Transcatheter PFO closure with GORE(®) septal occluder: early and mid-term clinical results.

BACKGROUND: Transcatheter closure of patent foramen ovale (PFO) is a widespread procedure. However the "quest" for the ideal device is still ongoing. Here we present the procedural and early results of transcatheter closure of PFO with the GORE® Septal Occluder. METHODS: Three Italian centers participated in a registry and collected data from 122 consecutive patients undergoing PFO closure by using GSO device. Indication for closure was previous stroke or transient cerebral ischemia in 110 and migraine in 12 subjects. RESULTS: The procedure was successful in all patients. The procedure was performed under general anesthesia, fluoroscopic, and trans-esophageal echocardiographic imaging in 80 subjects while it was performed with local anesthesia, fluoroscopic, and intracardiac echocardiographic monitoring in 42 subjects. Twenty patients received a 20 mm device, 70 patients received a 25 mm device, and 32 received a 30 mm device. Procedure and fluoroscopy times were 30 ± 20 and 5 ± 4 min, respectively. In three cases, the implanted device was retrieved because of unsatisfactory position. Four subjects (2.5%) experienced vascular complications. During a median follow-up of 9 months (range 1-18 months) seven patients experienced atrial arrhythmias and four of them required medical treatment. At six months follow-up, at chest X-ray in two cases there was evidence of fracture of two wires of the device. Devices were stable and no treatment was required. Moderate residual shunting was found in two patients at 6- and 12-months follow-up. No other complication occurred. CONCLUSION: GORE® Septal Occluder is an easy, safe, and effective device in closing PFO.

Does left atrial appendage closure with a cardiac plug system reduce the stroke risk in nonvalvular atrial fibrillation patients? A single-center case series.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and it is associated with an increased stroke risk, due mainly to cardiac embolism from the left atrial appendage (LAA). Percutaneous LAA closure is a method to reduce stroke risk in AF without using anticoagulant agents. In this study we report data from an Italian experience with the LAA occluder Amplatzer Cardiac Plug (ACP) device (Aga Medical Corporation, Plymouth, MN, USA). METHODS: The study was designed to evaluate the safety of LAA closure using ACP and the efficacy of the procedure in preventing strokes during a 1-year follow-up. Patients with permanent or paroxysmal AF, high stroke risk, and contraindication to warfarin therapy were selected for the procedure. RESULTS: The LAA closure was attempted in 37 patients and succeeded in 34 cases (91.9%). Four patients experienced serious complications (one cardiac tamponade requiring pericardiocentesis, two device embolizations, one low-rate response AF requiring artificial pacing). During a 1-year follow-up, ischemic stroke occurred in one of 34 patients, resulting in a stroke rate of 2.94%; thus there was a stroke rate reduction of 50.2% and 26.5% compared to the expected stroke rate, according to CHADS2 and CHA2 DS2 VASc score. None of the patients who received ACP experienced major bleeding during the follow-up. CONCLUSION: LAA closure using ACP is a relatively feasible procedure which can be performed by highly experienced operators to reduce stroke rate in patients with AF, high stroke risk, and contraindication to oral anticoagulants.

Left atrial appendage occlusion for stroke despite oral anticoagulation (resistant stroke). Results from the Amplatzer Cardiac Plug registry.

INTRODUCTION AND OBJECTIVES: Despite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment. METHODS: We analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications. RESULTS: A total of 115 patients (11%) with RS were identified. The CHA2DS2-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5±1.5 vs 4.3±1.6; P <.001; 3.9±1.3 vs 3.1±1.2; P <.001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P=.1). With a mean clinical follow-up of 16.2±12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction). CONCLUSIONS: Patients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.

Acetylcysteine and non-ionic isosmolar contrast-induced nephropathy--a randomized controlled study.

INTRODUCTION: Intravenous administration of saline and non-ionic isosmolar contrast media significantly reduces the incidence of contrast-induced nephropathy, one of the most common causes of acute renal failure. Results with oral N-acetylcysteine are conflicting. The aim of our study was to evaluate the prophylactic role of N-acetylcysteine in patients with stable chronic renal failure undergoing coronary and/or peripheral angiography and/or angioplasty. METHODS: We randomized 200 elective, consecutive patients (mean age 74.9 +/- 7.3 years; 65% male, 25% diabetics) with basal creatinine clearance 0.5 mg/dl or >25% within 3 days after the procedure. Serum creatinine was measured at baseline, 24, 48 and 72 h after the procedure. RESULTS: Contrast-induced nephropathy was 8/99 (8.1%) in the N-acetylcysteine group versus 6/101 (5.9%) in the placebo group, P = 0.6. No difference was noted in high-risk subgroups such as diabetics (4/25 versus 2/25 P = 0.4) and those with serum creatinine clearance <42.3 ml/min (5/54 versus 4/48; P = 0.9). CONCLUSION: In our experience, N-acetylcysteine did not prevent contrast-induced nephropathy in patients receiving isosmolar (iodixanol) contrast media and adequate hydration.

Implant success and safety of left atrial appendage occlusion in end stage renal disease patients: Peri-procedural outcomes from an Italian dialysis population.

AIMS: To estimate the safety and the efficacy of the off label left atrial appendage (LAA) occlusion in chronic dialysis patients with atrial fibrillation (AF). In this preliminary paper, we report the design of the study and the data on peri-procedural complications. METHODS: This is a prospective cohort study. Primary endpoints are i) incidence of peri-procedural complications, ii) cumulative incidence of two-year thromboembolic events iii) cumulative incidence of two-year bleedings iiii) mortality at two years. Adverse events and death within 30 days of the procedure were recorded. RESULTS: Fifty patients who underwent LAA occlusion between May 2014 and September 2017 were recruited. Both the mean age of the sample study and the dialysis duration were high [71.8 (9.6) years and 59.4 (78.2) months, respectively]. Most patients (84%) were hypertensive and 62% suffered a previous major bleeding. About half of them presented cardiovascular diseases. CHA2DS2VASCs and HASBLED scores were 4.0 (1.5) and 4.4 (0.9), respectively. Most patients (88%) showed atrial dilatation and 44% left ventricular hypertrophy; 32% had left ventricular ejection fraction <50%. Fifty five percent of patients had permanent AF and 32% paroxysmal AF. All devices were implanted successfully. No deaths or major adverse events were reported during a 30-day follow-up. Three episodes of peri-procedural access site bleeding were reported, requiring no transfusion. CONCLUSIONS: Our preliminary data suggest the feasibility and safety of LAA occlusion in patients undergoing dialysis. Only the follow-up of these patients over time can provide evidence that LAA occlusion is effective in preventing of thromboembolic events in this very high-risk population.

Intracardiac Versus Transesophageal Echocardiographic Guidance for Left Atrial Appendage Occlusion: The LAAO Italian Multicenter Registry.

OBJECTIVES: This study sought to evaluate the feasibility, safety, and efficacy of intracardiac echocardiography (ICE)-guided versus transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO) by the use of Amplatzer Cardiac Plug or Amulet devices included in a large Italian registry. BACKGROUND: TEE is widely used for LAAO procedure guidance. ICE may be a potential alternative imaging modality in LAAO. METHODS: Data from 604 LAAO procedures performed in 16 Italian centers were reviewed. ICE-guided LAAO was performed in 187 patients, whereas TEE was used in 417 patients. Procedural success was defined as LAAO without occurrence of pericardial tamponade, stroke, systemic embolism with end organ damage, major bleeding, and device embolization. Stroke, transient ischemic attack, major bleeding, overall and cardiovascular death were analyzed. RESULTS: CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, sex category) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores were similar between the ICE and TEE groups. TEE implied lower procedural (delta 12 min) and fluoroscopy time (delta 5 min) when compared with ICE. Procedural success was similarly high (≥94%) between the TEE and ICE groups with a complication rate of 6.5% for TEE versus 4.2% for ICE (odds ratio: 1.468; 95% confidence interval: 0.681 to 3.166; p = 0.327). At median follow-up of 451 days (interquartile range: 162 to 899 days), the rate of cerebral ischemic events was similar between TEE-guided and ICE-guided procedures. CONCLUSIONS: ICE-guided LAAO by means of Amplatzer devices may represent a second alternative imaging modality after an appropriate learning curve and bearing in mind that pre-procedural computed tomography imaging is mandatory. When comparing ICE with TEE, TEE remains the gold standard.

Left atrial appendage closure using AMPLATZER™ devices: A large, multicenter, Italian registry.

BACKGROUND: Left atrial appendage occlusion (LAAO) has been proven to be effective for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF). We aim to assess the safety and efficacy of LAAO by AMPLATZER™ devices in a large, multicenter, single-nation cohort of NVAF patients at high-risk of stroke and bleeding. METHODS: From December 2008 to April 2015 613 NVAF patients (75.1±8.0years, 62.5% male) underwent LAAO in 15 Italian centers by AMPLATZER™ devices. There were no restrictions on any personal/institutional protocols with respect to indications, pre-procedural planning, device implantation, drug therapy and follow-up. All the baseline characteristics, imaging, procedural and follow-up data were collected in a single dataset. RESULTS: AMPLATZER™ devices were successfully implanted in 95.4% of cases. Major complications occurred during 38 procedures (6.2%) and included more frequently major bleeding (3.3%) and pericardial tamponade (2.0%). At a mean follow-up of 20months, the overall annual rates of stroke and thromboembolic events, including those periprocedural, was 1.67% and 2.90%, respectively, consisting in a reduction in the rate of stroke and TIA of 66% compared with the risk-based expectation. Among the 218 patients undergoing transesophageal echocardiography at 6months of follow-up, device thrombosis was present in 1.8% of the patients whilst a significant or mild to moderate peri-device leak was found in 0.5% and 11.9% of cases, respectively. CONCLUSIONS: In this large, multicenter, single-nation study, LAAO with the AMPLATZER™ devices showed high procedural success, early safety and mid-term efficacy for the prevention of NVAF-related thromboembolism.

Flow dynamics and wall shear stress in the left internal thoracic artery: composite arterial graft versus single graft.

OBJECTIVE: Phasic blood flow dynamics and wall shear stress (WSS) have the potential to directly modulate endothelial responses, playing an important role in the development of bypass graft occlusion. This study compares phasic blood flow velocity patterns and WSS of the left internal thoracic artery (LITA) used as a composite Y-graft (27 patients, Y-group) and as a single graft (24 patients, S-group) on the left anterior descending (LAD) coronary artery. METHODS: An intravascular Doppler-tipped guide wire was used for postoperative analysis of phasic blood flow velocity. Flow velocities were recorded proximally and distally into the LITA in both groups. Digitalized spectral velocities were acquired to compute systolic peak velocity, diastolic peak velocity, and average peak velocity. The ratio of diastolic to systolic peak velocity was computed (DSVR). WSS was calculated from graft flow velocity and vessel diameter. RESULTS: Proximal LITA in Y-group had greater average peak velocity (APV) (p=0.000), DSVR (p=0.026), flow volume (p=0.000), WSS (p=0.02), and diameter (0.019) than S-group. There were not significant differences for the distal LITA between the two groups. CONCLUSIONS: The LITA shows a marked adaptability to flow dynamics. The proximal tract of the LITA in Y-group is able to match increased flow requirements, probably through the release of endothelial vasoactive mediators. Flow velocity spectra acquired in the proximal LITA in Y-group resemble the biphasic coronary artery pattern with a clear diastolic predominance. This pattern is probably consequence of the increase of blood flow due to the lower vascular resistance of the Y-graft system and to the active dilatation of the LITA.

Characterization of Cerebrovascular Events After Left Atrial Appendage Occlusion.

Cardioembolic strokes are generally more lethal and disabling than other source of strokes. Data from PROTECT AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) suggest that strokes after left atrial appendage occlusion (LAAO) with the Watchman device are less disabling than those in the warfarin group. No data assessing the severity of strokes after LAAO with the AMPLATZER Cardiac Plug (ACP) are available. The objective of the study was to evaluate the severity of cerebrovascular events after LAAO with the ACP in a population mostly characterized by an absolute or relative contraindication to oral anticoagulation. Data from the ACP multicenter registry were analyzed. Disabling strokes were defined as those with a modified Rankin score of 3 to 6 at 90 days after the event. A total of 1,047 subjects were included. The mean age and CHADS2 score were 75 ± 8 years and 2.8 ± 1.3, respectively. Procedural success was achieved in 97.3% and 4.9% of the patients presented procedural major adverse events. Clinical follow-up was complete in 98.2% of patients with a median of 13 months. There were 9 strokes (0.9%), 9 transient ischemic attacks (0.9%), and no intracranial hemorrhages (0%) at follow-up. After excluding 2 patients with pre-LAAO disability, functional assessment showed disabling events in 3 (19%) of the remaining 16 patients. The median time of presentation was 420 days (interquartile range 234 to 671) after LAAO, and 17 patients (94%) were on single-antiplatelet therapy when the event occurred. According to our results, cerebrovascular events after LAAO with the ACP system were infrequent and mostly nondisabling.

Comparison of Efficacy and Safety of Left Atrial Appendage Occlusion in Patients Aged <75 to ≥ 75 Years.

Left atrial appendage occlusion (LAAO) is emerging as a promising alternative to oral anticoagulation. Because aged patients present a greater risk of not only cardioembolic events but also major bleeding, LAAO might represent a valid alternative as this would allow oral anticoagulation cessation while keeping cardioembolic protection. The objective of the study was to explore the safety and efficacy of LAAO in elderly patients. Data from the AMPLATZER Cardiac Plug multicenter registry were analyzed. The cohort was categorized in 2 groups (<75 vs ≥ 75 years). A total of 1,053 subjects were included in the registry. Of them, 219 were excluded because of combined procedures. As a result, 828 subjects were included (54.6% ≥ 75 years). Procedural success was high and similar in both groups (97.3%). Acute procedural major adverse events were not statistically different among groups (3.2% in <75 years vs 5.1%; p = 0.17) although stratified analysis showed a higher incidence of cardiac tamponade in elderly patients (0.5% vs 2.2%; p = 0.04). With a median follow-up of 16.8 months, no significant differences in stroke/TIA (1.9% vs 2.3%; p = 0.89) and major bleeding (1.7% vs 2.6%; p = 0.54) were observed. In conclusion, LAAO was associated with similar procedural success in patients aged <75 and ≥ 75 years although older patients had a higher incidence of cardiac tamponade. At follow-up, stroke and major bleeding rates were similar among groups.

Impact of chronic kidney disease on left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation.

BACKGROUND: Left atrial appendage occlusion (LAAO) using the Amplatzer cardiac plug (ACP) is a preventive treatment of atrial fibrillation related thromboembolism. AIM: To assess the safety and efficacy of LAAO in patients with chronic kidney disease (CKD). METHODS: Among the ACP multicentre registry, 1014 patients (75±8yrs) with available renal function were included. RESULTS: Patients with CKD (N=375, CHA2DS2-VASc: 4.9±1.5, HASBLED: 3.4±1.3) were at higher risk than patients without CKD (N=639, CHA2DS2-VASc: 4.2±1.6, HASBLED: 2.9±1.2; p<0.001 for both). Procedural (97%) and occlusion (99%) success were similarly high in all stages of CKD. Peri-procedural major adverse events (MAE) were observed in 5.1% of patients, 0.8% of death, with no difference between patients with and those without CKD (6.1 vs 4.5%, p=0.47). In patients with complete follow-up (1319 patients years), the annual stroke+transient ischaemic attack (TIA) rate was 2.3% and the observed bleeding rate was 2.1% (62 and 60% less than expected, similarly among patients with and those without CKD). Kaplan-Meier analysis showed a lower overall survival (84 vs 96% and 84 vs 93% at 1 and 2yrs. respectively; p<0.001) among patients with an eGFR <30ml/min/1.73m(2). CONCLUSION: LAAO using the ACP has a similar procedural safety among CKD patients compared to patients with normal renal function. LAAO with ACP offers a dramatic reduction of stroke+TIA rate and of bleeding rate persistent in all stages of CKD, as compared to the expected annual risk.

Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug.

AIMS: To investigate the safety, feasibility, and efficacy of left atrial appendage occlusion (LAAO) with the AMPLATZER Cardiac Plug (ACP) for stroke prevention in patients with atrial fibrillation (AF). METHODS AND RESULTS: Data from consecutive patients treated in 22 centres were collected. A total of 1,047 patients were included in the study. Procedural success was 97.3%. There were 52 (4.97%) periprocedural major adverse events. Follow-up was complete in 1,001/1,019 (98.2%) of successfully implanted patients (average 13 months, total 1,349 patient-years). One-year all-cause mortality was 4.2%. No death at follow-up was reported as device-related. There were nine strokes (0.9%) and nine transient ischaemic attacks (0.9%) during follow-up. The annual rate of systemic thromboembolism was 2.3% (31/1,349 patient-years), which is a 59% risk reduction. There were 15 major bleedings (1.5%) during follow-up. The annual rate of major bleeding was 2.1% (28/1,349 patient-years), which is a 61% risk reduction. Patients with single LAAO on aspirin monotherapy or no therapy and longer follow-up had fewer cerebral and fewer bleeding events. CONCLUSIONS: In this multicentre study, LAAO with the ACP showed high procedural success and a favourable outcome for the prevention of AF-related thromboembolism. Modification in antithrombotic therapy after LAAO may result in reduction of bleeding events.

Novel nonpharmacologic approaches for stroke prevention in atrial fibrillation: results from clinical trials.

Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke that increases to 17-fold when associated with mitral stenosis. At this time, the most effective long-term solution to protect patients from stroke and thromboembolism is oral anticoagulation, either with vitamin K antagonists (VKAs) or a novel oral anticoagulant (NOAC). Despite the significant benefits they confer, both VKAs and NOACs are underused because of their increased potential for bleeding, and VKAs are underused because of their narrow therapeutic range, need for regular international normalized ratio checks, and interactions with food or medications. In patients with nonvalvular AF, approximately 90% of strokes originate from the left atrial appendage (LAA); in patients with rheumatic mitral valve disease, many patients (60%) have strokes that originate from the left atrium itself. Surgical LAA amputation or closure, although widely used to reduce stroke risk in association with cardiac surgery, is not currently performed as a stand-alone operation for stroke risk reduction because of its invasiveness. Percutaneous LAA closure, as an alternative to anticoagulation, has been increasingly used during the last decade in an effort to reduce stroke risk in nonvalvular AF. Several devices have been introduced during this time, of which one has demonstrated noninferiority compared with warfarin in a randomized controlled trial. This review describes the available technologies for percutaneous LAA closure, as well as a summary of the published trials concerning their safety and efficacy in reducing stroke risk in AF.

Primary PCI is associated with different cardiac autonomic patterns in relation to the site of myocardial infarction.

AIM: Reflex alterations of cardiac autonomic modulation have been described after acute myocardial infarction (AMI). The non-homogeneous autonomic innervation of the heart gives reason of different patterns of autonomic modulation depending upon the site of AMI. Conflicting data are available on cardiac autonomic modifications after primary percutaneous coronary intervention (pPCI). We evaluated cardiac autonomic changes in patients with ST-elevation myocardial infarction (STEMI) after pPCI, either within 24h after revascularization (T0) and at clinical stability (T1, 6±2days), taking into account the site of infarction. METHODS AND RESULTS: We enrolled 33 consecutive patients with STEMI treated with pPCI (25 males, mean age 61±12.1yr); 15 had an anterior wall STEMI (ANT) and 18 had an inferior wall STEMI (INF). ECG and respiration were recorded at T0 and at T1. Cardiac autonomic modulation was evaluated by means of symbolic analysis of heart rate variability. At T0, At T0, 0V% (marker of sympathetic modulation) was higher in INF compared to ANT [31% (18-43) vs 18% (7-32), p=0.014]. Moreover, ANT had a higher 2LV%, index of vagal modulation, compared to INF [8% (7-15) vs 5% (2-8), p=0.006]. CONCLUSION: After pPCI, these preliminary results suggest that patients with INF were characterized by a sympathetic predominance, while ANT by a predominant vagal modulation. Our data suggest that pPCI can be associated with specific autonomic patterns, which are different for ANT and INF STEMI, according to the different autonomic innervation. Future ad hoc studies are needed to confirm these preliminary observations.

Assessment of an aortosaphenous vein graft anastomotic device in coronary surgery: clinical experience and early angiographic results.

BACKGROUND: Until now technologic evolution in coronary bypass surgery has focused on extracorporeal circulation, on operation without extracorporeal circulation, and on the exposure of the operative site. Recently a one-shot anastomotic device for the proximal anastomosis in coronary surgery was developed. We investigated whether the use of the aortic connector system (ACS) could facilitate the creation of aortosaphenous vein graft anastomoses in myocardial revascularization. METHODS: From November 2000, 40 ACS devices were used in 36 consecutive patients (mean age 70.7 +/- 8.9 years); 12 patients (33.3%) underwent surgery on pump and 24 patients (66.6%) off pump; 50 distal anastomoses were performed. In all cases the connection with the ascending aorta was created before the distal anastomoses because of the necessity to slide the saphenous vein graft (SVG) over the vein transfer sheath. Intraoperative graft function was tested measuring blood flow by Doppler analysis. Postoperative evaluation of the anastomotic patency was carried out by early angiography in 34 patients (94.7%) but was excluded in 5 patients (5.3%) with extensive extracardiac vascular occlusive disease. RESULTS: Of 38 AC (95%) evaluated, 36 (94.7%) functioned properly. The end-to-side proximal anastomosis without aortic clamping is instantaneous, the quality of anastomoses was highly rated, no additional stitches were required, and all coronary arteries could be reached. Intraoperative quantity flow was measured by Doppler analysis and all but one showed good flow. Early postoperative angiography demonstrated good patency of the grafts in all cases but 2 (5.3%). At 1-year follow-up, 1 patient died of stroke; all other patients remained free of symptoms and no reoperation was required. CONCLUSIONS: The use of ACS makes end-to-side anastomosis rapid, effective, and reproducible while eliminating aortic cross clamping; it opens a new era in beating or nonbeating coronary surgery. Long-term results are mandatory to confirm our favorable preliminary results.

Effects of heart rate on phasic Y-graft blood flow and flow reserve in patients with complete arterial myocardial revascularizaton: an intravascular Doppler catheter study.

OBJECTIVE: It is not well established whether the blood flow of arterial composite Y-grafts can efficiently respond to the flow demand of the coronary system early postoperatively. The aim of this study was to evaluate if soon after the operation, arterial composite Y-grafts can increase blood flow in response to an increase in myocardial oxygen consumption (MVO2). METHODS: Twenty-seven patients who received complete arterial myocardial revascularization using the left internal thoracic artery (LITA) and the radial artery (RA) as composite Y-graft gave their consent to a pre-discharge coronary angiography and intravascular flow velocity measurements using a Doppler guide wire. Flow measurements were performed in the LITA main stem, the distal LITA and the RA, both at rest and during atrial pacing at the 85% of the patient age-predicted maximum. The heart rate-systolic blood pressure product was considered as an indirect index of MVO2. Hyperemic flow was determined after injection of adenosine. The flow reserve (FR) was defined as the ratio of blood flow during maximal hyperemia (Qmax) to baseline flow (Qbasal). RESULTS: Atrial pacing increased MVO2 significantly (P<0.000). None of the patients developed ischemic S-T segment modifications or complained of chest pain. Q(basal) increased significantly in the LITA main stem (P=0.001), distal LITA (P=0.041) and RA (P=0.004) while Qmax did not change significantly. As a consequence, the FR decreased in the LITA main stem (P=0.002), distal LITA (P<0.000) and RA (P<0.000) but was not completely exhausted. CONCLUSIONS: Soon after the operation, arterial composite Y-grafts can significantly increase blood flow in response to conditions of increased MVO2, keeping normal the myocardial O2 supply-to-demand ratio.

Angiographic demonstration of coronary dethrombosis with eptifibatide.

When dealing with acute coronary syndromes, the interventionists often go straight to balloon and stents, because they work quick and well in the majority of cases. However, it is not to forget that vigorous antithrombotic treatment is frequently highly beneficial in these settings. We report here on two clinical cases of coronary thrombosis in which we could appreciate on the angiograms the effect of GP IIb/IIIa inhibitor eptifibatide alone or in conjunction with alteplase.

Angiographic evidence of myocardial channels after percutaneous transmyocardial laser treatment.

The available clinical reports on percutaneous transmyocardial laser revascularization do not provide data on the visibility of the channels after the procedures. We present the case of a patient who had clear angiographic evidence of the presence of myocardial channels immediately after percutaneous transmyocardial laser revascularization.

A case of life-saving pharmacologic and mechanical coronary dethrombosis.

The present report refers to a case of life-threatening acute myocardial infarction due to thrombotic occlusion of the left main stem, in which an aggressive dethrombotic intervention (pharmacologic and mechanical) was totally successful, thanks to a well developed right coronary system and the use of intra-aortic balloon pump.

[Acute embolic myocardial infarction complicating bioprosthetic stentless aortic valve endocarditis]. / Infarto miocardico acuto embolico in corso di endocardite su bioprotesi valvolare aortica stentless.

We describe the case of bioprosthetic stentless aortic valve endocarditis due to Staphylococcus epidermidis in a female patient, who previously underwent mitral and aortic valve replacement: she presented left main coronary artery occlusion due to septic embolus with subsequent myocardial infarction complicated by cardiogenic shock. We discuss the therapeutic strategies, both medical and interventional, and the surgical options.