Carlo Penzo

Three-year follow-up of the MULTIcentre evaluation of Single high-dose Bolus TiRofiban versus Abciximab with Sirolimus-eluting STEnt or Bare-Metal Stent in Acute Myocardial Infarction StudY (MULTISTRATEGY)

BACKGROUND The Multicentre Evaluation of Single high-dose Bolus TiRofiban versus Abciximab with Sirolimus-eluting Stent or Bare Metal Stent in Acute Myocardial Infarction Study [MULTISTRATEGY]) randomised 745 patients with ST-elevation myocardial infarction to receive high-dose bolus (HDB) tirofiban or abciximab infusion and sirolimus-eluting (SES) or uncoated-stent (BMS) implantation. Tirofiban was non-inferior to abciximab in terms of ST-segment resolution after intervention, whereas 8 month-major adverse cardiac events occurred in 14.5% in the BMS and 7.8% in the SES groups (P = 0.0039), reflecting a reduction of reintervention rates (10.2% vs. 3.2%). A three-year follow-up was performed to extend previous short- to mid-term findings. METHODS AND RESULTS Complete data at 3 years was available for 736 patients (99%). All-cause mortality was 6.7% in the tirofiban and 7.8% in the abciximab (P = 0.56) and 7.5% in the BMS vs 7.0 in the SES groups, P = 0.79. The composite of all-cause death or MI was identical at 12.9% in tirofiban and abciximab groups, P = 0.99 and it occurred in 13.2% in the BMS vs. 12.6% in the SES groups (P = 0.83). The need for reintervention remained more than twice as common with BMS (13.7%; versus 6.2%, P = 0.0006). The cumulative rate of stent thrombosis (ST) did not differ. This is inspite of a higher very late definite, probable or possible ST thrombosis rate in the SES group. CONCLUSIONS The 3-year follow-up of MULTISTRATEGY demonstrated comparable outcomes with HDB Tirofiban or abciximab and a sustained efficacy of SES to reduce reintervention with no difference in death, repeat MI or ST.

Bioresorbable Scaffold vs. Second Generation Drug Eluting Stent in Long Coronary Lesions requiring Overlap: A Propensity-Matched Comparison (the UNDERDOGS study).

BACKGROUND Randomized clinical trials on bioresorbable scaffolds (BRS) enrolled patients with simple coronary lesions. The present study was sought to give preliminary findings about safety of BRS implantation in overlap in long coronary lesions. METHODS From June 2012 to January 2015, we prospectively collected data from 162 consecutive patients receiving overlapping BRS implantation in the 16 participating institutions. We applied a propensity-score to match BRS-treated patients with 162 patients receiving second generation drug eluting stents (DES) in overlap. The primary endpoint was a device-oriented endpoint (DOCE), including cardiac death, target vessel myocardial infarction, and target lesion revascularization. RESULTS DOCE rate did not significantly differ between the two groups (5.6% in BRS group vs. 7.4% in DES group, HR 0.79, 95%CI 0.37-3.55, p=0.6). Also stent/scaffold thrombosis did not differ between groups (1.2% in BRS group vs. 1.9% in DES group, p=0.6). Occurrence of procedural-related myocardial injury was significantly higher in the BRS group (25% vs. 12%, p=0.001), although it was not related to DOCE (HR 1.1, 95%CI 0.97-1.2, p=0.2). Imaging techniques and enhanced stent visualization systems were significantly more employed in the BRS group (p=0.0001 for both). Procedure length, fluoroscopy time and contrast dye amount were significantly higher in the BRS group (p=0.001, p=0.001 and p=0.01, respectively). CONCLUSIONS Overlapping BRS utilization in long coronary lesions showed a comparable DOCE rate at 1year if compared to second generation DES. Further and larger studies are on demand to confirm our findings.

Comparison of the Long-Term Safety and Efficacy of Drug-Eluting and Bare-Metal Stent Implantation in Saphenous Vein Grafts

Background—Concerns about the long-term safety of drug-eluting stents (DES) in saphenous vein grafts has become an area of controversy and uncertainty. Methods and Results—In this retrospective registry, we compared the outcomes in 127 patients (143 lesions) treated with DES from April 2002 to June 2006 (DES group) with 131 patients (160 lesions) treated with bare-metal stents in the preceding 36 months (bare-metal stent group). End points analyzed were cumulative death, myocardial infarction, and target vessel revascularization at 2 years after stent implantation. The DES group was significantly (P<0.05) more complex with a greater frequency of diabetes (33.1% versus 15.3%), older grafts (11.6±5.3 years versus 9.6±5.2 years), restenotic lesions (23.8% versus 4.4%), total occlusions (7.7% versus 1.2%), and smaller grafts (3.16±0.66 mm versus 3.44±0.76 mm) treated with longer stents (34.1±25.1 mm versus 22.7±11.6 mm). At 2 years, there was no statistical difference in death (8.7% versus 7.8%), myocardial infarction (6.3% versus 9.4%), or target vessel revascularization (19.7% versus 24.2%) between DES and bare-metal stents, respectively. A propensity analysis to adjust for baseline differences suggested that there was no observed association between DES and increased mortality (hazard ratio, 0.72; 95% CI, 0.21 to 2.44; P=0.60) but possibly an association with a reduction in target vessel revascularization (hazard ratio, 0.31; 95% CI, 0.14 to 0.66; P=0.002). Conclusions—Despite being implanted in patients and lesions more complex than the bare-metal stent group, there was no observed association between DES implantation in saphenous vein grafts and an increase in late mortality. DES may maintain their efficacy in reducing revascularization rates in diseased saphenous vein grafts over a 2-year follow-up period.

Radial versus femoral access in patients with acute coronary syndromes with or without ST-segment elevation

Aims To assess whether radial compared with femoral access is associated with consistent outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Methods and results In the Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX (MATRIX) programme patients were randomized to radial or femoral access, stratified by STEMI (2001 radial, 2009 femoral) and NSTE-ACS (2196 radial, 2198 femoral). The 30-day co-primary outcomes were major adverse cardiovascular events (MACE), defined as death, myocardial infarction, or stroke, and net adverse clinical events (NACE), defined as MACE or major bleeding In the overall study population, radial access reduced the NACE but not MACE endpoint at the prespecified 0.025 alpha. MACE occurred in 121 (6.1%) STEMI patients with radial access vs. 126 (6.3%) patients with femoral access [rate ratio (RR) = 0.96, 95% CI = 0.75–1.24; P = 0.76] and in 248 (11.3%) NSTE-ACS patients with radial access vs. 303 (13.9%) with femoral access (RR = 0.80, 95% CI = 0.67–0.96; P = 0.016) (Pint = 0.25). NACE occurred in 142 (7.2%) STEMI patients with radial access and in 165 (8.3%) patients with femoral access (RR = 0.86, 95% CI = 0.68–1.08; P = 0.18) and in 268 (12.2%) NSTE-ACS patients with radial access compared with 321 (14.7%) with femoral access (RR = 0.82, 95% CI = 0.69–0.97; P = 0.023) (Pint = 0.76). All-cause mortality and access site-actionable bleeding favoured radial access irrespective of ACS type (Pint = 0.11 and Pint = 0.36, respectively). Conclusion Radial as compared with femoral access provided consistent benefit across the whole spectrum of patients with ACS, without evidence that type of presenting syndrome affected the results of the random access allocation.

Percutaneous Left Atrial Appendage Closure: Rational, Patient Selection, and Preoperative Evaluation

Atrial fibrillation (AF) is the most common arrhythmia, affecting 1–2 % of worldwide population, the incidence is 0.05 % cases per year, and it is expected to more than double by 2050 in the western countries [1]. AF presence increases the risk of embolic stroke by four- to fivefold [2] and results in stroke incidence of 2–5 % per year in untreated patients [3]. Such disabling complication is mainly related to thrombus formation within the left atrial appendage (LAA) [4]. Furthermore, among patients with AF and history of stroke, the rate of new embolic events may increase up to 12 % per year if patients are not on oral anticoagulants and is at 3 % per year in patients who are properly under medical treatment [2].

Bifurcation Lesions: A Quicker Solution for Re-entry

When used alone, angiography may lead to unnecessary treatment of an overstented side branch. FFR evaluation may be used to functionally assess the severity of this lesion, but with conventional FFR wires it may be difficult to re-enter the side branch through the stent struts. The RXi FFR catheter (Acist/Bracco; Milan, Italy) has the advantage that it is used as a rapid exchange system over traditional wires that may more easily cross the stent struts into the side branch. We report on a case of FFR evaluation of a side branch which could only be wired after attempts with three different intracoronary wires.

TCT-365 Correlation between residual anticoagulation and radial artery occlusion after transradial catheterization: preliminary results from an Italian multicenter study

TCT-363 Patient Characteristics Influencing Physician Selection of Radial vs. Femoral Access in patients presenting emergently with STElevation Myocardial Infarction Jimmy Yee, James Higgins, Vishesh Kumar, Amornpol (Song) Anuwatworn, Shenjing Li, Alexander Pham, Julia Stys, Terezia Petraskova, Paul Thompson, Adam Stys, Marian Petrasko, Tomasz Stys University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota, United States; Interventional Cardiology, Sandro Pertini Hospital; CSI; Sanford School of Medicine of University of South Dakota, Sioux Falls, South Dakota, United States; Sioux Falls; MedStar Washington Hospital Center; Dallas VA Medical Center and UT Southwestern; UCLA, VA Greater Los Angeles Healthcare System; Dallas VA Medical Center and UT Southwestern; Sanford Cardiovascular Institute, Sioux Falls, South Dakota, United States; Sanford Cardiovascular Institute, Sioux falls, South Dakota, United States; Sanford Cardiovascular Institute, Sioux Falls, South Dakota, United States

RISK OF BRAIN INJURY RELATED TO SILENT CEREBRAL EMBOLIZATION DURING DIAGNOSTIC CORONARY ANGIOGRAPHY: DIRECT COMPARISON BETWEEN RIGHT RADIAL AND LEFT RADIAL APPROACH

Methods: 40 patients (40% difference of pMES, 80% power, p<0.05) with suspected coronary artery disease, scheduled for diagnostic coronary angiography, were randomized 1:1 to right or left transradial approach (R-TRA,L-TRA) with contemporaneous TCD monitoring of bilateral middle cerebral arteries (MCA) subsequently analyzed off-line by a blinded examinator. Statystical analysis was performed as appropriate, with multivariate logistic regression analysis to evaluate indipendent predictors of high incidence of pMES (3rd tertile).