Christos Maniotis

Dose-dependent effects of sildenafil on post-ischaemic left ventricular function in the rat isolated heart

Objectives Sildenafil may be beneficial during myocardial ischaemia/reperfusion, but this effect may be dose‐dependent, accounting for previous conflicting results. We have explored the effects of two acute and one chronic administration regimen on left ventricular function.

Chronic skeletal muscle ischemia preserves coronary flow in the ischemic rat heart

Chronic skeletal muscle ischemia confers cytoprotection to the ventricular myocardium during infarction, but the underlying mechanisms remain unclear. Although neovascularization in the left ventricular myocardium has been proposed as a possible mechanism, the functional capacity of such vessels has not been studied. We examined the effects of chronic limb ischemia on infarct size, coronary blood flow, and left ventricular function after ischemia-reperfusion. Hindlimb ischemia was induced in 65 Wistar rats by excision of the left femoral artery, whereas 65 rats were sham operated. After 4 wk, myocardial infarction was generated by permanent coronary artery ligation. Infarct size was measured 24 h postligation. Left ventricular function was evaluated in isolated hearts after ischemia-reperfusion, 4 wk after limb ischemia. Neovascularization was assessed by immunohistochemistry, and coronary flow was measured under maximum vasodilatation at different perfusion pressures before and after coronary ligation. Infarct size was smaller after limb ischemia compared with controls (24.4 ± 8.1% vs. 46.2 ± 9.5% of the ventricle and 47.6 ± 8.7% vs. 80.1 ± 9.3% of the ischemic area, respectively). Indexes of left ventricular function at the end of reperfusion (divided by baseline values) were improved after limb ischemia (developed pressure: 0.68 ± 0.06 vs. 0.59 ± 0.05, P = 0.008; maximum +dP/dt: 0.70 ± 0.08 vs. 0.59 ± 0.04, P = 0.004; and maximum -dP/dt: 0.86 ± 0.14 vs. 0.72 ± 0.10, P = 0.041). Coronary vessel density was markedly higher (P = 0.00021) in limb ischemic rats. In contrast to controls (F = 5.65, P = 0.00182), where coronary flow decreased, it remained unchanged (F = 1.36, P = 0.28) after ligation in limb ischemic rats. In conclusion, chronic hindlimb ischemia decreases infarct size and attenuates left ventricular dysfunction by increasing coronary collateral vessel density and blood flow.

Predictors of same day discharge after percutaneous coronary interventions

OBJECTIVES The aim of this study is to identify possible predictors for same day discharge (SDD) after percutaneous coronary interventions (PCI). BACKGROUND Same day discharge after PCI is becoming more and more appealing and patients selection criteria are being formulated. METHODS A retrospective analysis was performed in all PCI procedures from January 2013 until December 2015. Patients were discharged the same day (SDD group) or had at least one overnight stay (non-SDD group). The decision of SDD or not was on treating physician discretion. We evaluated predictors of SDD decision by a logistic regression analysis. RESULTS One thousand one hundred sixty eight procedures were performed from our department during the study period: 308 patients (26.4%) were discharged the same day (SDD group) and the rest 860 procedures (73.6%) had at least one overnight stay (non-SDD group). Multivariate analysis revealed that forearm approach (OR=5.498, CI: 2.067-14.629; p=<0.001), patients residency proximal to the hospital (OR=4.543, CI: 2.406-8.580; p<0.001), completion of the procedure before 13,00p.m. (OR=3.437, CI: 1.789-0.6.601; p<0.001) and the success of the performed procedure (OR=1.125, CI 1.043-2.135; p=0.044) were positive predictors of SDD, while presentation with non-ST elevation myocardial infarction or unstable angina (OR=0.542, CI: 0.268-0.872; p<0.010) and amount of contrast used (OR=0.910, CI: 0.852-0.969; p<0.030) were negative predictors of SDD. CONCLUSION In retrospect, both procedural and demographic details play a crucial role in patient selection for same day discharge post coronary percutaneous intervention.

Needle versus cannula over needle for radial artery cannulation during transradial coronary angiography and interventions

PURPOSE To evaluate the efficacy of radial artery cannulation with needle versus cannula over needle during transradial coronary angiography and intervention. METHODS Five hundred patients scheduled to undergo transradial catheterization were randomized between the two methods. Primary endpoint of the study was the combined endpoint of switching to another access site due to inability of successful sheath insertion or switching to another method of cannulation (from needle to cannula over needle and vice versa). RESULTS The primary end point was met in 12 patients (4.8%) from the needle group and 14 patients (5.6%) from the cannula over needle group (p=0.695). There were no differences in switching of cannulation method [10 (4.0%)% versus 11 (4.4%), p=0.831], switching of access site [6 (2.8%) versus 9 (3.6%), p=0.441), time for artery cannulation [1.20 (0.80-2.20) min versus 1.26 (1.01-2.39) min, p=0.152], total procedure time [15.05 (9.47-29.03) min versus 19.14 (10.13-32.02) min, p=0.112] number of attempts [2 (1-4) versus 2 (1-5), p=0.244] and number of skin punctures [1 (1-2) versus 1 (1-2), p=0.399] before successful radial artery cannulation. There were no differences recorded in the safety endpoints of EASY grade III or more radial hematomas [2 (0.8%) versus 1 (0.4%), p=1.000] or the incidence of radial artery occlusion after the procedure [9 (3.6% versus 16 (6.8%), p=0.358]. CONCLUSION Radial artery cannulation with needle and cannula over needle seems to be equal in terms of efficacy and safety.

Transulnar approach for coronary catheterization in patients with a harvested ipsilatelateral radial artery: A case series.

Forearm approach for coronary catheterization is associated with better outcomes, compared to the femoral approach. However, the possibility of post catheterization forearm artery occlusion is a medical concern, which leads many patients to be treated transfemorally. We present a case series of patients who had a harvested radial artery and were successfully catheterized from ipsilateral ulnar artery without any complications recorded.

Guide extension catheter stepwise advancement facilitated by repeated distal balloon anchoring

Coronary stent delivery can be extremely challenging in tortuous and calcified lesions especially when radial approach is chosen. Guide extension catheter is a useful tool for overcoming the inherent difficulties arising by the use of radial access in complex percutaneous interventions. We describe a technique for guide extension catheter system advancement by presenting two cases. This was performed stepwise by repeated distal balloon anchoring in the coronary artery of interest.

A systematic review on the safety of Prostar XL versus ProGlide after TAVR and EVAR.

BACKGROUND Endovascular aortic aneurysm repair (EVAR) and transfemoral transcatheter aortic valve replacement (TAVR) are widely spreading minimally invasive procedures performed mainly through the femoral artery. Prostar XL and ProGlide vascular closure devices are used in clinical practice for the hemostasis in these procedures and they have been shown to be safe and effective. PURPOSE The aim of our systematic review is to compare the safety of these two devices for percutaneous closure of large arteriotomies in patients undergoing TAVR and EVAR. METHODS We searched PubMed, EMBASE, Google Scholar and the Cochrane Central Register of Controlled Trials for all randomized and observational published studies that compared Prostar XL vs. ProGlide. Relative risk was calculated by random-effects model. Review Manager 5.1 was used for statistical analysis. RESULTS A total number of 2909 patients were included in our analysis. The rate of overall vascular complications did not differ between Prostar XL and ProGlide {RR 1.35 (0.80-2.29), p=0.27}. In contrary, the risk ratio of all bleeding complications with Prostar XL compared to ProGlide was 1.82 (1.47-2.24, p<0.001) and for major and life-threatening bleeding complications was 2.48 (1.65-3.73, p<0001, suggesting a lower bleeding risk with ProGlide). No statistical difference was found between groups for end-stage acute kidney injury (AKI), with a risk ratio of 2.14 (0.81-5.66), p=0.05. Finally, there were no differences in in-hospital and 30-days mortality rate between the two groups (1.41, 0.56-3.54, p=0.46 and 1.43, 0.55-3.73, p=0.47, respectively). CONCLUSIONS Prostar XL is associated with greater risk of any bleeding as well as life threatening bleeding compared to the ProGlide device. However, no significant differences were observed in the rate of overall vascular complications, end stage AKI and in-hospital and 30-days mortality.

Undilatable Stent Neoatherosclerosis Treated with Ad Hoc Rotational Atherectomy

A middle age woman with known ischemic heart disease and old stents in proximal left anterior descending coronary artery (LAD) was admitted to Coronary Care Unit with acute coronary syndrome. The coronary angiography showed one vessel disease with significant restenosis within the previously implanted stents. The lesion was tough and remained undilatable despite high pressure balloon inflation. Eventually, the balloon ruptured creating a massive dissection of the LAD beginning immediately after the distal part of the undilatable lesion. We proceeded with a challenging ad hoc rotational atherectomy of the lesion and finally stenting of the lesion. In-stent restenosis many years after stent implantation is considered to be mainly due to neoatheromatosis compared to intimal hyperplasia, making lesion treatment more difficult and unpredictable.

The Rise and Fall of Anticoagulation with Bivalirudin During Percutaneous Coronary Interventions: A Review Article

Bivalirudin is a direct thrombin inhibitor used during percutaneous coronary intervention (PCI). Treatment with bivalirudin compared to heparin plus glycoprotein IIb/IIIa inhibitors (GPI) reduced bleeding complications, but resulted in higher rates of ischemic events, including acute stent thrombosis in ST segment elevation myocardial infarction (STEMI) patients. Thus, it may be considered a reasonable alternative antithrombotic agent in patients at high risk of bleeding undergoing PCI. However its superiority over heparin alone is questioned particularly in the era of novel antiplatelet agents and transradial PCI.

TCT-359 ULnar artery Transient compression facilitating Radial Artery patent hemostasis (ULTRA): A novel technique to reduce radial artery occlusion

Transradial coronary catheterization is a world-wide growing technique. Its main complication is radial artery occlusion (RAO), which occurs in 1%-10% of the patients. We evaluate a novel technique with simultaneous compression of the ulnar artery in order to reduce the presentence of RAO.