Dries De Cock

Optical Coherence Tomography Findings in Patients With Coronary Stent Thrombosis A Report of the PRESTIGE Consortium (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort)

Background: Stent thrombosis (ST) is a serious complication following coronary stenting. Intravascular optical coherence tomography (OCT) may provide insights into mechanistic processes leading to ST. We performed a prospective, multicenter study to evaluate OCT findings in patients with ST. Methods: Consecutive patients presenting with ST were prospectively enrolled in a registry by using a centralized telephone registration system. After angiographic confirmation of ST, OCT imaging of the culprit vessel was performed with frequency domain OCT. Clinical data were collected according to a standardized protocol. OCT acquisitions were analyzed at a core laboratory. Dominant and contributing findings were adjudicated by an imaging adjudication committee. Results: Two hundred thirty-one patients presenting with ST underwent OCT imaging; 14 (6.1%) had image quality precluding further analysis. Of the remaining patients, 62 (28.6%) and 155 (71.4%) presented with early and late/very late ST, respectively. The underlying stent type was a new-generation drug-eluting stent in 50.3%. Mean reference vessel diameter was 2.9±0.6 mm and mean reference vessel area was 6.8±2.6 mm2. Stent underexpansion (stent expansion index <0.8) was observed in 44.4% of patients. The predicted average probability (95% confidence interval) that any frame had uncovered (or thrombus-covered) struts was 99.3% (96.1–99.9), 96.6% (92.4–98.5), 34.3% (15.0–60.7), and 9.6% (6.2–14.5) and malapposed struts was 21.8% (8.4–45.6), 8.5% (4.6–15.3), 6.7% (2.5–16.3), and 2.0% (1.2–3.3) for acute, subacute, late, and very late ST, respectively. The most common dominant finding adjudicated for acute ST was uncovered struts (66.7% of cases); for subacute ST, the most common dominant finding was uncovered struts (61.7%) and underexpansion (25.5%); for late ST, the most common dominant finding was uncovered struts (33.3%) and severe restenosis (19.1%); and for very late ST, the most common dominant finding was neoatherosclerosis (31.3%) and uncovered struts (20.2%). In patients presenting very late ST, uncovered stent struts were a common dominant finding in drug-eluting stents, and neoatherosclerosis was a common dominant finding in bare metal stents. Conclusions: In patients with ST, uncovered and malapposed struts were frequently observed with the incidence of both decreasing with longer time intervals between stent implantation and presentation. The most frequent dominant observation varied according to time intervals from index stenting: uncovered struts and underexpansion in acute/subacute ST and neoatherosclerosis and uncovered struts in late/very late ST.

Healing course of acute vessel wall injury after drug-eluting stent implantation assessed by optical coherence tomography

BACKGROUND Vessel wall injury after drug-eluting stent (DES) implantation can be characterized in detail by optical coherence tomography (OCT). Little is known about the healing course of these phenomena. METHODS AND RESULTS In 62 lesions (62 patients), the incidence of acute vessel trauma was assessed in the stented region and the edge segments immediately after DES implantation. The healing course of these injuries was assessed at 9-month OCT follow-up using a software algorithm allowing for reliable spatial comparison of baseline and follow-up cross-sectional images. Tissue prolapse (TP) and tissue protrusions were detected in 81 and 35% of lesions, respectively. A total of 342 intra-stent dissection flaps (ISD) and 114 intra-stent dissection cavities (ISC) were visualized in 98 and 81% of lesions, respectively. Thirty-five lesions (56%) showed edge dissections (EDs). No residual TP or protrusion was observed at follow-up. Incomplete healing was seen in 8% of ISD and in 20% of ISC. For ED, a residual flap was observed in one-third of the initially dissected stent edges. Incomplete healing of acute vessel injury was associated with the presence of underlying atherosclerotic disease at baseline. Uncovered and malapposed stent struts were observed more often with incomplete healing of vessel injury at follow-up. CONCLUSIONS Acute vessel wall trauma is highly prevalent immediately after DES implantation. Most of these injuries are minor and resolve at mid-term follow-up. Incomplete healing of ISDs seems to be associated with other OCT findings suggesting delayed arterial healing.

Additional tricuspid annuloplasty in mitral valve surgery results in better clinical outcome

Objective The clinical benefit of tricuspid annuloplasty (TA) in patients undergoing mitral valve surgery (MVS) is still debated. We evaluated the immediate surgical success, postoperative outcome and the medium-term effect of TA in MVS. Methods Patients were included between September 2003 and December 2009 and followed until September 2013 to achieve a median follow-up time of 5 years (IQR 3.7–6.9). The end point of mortality due to cardiac causes and combined end point of cardiac mortality or hospitalisation for heart failure were evaluated. Propensity score adjusted Cox regression was used to evaluate the clinical benefit of TA at the time of MVS. Results Of 150 patients (84 female; 67±12 years), 82 presented with tricuspid regurgitation (TR) <2/4 and underwent isolated MVS. Of 68 patients presenting with TR≥2/4, 31 underwent isolated MVS whereas 37 underwent additional TA. In patients with preoperative TR≥2/4, TR was significantly reduced until 5 years postoperatively (mean reduction 0.81±1.31; p=0.04) when additional TA was done. The combined end point occurred in 29% vs 6% at 1 year and in 57% vs 39% at 5 years follow-up for patients with isolated MVS and patients undergoing concomitant TA, respectively. Patients with preoperative TR≥2/4 had worse unadjusted survival than those with TR<2/4 (logrank p=0.009). In the patients with TR≥2/4, propensity score-adjusted risk for the combined end point was higher in those with isolated MVS versus MVS with additional TA (Cox HR 2.855 (1.082–7.532), p=0.035). Conclusions Additional TA is an effective surgical measure to reduce functional TR severity. This approach results in a decreased risk of cardiac mortality and hospitalisation in patients with preoperative TR≥2/4.

Myocarditis Associated With Campylobacter Enteritis: Report of Three Cases

Myocarditis connected with bacterial infection is rare in immunocompentent hosts.1 Campylobacter jejuni infection is a commonly recognized cause of bacterial gastroenteritis. Several case reports have suggested an association between Campylobacter enteritis and the development of myocarditis and pericarditis.2,3 Case 1. Six days after the onset of acute watery diarrhea, a 42-year-old previously healthy man was admitted with abnormal tiredness, dyspnea, and persistent watery diarrhea. Biochemical analysis showed elevated plasma creatine kinase (178 U/L; normal value 170 U/L), troponin I (3.67 μg/L; normal value <0.13), and NT-proBNP levels (1722 ng/L; normal value <115). The ECG was normal on admission. A moderately decreased systolic left ventricular (LV) function with diffuse hypokinesia was seen on echocardiography. Cardiac magnetic resonance imaging (cMR) confirmed a reduced LV systolic function (ejection fraction [EF] 40%; Supplemental Video 1 and 2; see online-only supplement) and showed patchy areas of increased signal intensity on T2-weighted images, suggesting myocardial edema (Figure 1, panel A). After administration of intravenous gadolinium, diffuse and persisting enhancement of the subepicardium and the midwall was seen (Figure 2, panel A). The next day troponin I reached a peak level of 15.6 ng/L, and new repolarization disturbances in the inferolateral leads were noticed. C jejuni , resistant to ofloxacine, …

The apical nipple sign: a useful tool for discriminating between anterior infarction and transient left ventricular ballooning syndrome.

Aims: Even after coronary angiography, transient left ventricular ballooning syndrome (TLVBS) can be misdiagnosed as ST-elevation myocardial infarction (STEMI) caused by transient thrombotic occlusion of the left anterior descending artery, as the appearance of the left ventricular angiograms is often very similar. As prognosis and antithrombotic treatment of these two conditions differ widely, it is desirable to make a correct diagnosis as early as possible. Methods: Between January 1998 and August 2012, we identified 145 patients diagnosed with TLVBS in a single tertiary hospital, based on the Mayo criteria and (near) normalization of left ventricular function over weeks. For 119 of these patients, coronary and left ventricular angiograms were available for detailed study. Results: In 27 (22.7%) patients, mid-ventricular ballooning was observed, with preserved contractility of the apex, while in 92 (77.3%) typical apical ballooning was seen, with extensive akinesis of the apex. In 28 of the patients with typical apical ballooning (30.4%), we observed the presence of a very small zone with preserved contractility in the most apical portion of the left ventricle. We coined this phenomenon ‘apical nipple sign’. For comparison, we reviewed the left ventricular angiograms of 405 patients who had been treated for anterior STEMI by emergency percutaneous intervention on the left anterior descending artery in our hospital between February 2007 and October 2012. On careful review, the apical nipple sign was not seen in any of these. Conclusion: While discrimination between TLVBS and anterior STEMI is warranted as early as possible after admission, this is very difficult, especially in the majority of cases presenting with the classical apical ballooning phenotype. By observing the herein-described apical nipple sign, the attending physician can make the diagnosis of TLVBS with virtual certainty in almost one-third of cases.

Detailed in vivo visualization of stent fracture causing focal restenosis using 3D reconstruction software for high-resolution optical coherence tomography images

A 55-year-old female underwent repeat coronary angiography for recurrent angina, 9 months after percutaneous coronary intervention (PCI) of a mid-right coronary artery (RCA) chronic total occlusion with implantation of two overlapping Orsiro™ sirolimus-eluting stents (3.0 × 30 mm at 20 atm; 2.5 × 30 mm at 16 atm) (see Supplementary data online, Video S1 ). The distal part of the stented segment showed a focal in-stent restenosis (ISR) with the abnormal motion pattern (see Supplementary data online, Video S2 ). Optical coherence tomography (OCT) with 3D reconstruction confirmed suspected stent …

Unusual stent fracture: diagnosis with optical coherence tomography

: We report an unusual case of new-generation drug-eluting stent fracture, diagnosed and managed with aid of optical coherence tomography.

Spontaneous bilateral carotid artery dissection in a patient with bovine aortic arch

Carotid artery dissections are commonly associated with trauma or various connective tissue disorders. Dissection of the cerebrovascular arteries can result in ischemic stroke and is a frequent stroke etiology in younger patients. Anatomical variants of aortic arch branching, such as the ‘bovine’ aortic arch, are assumed to have little or no physiological consequence. To the best of our knowledge, we present for the first time a case of spontaneous dissection of the common origin of the innominate and left common carotid artery in a bovine aortic arch, resulting in bilateral dissection of the carotid arteries.

Multimodality imaging of coronary artery dissection and cardiac contusion after blunt chest trauma

A 77-year-old male presented with chest pain, 3 weeks after a blunt chest trauma caused by a horse kick. Three months earlier, he underwent aortic valve replacement and a single arterial coronary bypass graft on the circumflex artery. Physical examination was normal, except for a large haematoma on the chest ( Panel E ). Coronary angiography revealed a 90% stenosis on the proximal part of the left anterior descending artery (LAD) ( Panel A ). Of note, the LAD …

Development of 3D IVOCT Imaging and Co-Registration of IVOCT and Angiography in the Catheterization Laboratory

Intravascular optical coherence tomography (IVOCT) has become the imaging modality of choice for the evaluation of coronary artery disease and percutaneous coronary intervention (PCI). Both for clinical practice and research, there is a growing interest in 3-dimensional (3D) visualization, as this gives a more comprehensive and intuitively easier to understand representation, compared with 2-dimensional, cross-sectional images. Integrating 3D-IVOCT with classic X-ray angiographic images offers additional advantages and the prospect of integrating IVOCT in fluoroscopic guidance during PCI. Different vendors of IVOCT technology already provide integrated 3D rendering software in their consoles, making 3D images available at the ‘push-of-a-button’. In this review, we will discuss (1) the basic principles and elaboration of 3D-IVOCT in recent years, (2) the feasibility and potential advantages of co-registration with X-ray angiography, (3) the currently available solutions for 3D imaging and their potential clinical applications, and (4) the ongoing development of applications for advanced 3D visualization.