rate of major adverse cardiac events (MACE, i.e., death, myocardial infarction, bypass surgery, or repeat ULM PCI). RESULTS: A total of 198 patients were included: 55 (28%) in the clinical follow-up group, 64 (32%) in the clinically driven angiographic follow-up group, and 79 (40%) in the routine angiographic follow-up group. After 37.0 +/- 15.7 months, mortality was similar in the 3 groups (respectively 7.3, 4.7, and 5.9%, p = 0.27). However, MACE were significantly more common in the clinically driven angiographic follow-up group (42.2 vs. 7.3 and 26.1%, p = 0.02), mainly due to the expected increase in repeat revascularization in those undergoing angiographic follow-up (23.4 vs. 1.8 and 13.14%). Notably, there were no differences in the rate of stent thrombosis across the three groups, with rates of 3.1 vs. 1.8 and 2.5% (p = 0.35). CONCLUSIONS: An expectant management can be safely adopted in most patients with ULM treated percutaneously, as long as a low threshold for control coronary angiography is maintained.

Bacteriology of infected extracted pacemaker and ICD leads.

INTRODUCTION: Pacemaker and implantable cardioverter defibrillator infections, when not treated, lead to serious consequences. The aim is to identify the prevalent strains of the responsible bacteria to guide an effective therapy. METHODS: Between May 2003 and April 2008, 118 leads were extracted from 61 patients, with chronic draining sinus, pocket infection, pacemaker endocarditis, or sepsis. Following extraction, samples of the leads underwent cultural and antibiogram examination. RESULTS: Staphylococcus epidermidis was the most frequently isolated bacterial strain (37.7%), followed by Gram-positive flora (16.1%), Staphylococcus aureus (14.3%), Candida parapsilosis (5.4%), Staphylococcus schleiferi (5.4%), Corynebacterium species, and Staphylococcus hominis (3.6%). Cultures were negative in 14.3% of the samples. Retained sensitivity to antibiotics were reported as follows: teicoplanin/vancomycin 100%, doxicyclin 96%, amikacin 94%, piperacillin-tazobactam 58%, cotrimoxazole 78%, gentamycin 65%, quinolones 47%, rifampicin 44%, cephalosporins 25%, and oxacillin 25%. Within staphylococci, involved in about 60% of the infections, S. hominis and S. epidermidis showed the highest antibiotic resistance. In case of sepsis, sensitivity was retained for glycopeptides and amikacin (about 100%), and to a lower degree for doxicyclin (80%). Arbitrarily stratifying into recent (<3 months) and chronic (>3 months) infections, an increase in time prior to referral for lead extraction was associated with a significant increase in antibiotic resistance. CONCLUSION: Bacteria associated with pacemaker and implantable cardioverter defibrillator-related infections, staphylococci in about 60% of the cases, show poor susceptibility to antibiotics, presenting three out of four methicillin-resistant features. Therefore, systemic antibiotics, mainly glycopeptides, must not be delayed awaiting the complete removal of the implanted system.

Current management of unprotected left main coronary artery disease: run-in survey of the RITMO (Registro Italiano sul Trattamento del tronco coMune non protettO) study.

The optimal approach for a significant unprotected left main coronary stenosis (ULM) is debated, in light of the recent progresses of percutaneous coronary intervention (PCI). However, coronary artery bypass grafting (CABG) is still considered the first choice treatment. Randomized trials comparing PCI and CABG are ongoing, yet patient selection will considerably limit their clinical applicability. We thus designed a prospective multicenter registry which will include patients with ULM disease independently from the subsequent medical, interventional or surgical treatment: the RITMO Study (Registro Italiano sul Trattamento del tronco coMune non protettO). During the RITMO run-in phase, we conducted a systematic survey of Italian catheterization laboratories to define current management strategies for ULM. A total of 240 Italian catheterization laboratory were sent an email questionnaire on current practices for ULM, with 45 (19%) detailed replies, for a total of 61,370 annual coronary angiographies. Data provided from responders showed a 5% (95% interval: 2-16) prevalence of ULM, with 50% (9-99) of ULM treated surgically and 10% (0-81) treated percutaneously. In conclusion, treatment of ULM in Italy remains prevalently surgical, even if PCI is performed in a sizable portion of patients with ULM.

Impact of multivessel stenting on top of percutaneous revascularization for unprotected left main disease in the drug-eluting stent era: insights from the Turin registry.

OBJECTIVE: Drug-eluting stents (DESs) are commonly used in patients with unprotected left main (ULM) disease. Although multivessel disease and stenting are frequent in this population, pertinent details on short-term and long-term outcomes are lacking. SETTING AND PATIENTS: We identified consecutive patients with DES treatment for ULM. We distinguished patients presenting isolated ULM stenting (group A) from those with additional treatment of at least another major vessel (group B). The primary end point was major adverse cardiovascular events (i.e. death, myocardial infarction or target vessel revascularization). We compared the impact of a DES-only versus a hybrid DES and bare metal stent strategy for non-ULM lesions. RESULTS: A total of 189 patients were included, 25% in group A and 75% in group B. In-hospital events were similarly favorable (cardiac death in 0 and 2%, respectively, P = 0.58). A total of 99% patients were followed for a median of 25 months, yielding major adverse cardiovascular events in 17 and 37.5% (P = 0.011). Specifically, death occurred in 4 and 8.5% (P = 0.52), cardiac death in 0 and 7% (P = 0.12), myocardial infarction in 6.5 and 9% (P = 0.76) and target vessel revascularization in 4.3 and 22% (P = 0.006). Adoption of a systematic DES-only strategy for non-ULM lesions conferred significant benefits on major adverse cardiovascular events and repeat non-ULM revascularizations in comparison to a hybrid strategy (22 versus 45%, P < 0.001, and 9 versus 19%, P = 0.004, respectively), at both bivariate and multivariable analyses. CONCLUSION: Multivessel stenting on top of DES implantation for ULM can be performed with favorable early results. Systematic DES implantation for both ULM and non-ULM lesions is pivotal to maximize clinical results and minimize long-term recurrences.

Long-term follow-up of patients eligible, deferred, or ineligible for heart transplantation.

BACKGROUND: When a patient is referred to a heart transplantation center, the patient and the physician should know the predicted long-term survival according to the first transplant committee decision. The aim of the study was to describe the follow-up of patients with heart failure referred to a heart transplantation center according to the initial decision to include (eligible), exclude (ineligible), or postpone (deferred) cardiac transplantation. METHODS: The study cohort consisted of 852 consecutive patients. Univariate and trend analyses were performed by classification of data into tertiles according to the date of the first visit. The Kaplan-Meier method was used to assess overall survival and probability of receiving a transplant. The Cox hazard model was used to identify predictors of survival. RESULTS: Transplantation incidence in the 3 groups (eligible, deferred, and ineligible) was 60%, 19%, and 5%, respectively. The 1-, 3-, 5-, and 10-year survival rates were 74%, 58%, 49%, and 37% among eligible patients; 87%, 72%, 62%, and 45% among deferred; and 69%, 50%, 39%, and 19% among ineligible patients (p < 0.001). The 10-year survival was 65% for eligible patients who received the transplant and 8.8% for eligible patients who did not receive the transplant. Transplantation was the most powerful predictor of survival. CONCLUSION: The initial decision identified 3 groups of patients with different survival rates. Heart transplantation increases the survival of eligible patients at a rate similar to that of less sick subjects for whom heart transplantation can be deferred.

Appraising the pathophysiologic impact of coronary collaterals as measured by fractional flow reserve on symptoms and signs of myocardial ischemia.

BACKGROUND: The purpose of coronary revascularization in stable patients is anginal relief, yet there is no linear relationship between stenosis severity and clinical significance. A major factor in this complex lesion-myocardium interaction is collateral flow. We aimed to define which collateral flow cut-offs separate asymptomatic from symptomatic patients during coronary occlusion. METHODS: Patients undergoing percutaneous transluminal coronary angioplasty for a single stenotic lesion were selected, collaterals were appraised angiographically, and fractional flow reserve was used during prolonged balloon occlusion to measure collateral flow index (FFRcoll). Changes in anginal symptoms, ST-T segment, and left ventricular wall motion were appraised before and during/shortly after balloon dilation. Receiver-operating-characteristic curves and area under the curve were computed to identify the most appropriate FFRcoll cut-offs. RESULTS: Twenty consecutive patients were enrolled. At baseline, 10 patients had angiographic evidence of collaterals, whereas 10 had no angiographic evidence of collateral flow distal to the target lesion. FFRcoll had an excellent discriminatory performance for the presence of angiographic collaterals (area under the curve = 0.90, P = 0.003), a good discriminatory performance for the occurrence of angina (area under the curve = 0.80, P = 0.025), and a trend toward a good discriminatory performance for the occurrence of asynergy (area under the curve = 0.81, P = 0.06). On the basis of receiver-operating-characteristic curves, an FFRcoll cut-off greater than 0.26 could reliably distinguish patients with adequate collaterals (sensitivity = 0.90, specificity = 0.80), whereas a greater than 0.41 cut-off distinguished patients having angina or wall motion abnormalities from those remaining asymptomatic. CONCLUSION: This study shows that distal collateral pressure greater than 41% of proximal perfusion pressure protects from anginal symptoms or regional systolic dysfunction during coronary occlusion, whereas a greater than 26% cut-off is more appropriate to identify angiographically evident collaterals ensuring distal myocardial viability.