Fernando Rivero

Thrombosis of Second-Generation Drug-Eluting Stents in Real Practice: Results From the Multicenter Spanish Registry ESTROFA-2 (Estudio Español Sobre Trombosis de Stents Farmacoactivos de Segunda Generacion-2)

OBJECTIVESnThis study sought to evaluate second-generation drug-eluting stent (DES) thrombosis in clinical practice.nnnBACKGROUNDnFirst-generation DES are associated with a significant incidence of late thrombosis. There is paucity of data regarding real practice late thrombosis incidence and predictors with second-generation DES, zotarolimus-eluting stent (ZES), and everolimus-eluting stents (EES).nnnMETHODSnA prospective, large-scale, non-industry-linked multicenter registry was designed. Complete clinical-procedural data and systematic follow-up of all patients treated with these stents was reported in a dedicated registry supported by the Spanish Working Group on Interventional Cardiology.nnnRESULTSnFrom 2005 to 2008, 4,768 patients were included in 34 centers: 2,549 treated with ZES, and 2,219 with EES. The cumulative incidence of definite/probable thrombosis for ZES was 1.3% at 1 year and 1.7% at 2 years and for EES 1.4% at 1 year and 1.7% at 2 years (p = 0.8). The increment of definite thrombosis between the first and second year was 0.2% and 0.25%, respectively. In a propensity score analysis, the incidence remained very similar. Ejection fraction (adjusted hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.95 to -0.99; p = 0.008), stent diameter (adjusted HR: 0.37; 95% CI: 0.17to 0.81; p = 0.01) and bifurcations (adjusted HR: 2.1; 95% CI: 1.14 to 3.7; p = 0.02) emerged as independent predictors of thrombosis. In the subgroup of patients with bifurcations, the use of ZES was independently associated with a higher thrombosis rate (adjusted HR: 4; 95% CI: 1.1 to 13; p = 0.03).nnnCONCLUSIONSnIn a real practice setting, the incidence of thrombosis at 2 years with ZES and EES was low and quite similar. The incidence of very late thrombosis resulted lower than was reported in registries of first-generation DES. In the subset of bifurcations, the use of ZES significantly increased the risk of thrombosis.

Treatment of In-Stent Restenosis With Bioresorbable Vascular Scaffolds: Optical Coherence Tomography Insights

The role of the bioresorbable vascular scaffold (BVS) in patients with in-stent restenosis (ISR) remains unsettled. We present optical coherence tomography (OCT) findings in a series of 15 consecutive patients undergoing treatment of ISR with a BVS under systematic OCT guidance. OCT disclosed severe ISR in all patients (minimal lumen area [MLA], 1.3 ± 0.6 mm(2); stent obstruction 80% ± 10%). After the procedure, OCT MLA was 6.4 ± 2 mm(2) with a final BVS expansion of 79% ± 19%. Angiographically silent edge dissections (nxa0= 6), intradevice dissections (nxa0= 3), tissue prolapse (nxa0= 3), and malapposition (nxa0= 3) were also readily visualized. These findings underscore the diagnostic value of OCT in patients undergoing BVS implantation for ISR.

Recurrent Neoatherosclerosis After Bioresorbable Vascular Scaffold Treatment of In-Stent Restenosis

A 66-year-old man presented a non–ST-segment elevation myocardial infarction 3xa0years afterxa0the implantation of an everolimus-eluting stent (3.5xa0× 12 mm) in the proximal segment ofxa0a saphenous vein graft to a marginal branch. Coronary angiography showed focal in-stent restenosis (ISR) and

Dynamic single gold nanoparticle visualization by clinical intracoronary optical coherence tomography.

The potential use of Gold Nanoparticles (GNPs) as contrast agents for clinical intracoronary frequency domain Optical Coherence Tomography (OCT) is here explored. The OCT contrast enhancement caused by GNPs of different sizes and morphologies has been systematically investigated and correlated with their optical properties. Among the different GNPs commercially available with plasmon resonances close to the operating wavelength of intracoronary OCT (1.3 µm), Gold Nanoshells (GNSs) have provided the best OCT contrast due to their largest scattering cross section at this wavelength. Clinical intracoronary OCT catheters are here demonstrated to be capable of three dimensional visualization and real-time tracking of individual GNSs. Results here included open an avenue to novel application of intravascular clinical OCT in combination with GNPs, such as real time evaluation of intravascular obstructions or pressure gradients.

Gold nanoshells: Contrast agents for cell imaging by cardiovascular optical coherence tomography

Optical coherence tomography (OCT) has gained considerable attention in interventional cardiovascular medicine and is currently used in clinical settings to assess atherosclerotic lesions and to optimize stent placement. Artery imaging at the cellular level constitutes the first step towards cardiovascular molecular imaging, which represents a major advance in the development of personalized noninvasive therapies. In this work, we demonstrate that cardiovascular OCT can be used to detect individual cells suspended in biocompatible fluids. Importantly, the combination of this catheter-based clinical technique with gold nanoshells (GNSs) as intracellular contrast agents led to a substantial enhancement in the backscattered signal produced by individual cells. This cellular contrast enhancement was attributed to the large backscattering cross-section of GNSs at the OCT laser wavelength (1,300 nm). A simple intensity analysis of OCT cross-sectional images of suspended cells makes it possible to identify the sub-population of living cells that successfully incorporated GNSs. The generalizability of this method was demonstrated using two different cell lines (HeLa and Jurkat cells). This work provides novel insights into cardiovascular molecular imaging using specifically modified GNSs.

Time-Related Microcirculatory Dysfunction in Patients With Takotsubo Cardiomyopathy

This study assesses whether there is a time-dependent trend in microvascular damage in patients presenting with takotsubo cardiomyopathy by invasively measuring the index of microvascular resistance.

Factors Associated With Delays in Seeking Medical Attention in Patients With ST-segment Elevation Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVESnPrompt coronary reperfusion is crucial in patients with ST-segment elevation acute coronary syndrome. The aim of this study was to determine factors associated with a delay in seeking medical attention after the onset of symptoms in patients with this condition.nnnMETHODSnProspective cohort study in consecutive patients with ST segment elevation infarction. Multiple logistic regression analysis was used to identify factors independently associated with a longer delay in requesting medical help.nnnRESULTSnIn total, 444 consecutive patients were included (mean age, 63 years; 76% men, 20% with diabetes). Median total ischemia time was 225 (160-317) minutes; median delay in seeking medical attention was 110 (51-190) minutes. Older patients (age > 75 years; odds ratio = 11.6), women (odds ratio = 3.4), individuals with diabetes (odds ratio = 2.3), and those requesting medical care from home (odds ratio = 2.2) showed the longest delays in seeking medical attention. Lengthy delay was associated with higher in-hospital mortality (9.8% vs 2.7%; P<.005) and 1-year mortality (7.3% vs 2.9%; P<.05) than when attention was promptly solicited.nnnCONCLUSIONSnElderly patients, women, and diabetic individuals with ST-segment elevation myocardial infarction show longer delays in seeking medical attention for their condition. Delays in seeking medical attention are associated with greater in-hospital and 1-year mortality.

Nonatherosclerotic Causes of Acute Coronary Syndrome: Recognition and Management

Acute coronary syndromes (ACS) frequently result from the rupture or erosion of a vulnerable coronary plaque, with associated intracoronary thrombosis. ACS also may occur in patients with angiographically normal coronary arteries. Some of these patients, however, still have angiographically silent underlying coronary artery disease. In this setting, subtle atherosclerotic changes frequently associated with unstable morphologic features or residual intracoronary thrombus may be detected with intracoronary imaging techniques. Nevertheless, other patients develop ACS as a result of nonatherosclerotic coronary artery disease (NA-CAD). ACS in patients with NA-CAD may be the consequence of coronary spasm or transient coronary embolic phenomena. In these patients, after the initial ischemic insult, late coronary angiography usually reveals normal epicardial coronary vessels. Kounis syndrome is a type of ACS generated by allergic reactions. Takotsubo cardiomyopathy is characterized by normal coronary arteries with a distinct pattern of transient left ventricular wall motion abnormalities. ACS also may occur in young patients following illicit drug use. Finally, spontaneous coronary artery dissection and intramural hematoma represent other etiologies of NA-CAD. In this review, we discuss current evidence regarding diagnostic and treatment strategies in patients presenting with ACS as a result of NA-CAD.

Diagnostic accuracy of a hybrid approach of instantaneous wave-free ratio and fractional flow reserve using high-dose intracoronary adenosine to characterize intermediate coronary lesions: Results of the PALS (Practical Assessment of Lesion Severity) prospective study

We sought to investigate the diagnostic accuracy of instantaneous wave‐free ratio (iFR) and high‐dose intracoronary adenosine fractional flow reserve (IC‐FFR) compared with classical intravenous adenosine fractional flow reserve (IV‐FFR) to assess coronary stenosis severity. The usefulness of two hybrid strategies combining iFR and high‐dose IC‐FFR was also evaluated. Background: Physiological assessment of intermediate coronary stenoses to guide revascularization is currently recommended. Methods: Consecutive real‐world patients with angiographically intermediate coronary stenosis (40–80% diameter stenosis) were prospectively included in the PALS (Practical Assessment of Lesion Severity) study. In every target lesion iFR, high‐dose IC‐FFR and IV‐FFR were systematically measured to assess the accuracy of an hybrid sequential approach combining iFR and IC‐FFR. Results: A total of 106 patients with 121 intermediate coronary lesions were analyzed. Both, iFR and IC‐FFR showed a significant correlation with IV‐FFR (iFR: ru2009=u20090.60, 95%CI 0.48–0.70; IC‐FFR: ru2009=u20090.88; 95%CI: 0.83–0.92). High‐dose IC‐FFR provided lower FFR values than IV‐FFR (0.81u2009±u20090.08 vs. 0.82u2009±u20090.09, Pu2009=u20090.25). Using a receiver‐operating‐characteristic curve an optimal iFR threshold of 0.91 for the screening test was identified. A sequential test strategy (initial iFR followed by IC‐FFR only in lesions with iFR <0.91) yielded an excellent diagnostic accuracy (96.7%, 95%CI 96.7–99.1%) with a sensitivity, specificity, positive and negative predicted values of 100%, 94.7%, 91.8%, and 100%, respectively. A hybrid approach using the previously described iFR gray zone (0.85–0.94) also provided an excellent diagnostic accuracy (95%, 95%CI: 89.5–98.1%). Conclusions: In patients with intermediate coronary lesions a hybrid strategy by using a sequential approach of iFR and high‐dose IC‐FFR, provided a very good diagnostic performance to identify physiologically significant stenoses.

Neoatherosclerosis causing edge in-stent restenosis: optical coherence tomography findings

A patient presenting with ‘edge’ in-stent restenosis 12 years after the implantation of a bare-metal stent in the mid-left anterior descending coronary artery is described. Optical coherence tomography disclosed the presence of ruptured neoatherosclerosis at the stent edge. The value of this imaging technique to unravel this unique underlying anatomic substrate is discussed. The therapy of choice for patients presenting with edge in-stent restenosis (ISR) is reviewed.