Alessio Arrivi

Operator exposure to x-ray in left and right radial access during percutaneous coronary procedures: OPERA randomised study

Objective Left radial access (LRA) and right radial access (RRA) have been shown to be safe and effective for coronary arteries catheterisation. However, the differences between the two approaches in terms of radiation exposure are still unclear. The aim of the present investigation is to evaluate in a randomised study, the dose of radiation absorbed by operators using either LRA or RRA. Design Randomised, prospective, double arm, single centre study. Setting University Hospital. Patients Male or female subjects with stable, unstable angina and silent ischaemia. Interventions The present study is a comparison of LRA and RRA for coronary artery catheterisation in terms of operators’ radiation exposure. Main outcome measures The primary outcome measure was the radiation dose absorbed by operators; secondary outcome measures were fluoroscopy time, dose-area product and contrast delivered. Results A total of 413 patients were enrolled; 209 were randomly selected to undergo diagnostic procedures with RRA and 204 with LRA. The operators radiation exposure was significantly lower in the left radial group (LRA 33±37 μSv vs RRA 44±32 μSv, p=0.04). No significant differences were observed in fluoroscopy time (LRA 349±231s vs RRA 370±246 s p=0.09) and dose-area product (LRA 7011.42±3617.30 μGym2 vs RRA 7382.38±5226.61 μGym2, p=0.80), even though in both there was a trend towards a lower level in the LRA. No differences were observed in contrast medium delivered (LRA 89.92±32.55 ml vs RRA 88.88±35.35 ml, p=0.45). Conclusions The LRA was associated in the present report with a lower radiation dose absorbed by the operator during coronary angiography.

Dipyridamole versus verapamil for treatment of no‐reflow during primary angioplasty

Background: No previous study has assessed the possible role of dipyridamole for treatment of no‐reflow during acute myocardial infarction (AMI). Methods and Results: Forty‐six consecutive patients (age 64 ± 13 years, 37 men) with no reflow during primary percutaneous coronary intervention were randomized to initial treatment with either dipyridamole (0.56 mg/kg i.c.) or verapamil (1 mg i.c.). Patients with unsuccessful response to the first drug were then switched to the second one (from dipyridamole to verapamil and vice versa). Angiographic end‐points were similar in the two groups: TIMI flow was 2.9 ± 0.3 versus 2.8 ± 0.4 (P = 0.28), corrected TIMI frame count (cTFC) 26.4 ± 8.8 versus 31.6 ± 11.4 (P = 0.14) and TIMI myocardial perfusion grade (TMPG) 2.1 ± 1.2 versus 1.7 ± 1.2 (P = 0.12) in dipydidamole and verapamil group, respectively. Optimal myocardial perfusion (TMPG‐3) was achieved by 56% of patients with dipyridamole and 39% with verapamil (P = 0.38). In patients with persistent no‐reflow administration of dipyridamole on top of verapamil resulted in a significant further improvement of cTFC (from 31.6 ± 11.4 to 24.6 ±5.7 P = 0.009) and of TMPG (from 1.7 ± 1.2 to 2.6 ± 0.7, P = 0.007). Conversely, verapamil did not induce a significant improvement in coronary flow (cTFC changed from 26.4 ± 8.8 to 24.5 ± 8.5, P = 0.28 and TMPG from 2.1 ± 1.2 to 2.4 ± 1.2, P = 0.13). There were no significant side effects induced by dipyridamole, while verapamil caused AV block in 9% of cases. Conclusions: Dipyridamole is a safe and effective first‐line drug for treatment of no‐reflow. Dipyridamole can also be successfully used in patients with incomplete response to verapamil.

Aspirin Reload Before Elective Percutaneous Coronary Intervention Impact on Serum Thromboxane B2 and Myocardial Reperfusion Indexes

Background—Microvascular obstruction seems to predict poor outcome in patients undergoing elective percutaneous coronary intervention (PCI), but the underlying mechanism is still unclear. We analyzed whether serum thromboxane B2, a stable metabolite of thromboxane A2, may be implicated in post-PCI microvascular obstruction. Methods and Results—We enrolled 91 patients (74 males, 66±10 years) on chronic low-dose aspirin therapy (aspirin, 100 mg daily) scheduled for elective PCI and randomly assigned to receive aspirin reload (325 mg orally, n=46) or no reload (control group, n=45) ≥1 hour before elective PCI. Serum levels of thromboxane B2, reperfusion indexes (corrected Thrombolysis In Myocardial Infarction frame count and myocardial blush grade), and serum cardiac troponin I were assessed before and after PCI. Serum thromboxane B2 significantly increased after 120 minutes (P=0.0447) from PCI in control but not in aspirin reload group. After PCI, both groups showed a statistically significant reduction in corrected Thrombolysis In Myocardial Infarction frame count more evident in aspirin reload group (P=0.0023). Moreover, after PCI, 61% of patients allocated to aspirin reload and only 32% of patients allocated to control group reached normal microcirculatory reperfusion (myocardial blush grade=3); patients with myocardial blush grade=3 exhibited lower values of serum thromboxane B2 compared with those with myocardial blush grade <3 (P=0.05). Periprocedural cardiac troponin I significantly increased (F=3.64; P=0.01334) and correlated with serum thromboxane B2 (&rgr;=0.31; P=0.0413) in control but not in aspirin reload group. In addition, left ventricular ejection fraction significantly increased after PCI only in the aspirin reload group (P=0.0005). Conclusions—Aspirin loading dose before elective PCI improves myocardial reperfusion and injury indexes, suggesting a possible role of platelet thromboxane A2 in microvascular occlusion. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01374698.

Idiopathic, Serial Coronary Vessels Dissection in a Young Woman with Psychological Stress: A Case Report and Review of the Literature

Spontaneous coronary artery dissection (SCAD) is a very rare disease, associated with high mortality rate, whose etiology and pathogenesis are poorly understood. Its sporadic nature and the varied angiographic extent make firm recommendations regarding revascularization impossible. The case described is that of a young, otherwise healthy woman, without a known underlying condition which may lead to SCAD, but with a history of intense psychological stress. We managed the patient with a conservative approach based on watchful waiting, medical therapy, and plain old balloon angioplasty (POBA) with low inflation atmospheres.

Spontaneous-Idiopathic Left Anterior Descending Artery Dissection: Is Watchful Waiting Better Than Immediate Stenting?

Spontaneous coronary artery dissection (SCAD) is a rare, complex disease, nowadays poorly understood yet. The lack of firm recommendations about this issue is a great limitation which makes any therapeutic decision controversial. The case described is that of a young, otherwise healthy woman, who presented with an ostial dissection of the left anterior descending (LAD) artery. Due to patients stable clinical and hemodynamic parameters, we used a cautious approach based on watchful waiting and medical therapy, postponing stenting in order to achieve a partial vessel reopening with a more comfortable access to PCI.

Acute Aortic Dissection Mimicking STEMI in the Catheterization Laboratory: Early Recognition Is Mandatory

Coronary malperfusion due to type A aortic dissection is a life-threatening condition where timely recognition and treatment are mandatory. A 77-year-old woman underwent an acute evolving type A aortic dissection mimicking acute myocardial infarction. Two pathophysiologic mechanisms are discussed: either thrombosis migrating from a previously treated giant aneurism of proximal left anterior descending or a local arterial complication due to left main stenting. Recognition of these occurrences in the catheterization laboratory is important to look immediately for surgery.

320-slice CT and myocardial bridge

A 29-year-old professional athlete was referred for cardiac evaluation after a syncope occurring during strenuous exercise. Twelve-lead ECG showed Brugada-like pattern (figure 1), but both flecainide and genetic tests were negative. ECG Holter and echocardiogram were normal. ECG stress test showed no significant ST-segment changes. In order to rule out coronary artery disease or anomalies, 320-slice multi …

Acute profound abciximab induced thrombocytopenia: a correct management of a methodological error

Thrombocytopenia is a rare complication of glycoprotein IIb/IIIa treatment. We report a case of an acute profound abciximab induced thrombocytopenia and its successful management. The patient, presenting with unstable angina, underwent percutaneous coronary intervention with implantation of three drug eluting stents without receiving a clopidogrel loading dose according to guidelines. The rapid drop in the platelet count after abciximab elastomeric pump infusion was treated with drug discontinuation and platelet transfusion. The high risk of stent thrombosis was avoided by a timely readministration of the dual antiplatelet treatment.

Interplay between Oxidative Stress and Platelet Activation in Coronary Thrombus of STEMI Patients

Background: Platelet activation and oxidative stress seem to play a key role in coronary thrombus formation and are associated with thrombus burden in ST-elevation myocardial infarction (STEMI). However, the interplay between oxidative stress and platelet activation has not been fully elucidated. Materials and Methods: For 32 patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) and 10 patients with stable angina (SA) and oxidative stress, as assessed by NADPH isoform 2 activity (soluble Nox2-derived peptide, sNox2-dp), levels of oxidized low-density lipoproteins (oxLDLs) and platelet activation markers such as soluble CD40 Ligand (sCD40L) and soluble P-selectin (sP-selectin) were measured in the retrieved material (coronary thrombi plus blood waste) of STEMI patients and in intracoronary blood of SA patients, respectively, and in peripheral blood samples of both groups. Results: In aspirated thrombi and blood waste of STEMI patients we found higher serum levels of sNox2-dp, oxLDLs, sCD40L, and sP-selectin, as compared to the intracoronary blood samples of SA patients. Moreover, in thrombi and blood waste of STEMI patients, a direct correlation between markers of oxidative stress and of platelet activation was found. Also, in STEMI patients a progressive increase of oxidative stress and platelet activation markers was observed according to the thrombus score burden. STEMI patients showed higher peripheral blood Nox2 activity and oxLDL levels as compared to SA patients. Conclusion: This study shows a close relationship between oxidative stress and platelet activation in the intracoronary blood waste and aspirated thrombi of STEMI patients, suggesting a role of oxidative stress in promoting thrombus formation and growth.

Rosuvastatin was Effective in Acute Heart Failure and Slow Coronary Flow: A Hypothesis-generating Case Report.

Slow coronary flow phenomenon (SCFP) is characterized by angiographically normal coronary arteries with delayed run-off of contrast medium across the vasculature. Its etiology and clinical significance are still not completely known; however, acute congestive heart failure (CHF) is rare in this context. A 71 year-old woman with SCFP presented with acute CHF complicated by ventricular tachycardia. Treated with rosuvastatin (20 mg/day for 6 days) and inotropic drug infusion she had a complete recovery of left ventricular function and normalization of serum levels of the high-sensitivity C-reactive protein (hs-CRP), which were increased (3.6 mg/L) during the acute phase. This case illustrates that the anti-inflammatory properties of rosuvastatin may deserve specific clinical tests not only during the chronic phase but also in the acute phase of CHF patients.