Adam Rdzanek

Access for percutaneous coronary intervention in ST segment elevation myocardial infarction: radial vs. femoral ??? a prospective, randomised clinical trial (OCEAN RACE)

BACKGROUNDnPercutaneous treatment of patients with ST segment elevation myocardial infarction (STEMI) has become the standard and default mode of management as recommended by the European Society of Cardiology guidelines for managing acute myocardial infarction in patients presenting with STEMI. The choice of vascular access is made by the operator and has a potential impact on the safety and efficacy of the procedure and outcomes.nnnAIMnTo understand the influence of a radial approach on bleeding complications and angiographic success, we performed a prospective, controlled randomised trial.nnnMETHODSnPatients were allocated to radial (TR) or femoral (TF) vascular access. The primary endpoints were major bleeding by the REPLACE-2 scale and minor bleeding by the EASY scale (TR arm) or the FEMORAL scale (TF arm). Other outcomes included procedural data, in-hospital and long-term survival.nnnRESULTSnThere were 103 patients analysed in total, 52 in the TR arm and 51 in the TF arm. The demographic and clinical baseline characteristics were well matched between the two study groups. The frequency of the primary endpoint was the same in both arms (TR: 25.0% vs. TF: 33.3%, p = 0.238). In per protocol analysis, there was a significant benefit of the TR approach among independent operators (17.4% vs. 36.8%, p = 0.038). Major bleeding by the REPLACE-2 scale occurred in 4.2% of patients (TR: 5.8% vs. TF: 3.9%, p = 0.509). There were no differences in terms of the rate of major cardiac adverse events, which happened in 10.7% of the study population (TR: 9.6% vs. TF: 11.8%, p = 0.48). In the TF arm, there was a trend towards a higher risk of local bleedings (TR: 22.4% vs. TF: 37.7%, p = 0.081) and a significantly higher frequency of local haematoma (class III, EASY/FEMORAL) (TR: 0% vs. TF: 9.8%, p = 0.027).nnnCONCLUSIONSnThere were no significant differences between the TR and TF approaches in terms of clinical efficacy and patient safety. However, patients treated by independent operators might benefit from TR access. The overall complication risk of percutaneous coronary intervention treatment of STEMI patients remains low.

A 12–month angiographic and optical coherence tomography follow-up after bioresorbable vascular scaffold implantation in patients with ST-segment elevation myocardial infarction

The aim of the study was to evaluate the healing process at 12 months after ABSORB™ bioresorbable vascular scaffold (BVS) implantation in patients with ST‐segment elevation myocardial infarction (STEMI).

A prospective randomised comparison of minor bleedings in transradial vs. transfemoral access percutaneous coronary interventions for STEMI: a new FEMORAL bleeding classification

BACKGROUNDnLocal bleedings related to vascular access site in percutaneous procedures are relatively common complications. However, no uniform definitions exist to classify them.nnnAIMnTo compare minor bleedings related to transradial (TR) and transfemoral (TF) percutaneous coronary intervention (PCI) approaches in ST elevation myocardial infarction (STEMI). In addition, a new classification of TF access-related bleeding - the FEMORAL scale - was proposed.nnnMETHODSnOCEAN RACE is a prospective, randomised, open-label, clinical trial performed in STEMI patients treated with primary PCI. Patients were randomly assigned to the TR or TF arm. Bleedings related to the TR approach were assessed by the EASY scale, whereas bleedings related to the TF approach were classified according to the new FEMORAL scale. A combined analysis of all bleedings was performed using the TIMI scale.nnnRESULTSnThere were 103 patients analysed, including 52 in the TR arm and 51 in the TF arm. Analysis of demographic and clinical baseline characteristics revealed no significant differences between the two study groups. In-hospital bleedings related to the access site were observed in 29.8% of patients. In the TR group, a trend towards lower risk of local bleedings was observed compared to the TF group (TR: 22.4% vs. TF: 37.7%, p = 0.081). Analysis of each class of access site bleeding according to EASY/FEMORAL scales showed that patients in the TR group had a significantly lower risk of class III local haematoma compared to the TF group (TR: 0% vs. TF: 9.8%, p = 0.027). The risk of bleeding in other classes was comparable in both groups. A trend towards less frequent minimal bleedings according to the TIMI scale was observed in the TR group (HR: 0.41, 95% CI: 0.152-1.112, p = 0.059).nnnCONCLUSIONSnTF patients had a higher risk of access-related bleedings than TR patients. The FEMORAL scale was effective in the classification of TF access-related bleedings. Although the popularity of TF access in PCI decreases, this approach is increasingly used in transcatheter aortic valve implantation, renal denervation and closure of paravalvular leaks. Therefore a scale accessing local bleeding in the TF approach may be useful.

Echocardiographic Assessment of Aortic Pulse-Wave Velocity: Validation against Invasive Pressure Measurements

BACKGROUNDnAortic pulse-wave velocity (PWV) is a measure of aortic stiffness that has a prognostic role in various diseases and in the general population. A number of methods are used to measure PWV, including Doppler ultrasound. Although echocardiography has been used for PWV measurement, to the authors knowledge, it has never been tested against an invasive reference method at the same time point. Therefore, the aim of this study was to compare prospectively an echocardiographic PWV measurement, called echo-PWV, with an invasive study.nnnMETHODSnForty-five patients (mean age, 66xa0years; 60% men) underwent simultaneous intra-arterial pressure recording and echocardiographic Doppler flow evaluation during elective cardiac catheterization. Proximal pressure and Doppler waveforms were acquired in the aortic arch. Distal pressure waveforms were registered in the right and distal Doppler waveforms in the left external iliac artery. Transit time was measured as a delay of the foot of pressure or Doppler waveform in the distal relative to the proximal location. Distance was measured on the catheter for invasive PWV and over the surface for echo-PWV. Echo-PWV was calculated as distance divided by transit time.nnnRESULTSnIn the whole group, mean invasive PWV was 9.38xa0m/sec and mean echo-PWV was 9.51xa0m/sec (Pxa0=xa0.78). The Pearson correlation coefficient between methods was 0.93 (Pxa0<xa0.0001). A Bland-Altman plot revealed a mean difference between invasive PWV and echo-PWV of 0.13xa0±xa00.79xa0m/sec.nnnCONCLUSIONSnEcho-PWV, based on Doppler echocardiography, is a reliable method of aortic PWV measurement, with a close correlation with invasive assessment. Wider implementation of the echo-PWV method for the evaluation of aortic wall stiffness can further expand the clinical and scientific utility of echocardiography.

In-Scaffold Neovascularization 24 Months After Bioresorbable Vascular Scaffold Implantation in a Patient With ST-Segment Elevation Myocardial Infarction

A 66-year-old man with hypertension, without diabetes, presenting with inferior ST-segment elevation myocardial infarction was treated with uncomplicated primary percutaneous coronary intervention with implantation of 2 overlapping Absorb bioresorbable vascular scaffolds (3.0xa0× 28 and 3.5xa0× 20

Delayed neointimal healing pattern after bioresorbable scaffold implantation

Fig. 1 a (Baseline) Optical coherence tomography (OCT) directly after implantation of the bioresorbable scaffold (BVS). Adequate BVS expansion and focally malapposed struts in the distal 3-mm scaffold segment (white arrow) into right coronary artery. b (1-year follow-up) Uncovered stent struts (blue arrows) at 12 months after the intervention. c (2-year follow-up) 24-month OCT revealed complete coverage of all struts with a homogeneous, bright neointimal layer and resolved malapposition in the distal segment

A serial 3- and 9-year optical coherence tomography assessment of vascular healing response to sirolimus- and paclitaxel-eluting stents

Early-generation drug-eluting stents (DES) have been demonstrated to delay vascular healing. Limited optical coherence tomography (OCT) data on the very long-term neointimal response after DES implantation are available. The aim of this study was a serial OCT assessment of neointimal thickness, stent strut coverage, malapposition, and protrusion as markers of neointimal response at 3 and 9xa0years after implantation of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES). In this single-centre, longitudinal study consecutive patients undergoing elective PCI with SES or PES were included. OCT analysis was performed after 3 and 9xa0years by the independent core laboratory. A total of 22 subjects (8 SES and 14 PES) underwent an OCT assessment at 3 and 9xa0years post index procedure. The lumen, neointimal and malapposition area and the neointimal thickness (SES ∆50xa0µm, pu2009=u20090.195, PES ∆10xa0µm, pu2009=u20090.951) did not change significantly over the 6xa0year follow-up. No differences in the incidence of uncovered, malapposed or protruding struts were found in each type of stent. At 3 and 9xa0years after PCI, implantation of early-generation SES and PES may be associated with similar neointimal thickness, strut coverage, malapposition and protrusion, as assessed by serial OCT examination among patients with uneventful follow-up at 3xa0years post procedure. The small size of the study warrants judicious interpretation of our results and confirmation in larger multimodality imaging studies, including patients treated with contemporary stent platforms.

Early partial clip detachment following transcatheter mitral valve repair

A 71-year-old man with a history of dyspnoea in New York Heart Association functional class III, due to heart failure and severe mitral regurgitation, was admitted to hospital for the treatment of valvular heart disease. The patient, diagnosed with type 2 diabetes in the past, had undergone two coronary artery bypass surgeries (in 1998 and 2014), the latter complicated by periprocedural myocardial infarction. Heart failure, which developed subsequently, led to the implantation of a cardioverter-defibrillator. Transthoracic echocardiography (TTE) confirmed impairment of left ventricular function (LVDD 66 mm; EF 26%) and the presence of severe functional mitral regurgitation (ERO 0.42 cm2, MRvol 51 mL). In a transoesophageal echocardiography (TEE) examination, the patient was found to be amendable for the percutaneous mitral valve repair. Due to the high risk of open heart surgery (EUROSCORE II 12.82%), the patient was scheduled for MitraClip implantation. The procedure was carried out successfully. A single MitraClip device was implanted in the area of the largest regurgitation jet. It led to a significant reduction of mitral insufficiency (Fig. 1A, B). The following hospitalisation was uneventful. However, on the third day after the procedure, in a pre-discharge TTE followed by immediate TEE, loss of posterior leaflet insertion into the MitraClip device and the recurrence of severe mitral regurgitation was found (Fig. 2A). Moreover, three-dimensional TEE showed a small indentation in the posterior leaflet edge, indicating the area of possible device-related leaflet damage (Fig. 2B). Because of the asymptomatic course of the event, after careful consideration of therapeutic options, the patient was discharged home without further interventions. Clinical evaluation, as well as TTE examination, was planned for the following weeks. Partial clip detachment (PCD), a complication observed in 2–4.8% of MitraClip procedures, usually occurs within the first six months following the implantation. In most the cases, loss of insertion involves posterior mitral valve leaflet. There are no specific guidelines regarding the treatment of this phenomenon. In a large European registry (ACCESS-EU), out of 27 patients in whom PCD was diagnosed, 11 underwent another clip implantation, most of them as a separate procedure. Pharmacological treatment was continued in 10 cases, whereas only six patients were referred for open heart surgery. However, repeat MitraClip therapy is associated with a significantly lower success rate when compared to the first procedure (62% vs. 95%) and heart surgery requires valve replacement more often than annuloplasty. On the other hand, clip embolisation, a potentially life threatening complication, is a very rare phenomenon, and most of the registries do not report such cases following PCD. Taking that into consideration, in our opinion, further pharmacological treatment and a watchful-waiting strategy remains a possible therapeutic option in clinically stable high-risk patients with diagnosed PCD following MitraClip implantation.

Extra-corporeal cardiopulmonary resuscitation in the treatment of cathlab complication

A 68-year-old man with a history of chest pain and a positive result of exercise tolerance test was scheduled for elective coronary angiography. Echocardiographic examination performed on admission showed normal left ventricular function with an ejection fraction (EF) of 58%. In angiography total occlusion of the right coronary artery and significant stenosis of the left circumflex were found. Furthermore, ambiguous lesions in the left main (LM) and left anterior descending artery (LAD) were observed (Fig. 1A, B). In order to assess its physiological significance, a fractional flow reserve (FFR) examination was started. Due to vessel tortuosity and difficulties in LAD wiring, an additional guidewire was placed into the vessel but failed to pass through the mid-LAD bending and was left in the large diagonal branch (Fig. 1C). After prolonged manipulation with the FFR wire, the patient complained of chest pain, and angiography showed acute occlusion of LAD (Fig. 1D). Rescue angioplasty was started. Consecutive balloon-catheter inflations failed to re-open the artery, and the patient developed cardiac arrest. During cardiopulmonary resuscitation (CPR), drug-eluting stents were implanted, covering the LM and proximal LAD segment; however, angiography showed a no-flow phenomenon, and no spontaneous rhythm restoration was seen (Fig. 2A, B). Via groin incision, femoral vein and artery cannulas were inserted for the extracorporeal membrane oxygenation (ECMO) system. After haemodynamic stabilisation, angioplasty was completed and normal epicardial flow was restored (Fig. 2C, D). The patient was transferred to the intensive care unit where, 4 h later, he was extubated and regained consciousness. He was gradually weaned off ECMO, and the device was surgically explanted 15 h after insertion. Echocardiography showed akinesis of the lateral wall, as well as the apical segment of the anterior and inferior walls with an EF of 44%. No neurological deficits were observed, and the patient was discharged home after prolonged rehabilitation. In today’s clinical practice, FFR is considered to be a routine and safe procedure with a complication rate of less than 1%. Cardiac arrest requiring prolonged CPR during scheduled examination is also a very rare cathlab situation. However, a well-defined procedure should be available in every institution in case of this unlikely condition occurring. In case of standard CPR procedure futility, the introduction of mechanical circulatory support with e.g. an ECMO device should be considered. This concept, known as extracorporeal CPR, is supposed to have a beneficial effect on survival in cases of in-hospital cardiac arrest. (Supplementary video files — see journal website)

Bilateral, progressive coronary ostial stenosis following valve sparing aortic root replacement

A 63-year-old man with ascending aorta aneurysms was scheduled for valve sparing aortic root replacement (David procedure). Preoperative angiography showed normal coronary arteries. The operation was carried out according to the standard procedure and aorto-coronary anastomoses were strengthened with surgical adhesive. The patient was discharged home on the 14th day after the procedure. There were no signs of ischaemia in the electrocardiography (ECG), and echocardiography showed a positive result of the operation with preserved left ventricular (LV) function. Three days later he was brought to the emergency department following a syncope episode preceded by prolonged chest pain. An ECG showed signs of anterior and lateral wall ischaemia and troponins were elevated. Echocardiography revealed severe depression of LV function with an ejection fraction (EF) of 25% and an atypical mass surrounding the aortic bulb (Fig. 1A, B). The patient was referred for coronary angiography in which borderline stenosis of the proximal right coronary artery (Fig. 1C) and critical lesion in the left main were found (Fig. 1D). The left main coronary artery was immediately stented (Fig. 1E) and the ECG, as well as EF, returned in subsequent days to baseline. Three months later, the patient was readmitted for a routine check-up. He complained of gradual symptom recurrence during the previous weeks, described mainly as shortness of breath during mild exertion. Echocardiography findings were comparable to those previously reported. Because of an elevated lesion recurrence risk, the patient was scheduled for invasive coronary angiography. The examination showed the sustained result of left main coronary artery stenting (Fig. 2A), but significant progression of right coronary artery ostial stenosis with slow epicardial flow was noted (Fig. 2B). The patient underwent subsequent percutaneous coronary intervention. The right coronary ostium was stented, and complete patency, as well as rapid artery flow, were restored (Fig. 2C). Significant stenosis of coronary artery ostium is a rare but a potentially life-threatening complication of aortic root and valve surgery. There are several possible causes of this phenomenon, such as surgical error or vessel injury caused by artery cannulation during the infusion of cardioplegic solution. Compression of the artery by the external mass, for example, through overuse of surgical adhesive or later in time, fibrotic tissue formation, seems to be another likely reason. Current literature provides numerous cases of coronary artery stenosis following aortic root and valve surgery. Most of them describe left main artery lesions. Bilateral coronary stenosis is less frequent, but this phenomenon might be under-reported due to the potential high risk of fatality. Figure 1. A, B. Atypical mass surrounding the aortic bulb in the area of left main coronary artery origin; C. Borderline stenosis of the proximal right coronary artery; D. Critical lesion in the left main coronary artery; E. Immediate result of the left main coronary artery stenting