Diego Calzolari

C2 is superior to C0 as predictor of renal toxicity and rejection risk profile in stable heart transplant recipients

To assess whether cyclosporine A (CsA) 2‐h peak (C2) is superior to trough levels (C0) for Neoral dose monitoring in heart transplantation (HT), we studied 928 C0–C2 paired determinations from 313 stable HT patients (257 male, aged 50 ± 14 years at HT, follow‐up 6.9 ± 4 years), on a C0‐based regimen. Our target C0 levels (ng/ml) were 150–400 (first 3 months), 150–300 (4–12 months), 100–250 (>12 months). Mean C0 and C2 levels were 268 ± 80 and 1031 ± 386, respectively (first 3 months); 230 ± 49 and 955 ± 239 (4–12 months); 157 ± 53 and 745 ± 236 (>12 months). For patients within the target C0, the corresponding C2 were 600–1500 (first 3 months), 600–1300 (4–12 months), 400–1100 (>12 months). C2 correlated with C0 (r = 0.64, P = 0.0001). C2 correlated better with CsA dose than C0 (r = 0.41, P = 0.0001 vs. r = 0.33, P = 0.0001). Between patients, CsA dose varied by a factor of 9.3; the C/dose ratio varied by a factor of 8.5 for C2 and of 15.6 for C0. Patients with higher C2 (>740) had higher severe rejection score at 2 years (P = 0.02) than patients with lower C2. This did not apply to C0. Both C2 and C0 correlated with blood urea (r = −0.18, P = 0.0001; r = −0.12, P = 0.0002) and creatinine (r = −0.19, P = 0.0004; r = −0.19, P = 0.0001 respectively). By logistic regression higher C2 (>740) was associated with higher total severe rejection score at 2 years (P = 0.006). C2 showed better correlation with CsA dose, renal function, rejection profile and less variability between patients than C0. C2 may improve CsA‐based immunosuppression in HT.

Abnormal total ejection isovolume index as early noninvasive marker of chronic rejection in heart transplantation

Abnormally high myocardial performance index (MPI) is a Doppler‐derived marker of combined systolic and diastolic left ventricular (LV) dysfunction. To identify early stage allograft dysfunction by MPI, we studied 154 long‐term heart transplantation (HT) recipients (131 male, aged 51 ± 13 years at HT, mean follow up 8.4 ± 3.5 years), with normal left ventricular ejection fraction (LVEF) and free from acute rejection (AR), and 25 normals (13 male, aged 39 ± 16 years). Rejection score (RS) on endomyocardial biopsy was calculated in the first year. MPI was prolonged (0.45 ± 0.18 vs. 0.28 ± 0.10, P = 0.0001) in patients and directly related with mean time from HT (P = 0.001), higher cumulative dosages of cyclosporine at 3 months (P = 0.01), 6 months (P = 0.03), 1 year (P = 0.02), 3 years (P = 0.04) and with cumulative dosage of methylprednisolone at 1 year (P = 0.002). The index was inversely related with mean age at HT (P = 0.002) and tended to be directly related with RS at 1 year (P = 0.05). Thus, MPI is abnormal in long‐term HT recipients with normal LVEF. Its direct relation with time from HT as well as immunosuppressive load suggests an early stage of graft dysfunction because of chronic rejection. Extended prospective studies are warranted to clarify its potential role as a negative prognostic marker in HT.

Strut fracture: a further concern with drug-eluting stents.

A potential cause of drug-eluting stent restenosis is strut fracture. To date, few cases have been reported in the available literature and a best treatment method has not been established. We describe two cases of sirolimus-eluting stent fracture combined with focal restenosis and also review those previously reported.

Transfemoral transcatheter aortic valve implantation for treatment of severe aortic regurgitation in a patient with previous aortic valve-sparing operation according to David

The regurgitation of the native aortic valve in patient with previous David operation may represent a clinical challenge because the morbidity and mortality risk of re-operation is not negligible. Here we describe the case of a patient suffering from late severe aortic regurgitation, many years after David operation, efficaciously treated with transfemoral transcatheter aortic valve implantation. To the best of our knowledge, this is the first description of such treatment in a patient with aortic regurgitation and previous David operation.

TCT-417 Bioresorbable vascular scaffold in chronic total coronary artery occlusions: results from the RAI registry

Bioresorbable vascular scaffold (BVS) implantation appears to be a potentially beneficial therapeutic option in chronic total coronary artery occlusions (CTO). The available data on BVS use in this challenging subset of lesions is limited. RAI registry (Registry Absorb Italian, [ClinicalTrials.gov