Annalisa Mongiardo

The instantaneous wave-free ratio (iFR) for evaluation of non-culprit lesions in patients with acute coronary syndrome and multivessel disease

BACKGROUND Adenosine administration is currently required for evaluation of stenosis severity with fractional flow reserve (FFR). The instantaneous wave-free ratio (iFR) was recently introduced as an adenosine-free alternative in patients with stable CAD. The aim of the present study was to replicate the findings of previous iFR studies using an independent calculation algorithm and to evaluate the iFR for the assessment of non-culprit vessels in patients with acute coronary syndrome (ACS). METHODS AND RESULTS 53 patients with ACS (65%) and at least one non-culprit intermediate lesion and 29 (35%) with stable CAD were included. A total of 123 stenoses were evaluated with both FFR and iFR. Classification match of iFR in ACS was not inferior to stable CAD (79.5% in ACS and 84.4% in CAD; p=0.497). Accordingly, no difference was observed in iFR/FFR correlation between ACS and stable CAD (r=0.66 in ACS vs. r=0.69 in CAD). Overall, a significant correlation was found between iFR and FFR (r=0.68; p<0.001) with a good diagnostic efficiency at ROC analysis (area under the curve: 0.87). In addition, neither the localization of the stenosis within the coronary tree (p=0.147) nor the time interval from the acute event (p=0.550) significantly influenced the concordance of iFR with FFR. CONCLUSIONS The iFR is a promising method for the assessment of non-culprit lesion severity in patients with acute coronary syndrome.

Mediterranean jellyfish sting-induced Tako-Tsubo cardiomyopathy.

We report a case of a 53-year-old woman swimming in the southern Mediterranean Sea on the Calabrian coast that was suddenly stung on her right forearm by a mauve-pink jellyfish. She got extremely scared and while swimming back to the shore, she accused fatigue and an intense itch sensation. She lost consciousness on the beach as a consequence of a condition of pulseless electrical activity …

Polytetrafluoroethylene Stent Deployment for a Left Anterior Descending Coronary Aneurysm Complicated by Late Acute Anterior Myocardial Infarction

We report the case of a 66-year-old man with a left anterior descending (LAD) coronary artery aneurysm. Cigarette smoking and hepatitis C virus infection were in his clinical history. Coronary angiography performed in 2002 showed a LAD aneurysm, a 50% stenosis of the right coronary artery, and a 30% stenosis of the left main artery (Figure 1, a through c). The ECG in 2002 was normal (Figure 2b i ). In 2002, the patient underwent successful Jomed polytetrafluoroethylene (PTFE)-coated stenting (3.0×20 mm) to cover the aneurysm (Figure 1d). After stenting, the patient was discharged on ticlopidine 250 mg/d for 1 year, aspirin 100 mg/d, metoprolol 25 mg/d, and transdermal nitrates. Figure 1. LAD …

DIAGNOSTIC PERFORMANCE OF IFR FOR EVALUATION OF INTERMEDIATE LEFT MAIN CORONARY ARTERY STENOSES

Coronary angiography presents several limitations for the evaluation of left main (LMCA) stenoses, due to several reasons: short length, frequent overlapping with side branches, lack of a reference segment, reverse tapering. Fractional flow reserve (FFR) is a useful tool for functional evaluation of

Tips and tricks to implant a MitraClip in a patient with previous surgical closure of atrial septal defect

Percutaneous edge-to-edge mitral valve repair using the MitraClipdevicehasevolvedasanewtoolfortreatmentofmitralvalveregurgita-tion (MVR). The first randomized controlled trial (EVEREST II) com-pared the standard surgical repair/replacement of mitral valve versuspercutaneous repair by MitraClip and demonstrated its superior safetycomparedtosurgicalprocedure,withinferiorefficacyinMVRreduction,but similar improvements in clinical outcomes at 4 years follow-up [1].The guidelines [2,3] on the management of valvular heart disease, pub-lished in 2012 and 2014, suggested to consider percutaneous edge-to-edge mitral valve repair in patients with symptomatic severe MR, con-sidered inoperable or at high surgical risk by “heart team” and thathave a reasonable life expectancy (Class IIb). Percutaneous edge-to-edge mitral valve repair by MitraClip device using trans-septal leftheartcatheterization[4] isbecomingafirst-line treatmentfor function-alMR,whenanatomicalfeaturesaresuitable.Infact,thesepatientsusu-ally show a higher surgical risk and hospital mortality and a longerhospital stay than degenerative MR [5].We describea rarecaseof a61-year-oldmanwithsevere functionalMR, idiopathic dilatative cardiomyopathy and low ejection fraction(30%), in which the MitraClip implantation was very demanding. Healso had arterial hypertension, chronic renal failure on dialysis, moder-ate pulmonary hypertension and previous surgical closure of atrialseptum defect with direct suture. He underwent to automatedcardioverter defibrillator implantation in primary prevention and wasreferred to our hospital for a severe MVR in functional Class IV NYHA.The patients anterior chest wall revealed a well healed sternotomyscar. The results of his laboratory analysis, including metabolic profileand complete blood count, were normal, with the exception of serumcreatinineandpro-BNPlevelsthatwereelevated.TheECGshowednor-mal sinus rhythm at 78 bpm. The trans-thoracic echocardiogramshowedanincreased diameter of theleft atrium and ventricle with dif-fuse hypokinesia and severe reduction of left ventricular systolic func-tion (Simpson ejection fraction 30%); thickening of the mitral valveleaflets, annulus and subvalvular apparatus and increased diameters oftherightsectionswithslightreductionofrightventricularsystolicfunc-tion (TAPSE 14mm). The color-Doppler demonstrated a severe MR (jetarea 11 cm

Response to Letter Regarding, “Administration of a Loading Dose Has No Additive Effect on Platelet Aggregation During the Switch From Ongoing Clopidogrel Treatment to Ticagrelor in Patients With Acute Coronary Syndrome”

We thank Dr Gurbel et al1 for their interest and their comments on our recently published Administration of a Loading Dose Has No Additive Effect on Platelet Aggregation During the Switch From Ongoing Clopidogrel Treatment to Ticagrelor in Patients With Acute Coronary Syndrome (SHIFT-OVER) study.2 The novel antiplatelet agent, ticagrelor, has several advantages over the long-standing clopidogrel, as the virtual absence of nonresponders and the more powerful platelet inhibition. As highlighted by Gurbel et al,1 clopidogrel nonresponders were excluded from our study, for multiple reasons. First, because it is known that high on-treatment platelet reactivity is associated to a higher incidence of stent thrombosis and adverse events,3 it would have been unethical to randomize those patients. In fact, we …