Dario Buccheri

Effect of Drug-Coated Balloons in Native Coronary Artery Disease Left With a Dissection.

OBJECTIVES The authors sought to understand the clinical and angiographic outcomes of dissections left after drug-coated balloon (DCB) angioplasty. BACKGROUND Second-generation DCB may be an alternative to stents in selected populations for the treatment of native coronary lesions. However, the use of these devices may be hampered by a certain risk of acute vessel recoil or residual coronary dissection. Moreover, stenting after DCB has shown limited efficacy. Little is known about when a non-flow-limiting dissection is left after DCB angioplasty. METHODS This was a prospective observational study whose aim was to investigate the outcome of a consecutive series of patients with native coronary artery disease treated with second-generation DCB and residual coronary dissection at 2 Italian centers. We evaluated patient clinical conditions at 1 and 9 months, and angiographic follow up was undertaken at 6 months. RESULTS Between July 2012 and July 2014, 156 patients were treated with DCB for native coronary artery disease. Fifty-two patients had a final dissection, 4 of which underwent prosthesis implantation and 48 were left untreated and underwent angiographic follow-up after 201 days (interquartile range: 161 to 250 days). The dissections were all type A to C, and none determined an impaired distal flow. Complete vessel healing at angiography was observed in 45 patients (93.8%), whereas 3 patients had persistent but uncomplicated dissections, and 3 had binary restenosis (6.2%). Late lumen loss was 0.14 mm (-0.14 to 0.42). Major adverse cardiovascular events occurred in 11 patients in the entire cohort and in 4 of the dissection cohort (7.2% vs. 8.1%; p = 0.48). We observed 8 and 3 target lesion revascularizations, respectively (5.3% vs. 6.2%; p = 0.37). CONCLUSIONS In this cohort of consecutive patients treated with new-generation DCB and left with a final dissection, this strategy of revascularization seemed associated with the sealing of most of dissections and without significant neointimal hyperplasia.

Treatment of bifurcation lesions with drug-coated balloons: A review of currently available scientific data

Bifurcation lesion management still represents a challenge for interventional cardiologists and currently there is a number of different approaches/techniques involving coronary stents. The use of a drug-coated balloon for native coronary vessel management is emerging as an alternative treatment, although in selected patient populations only. In particular, this technology has been tested for the treatment of bifurcations, both for the main vessel and the side branches. Several studies have evaluated this treatment as an alternative or as a therapeutic option complementary to stents, with conflicting and debatable results. However, the perspective of leaving lower metallic burden in this type of lesions is highly appealing and should be deeply investigated. We review here the currently available scientific data and future perspectives on drug-coated balloon use for bifurcation lesions.

Coronary bifurcation lesions: Some questions need an answer to make bioresorbable vascular scaffold technology more "coronary bifurcation-friendly"

In the last years, the use of bioresorbable vascular scaffold (BVS) has been increasing in daily interventional practice, especially in the setting of patients considered off-label until a few years ago as coronary bifurcation lesions (CBL). In these complex lesions, although the introduction of drug eluting stent (DES) has reduced the rate of complications, the incidence of instent restenosis (ISR) and/or stent thrombosis (ST) is still high in both provisional and double strategy [1]. According to the fully resorbable poly-L-lactide (PLLA) structure of BVS, this device might represent an optimal choice to revascularize CBL overcoming the limits of metallic DES struts, because of its temporary scaffold support without permanent metal layers allowing a bifurcation anatomy and vasomotion restoration, a normal flow pattern due to the resorption of the struts across the side branch (SB) with a natural remodeling. However the other side of the coin is the high thickness of its struts and the large profile that decreases the deliverability andmay induce an alteration of flow pattern with an anomalous endothelial shear stress and an unnatural alteration of the bifurcation integrity, due to the formation of tissue bridge called “neo-carina” after struts resorption [2].

Recurrent in-stent restenosis, certainty of its origin, uncertainty about treatment

Treatment of recurrent in-stent restenosis is a real brainteaser for the interventional cardiologist who cannot resort to the guidelines to have indications about the type of treatment to be preferred. The use of intracoronary imaging may provide insights into the underlying mechanisms of this complication and use of drug-coated balloons may be a valid alternative and especially a thoughtful treatment when the repeated and perseverant use of drug-eluting stents clearly fails. In this setting, we present a review of the literature about this interesting topic, going deep into the heart of the problem, its origin and possible treatment options.

STEMI patients and nonculprit lesions: To treat or not to treat? and when? A review of most recent literature.

Patients with ST segment elevation myocardial infarction and multivessel disease represent a high percentage of ischemic patient with a worse outcome than patient with single coronary artery disease. Therefore, initial management of these patients is of high importance, but unfortunately this is not clarified yet. We analyze the available literature trying to afford current doubts to determine which way of revascularization is to be preferred.

Coronary artery fistulas as a cause of angina: How to manage these patients?

Coronary artery fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the clinical presentation is mainly dependent on the severity of the left-to-right shunt. We describe a case of a 55-year-old man with history of chest pain and without history of previous significant chest wall trauma or any invasive cardiac procedures. A coronary multislice computed tomography showed two large coronary fistulas arising from the left anterior descending coronary artery and ending in an angiomatous plexus draining into the common pulmonary trunk. Coronary angiography confirmed the CT finding and showed a third fistulous communication arising from the sinus node artery. Although coronary fistulas are infrequent, they are becoming increasingly important because their management and treatment could prevent serious complications. The latest guidelines of the American College of Cardiology/American Heart Association indicate as Class I recommendation the percutaneous or surgical closure for large fistulas regardless of symptoms. In this manuscript, we provide a detailed review of the literature on this topic, focusing on the clinical management of these patients.

The Contemporary Pulse of Bioresorbable-Scaffold Thrombosis Among Expert Operators.

Fully bioresorbable scaffolds (BRS) represent a promising new technological frontier in percutaneous revascularization. BRS provide scaffolding properties and controlled release of antiproliferative agents followed by complete resorption of the backbone. The bioresorbable vascular scaffold (BVS) (

Impact of insulin resistance on cardiac and vascular function.

BACKGROUND Insulin resistance (IR), constitutes an important cardiovascular risk factor and can cause ischemic heart disease. It can lead to left ventricular dysfunction with a mechanism independent of ischemic heart disease and it is closely associated with impaired vascular function. The aim of our study was to explore the impact of IR on cardiac and vascular function, in patients with cardiovascular risk factors but angiographically undamaged coronary arteries. METHODS We studied 32 patients (62.06±11.19years) with cardiovascular risk factors. All patients underwent coronary angiography, echocardiography, Doppler ultrasound of carotid arteries and laboratory tests. Exclusion criteria were coronary artery disease detected by coronary angiography, diabetes mellitus, creatinine above 1.5mg/dl, atrial fibrillation or malignant arrhythmias, left-ventricular hypertrophy, valvular heart disease, ejection fraction below 50%. The presence of insulin resistance was assessed using the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR). Each patient underwent a complete echocardiographic examination including Global Longitudinal Strain assessment and carotid artery ultrasound scan including measurement of arterial stiffness. RESULTS The patients were divided into two groups based on the median value of HOMA-IR, the first group for values <4.14 and, the second, for values ≥4.14. Ejection fraction and diastolic function did not significantly differ between the two groups, whether in patients with higher levels of HOMA-IR (≥4.14) we observed a Global Longitudinal Strain (GLS) that was significantly reduced (-16.50±1.37% vs. -20.73±1.84%, p=0.0015) vascular stiffness, measured in the carotid arteries as pulse wave velocity (PWV) (9.70±1.75m/s vs. 7.40±1.89m/s, p=0.00148) that was increased. At multivariate analysis HOMA-IR was an independent predictor of myocardial dysfunction (GLS: coefficient 0.1156, p<0.0001). CONCLUSION Insulin resistance is associated with subclinical myocardial and vascular alterations in patients without significant coronary artery disease, measured as a reduction of Global Longitudinal Strain, and increased arterial stiffness. Our results underscore the importance of studying the interaction between ventricular function and vessels, in the perspective of more effective preventive and therapeutic interventions.

Effective Treatment of Intermediate-Risk Pulmonary Embolism by Manual Thrombus Aspiration. A Report of Two Cases.

Manual thrombectomy, part of the armamentarium of interventional cardiologists, might also be considered as an effective and safe alternative to manage intermediate/high risk acute PE patients with contraindications to thrombolysis or with acute haemodynamic decompensation. We here describe two cases with intermediate risk pulmonary embolism and severe hypoxaemia where manual thrombectomy with a 10F dedicated catheter was effective and improved clinical and haemodynamic parameters. Currently, theres no clear and effective treatment for these patients, thus we believe that this therapy, as current ESC guidelines suggest, should become a possible alternative to systemic thrombolysis and anticoagulant regimen.

The link between spontaneous coronary artery dissection and takotsubo cardiomyopathy: analysis of the published cases

Spontaneous coronary artery dissection (SCAD) and takotsubo cardiomyopathy (TTS) are two non-atherosclerotic causes of myocardial infarction. They share several common features. Firstly, they have a predilection for the female gender and, in both, the exact mechanism has yet to be fully established. Both they could be responsible for an acute coronary syndrome. Hence, we want to do further consideration based on pathophysiology, literature review, and cases presented affected by both entities up today.