Francesc Jara

Lumen enlargement of the coronary segments located distal to chronic total occlusions successfully treated with drug-eluting stents at follow-up.

AIMS Chronic total occlusions (CTO) are the final stage of atherosclerosis. Occluded coronary arteries have large plaque burden and negative remodelling. The aim of this study was to assess lumen and vessel changes of segments located distal to successfully recanalised CTO. METHODS AND RESULTS Ninety-one CTO treated with drug-eluting stents underwent quantitative coronary angiography (QCA) at baseline and at 12-18 months; 31 underwent serial intravascular ultrasound (IVUS) imaging. Angiographic changes were assessed with QCA as differences in minimal, mean and maximal lumen diameter (MinLD, MeanLD and MaxLD, respectively). Vessel changes were assessed with IVUS as changes in plaque and vessel volume. At follow-up, angiographic MinLD increased 23.9% (from 0.88±0.32 to 1.09±0.35 mm; p<0.01), MeanLD 16.4% (from 1.59±0.44 to 1.85±0.45 mm; p<0.01) and MaxLD 11.7% (from 2.39±0.67 to 2.67±0.70 mm; p<0.01). Lumen enlargement was greater in non-restenotic lesions, small lumen area at the end of the index procedure and low LDL-cholesterol levels during the study. By IVUS, lumen volume increased 26.9% (from 108.1±89.2 to 137.3±115.3 mm3; p<0.01), vessel volume increased 12.1% (from 207.1±170.2 to 232.2±196.0 mm3; p<0.01) and plaque volume tended to decrease 3.9% (from 98.9±88.7 to 94.9±89.3 mm3; p=0.07). Small lumen at baseline was related to greater lumen enlargement. CONCLUSIONS Segments distal to recanalised CTO showed a notable lumen and vessel enlargement with a trend toward mild plaque regression. Low LDL-cholesterol levels increase lumen enlargement.

Use of Impella Recover LP 2.5 in elective high risk percutaneous coronary intervention

We describe a single-center experience in using the Impella Recover LP 2.5 in the setting of high-risk elective percutaneous coronary interventions. This device is placed percutaneously to support cardiac output and has a better profile than other left ventricular assist devices. Our study shows that the use of the Impella Recover LP 2.5 device is feasible, has an overall favorable safety profile, and may help prevent periprocedural and short-term complications derived from high-risk procedures.

Mejoría de la función endotelial al reducir las concentraciones lipídicas en pacientes con hipercolesterolemia y arterias coronarias normales

Introduccion y objetivos En pacientes con factores de riesgo coronario se ha documentado la presencia de disfuncion endotelial en las arterias epicardicas. El proposito del estudio fue determinar si la disfuncion endotelial en pacientes hipercolesterolemicos y coronarias angiograficamente normales mejoraba despues de reducir y mantener normalizadas las concentraciones lipidicas. Pacientes y metodo En 10 pacientes con hipercolesterolemia y coronarias sin lesiones angiograficas, la vasomotilidad dependiente del endotelio se estudio mediante la administracion intracoronaria de acetilcolina en la arteria descendente anterior. Los cambios vasomotores fueron analizados mediante angiografia cuantitativa. Cinco pacientes sin factores de riesgo y con coronarias normales formaron el grupo control. Los pacientes hipercolesterolemicos fueron tratados con lovastatina y dieta, reevaluandose la funcion endotelial 24 ± 4 meses despues. Resultados En el estudio inicial los pacientes hipercolesterolemicos presentaron una respuesta vasoconstrictora a dosis crecientes de acetilcolina (10–6 M, 10–5 M y 10–4 M) indicativa de disfuncion endotelial (grupo estudio: –0,3 ± 10%, –6 ± 4% y –18 ± 10%, frente al grupo control: –0,6 ± 6%, –2 ± 6% y 3 ± 6%; p Conclusion En pacientes con hipercolesterolemia y coronarias angiograficamente normales en quienes se documenta disfuncion endotelial, la reduccion y normalizacion de las concentraciones lipidicas condiciona una mejoria de dicha disfuncion endotelial.

Predictive factors and long-term evolution of early endothelial dysfunction after cardiac transplantation☆

BACKGROUND Abnormal coronary vasomotion appears to be a common finding after heart transplantation (HTx). However, the pathophysiology and outcome of this functional disturbance remains poorly understood. Aims of the study were to determine the prevalence, predictive factors and long-term evolution of endothelial dysfunction after cardiac transplantation. METHODS The endothelium-dependent coronary vasomotion of 50 patients, who showed angiographically normal coronary arteries, were studied early (at 3 +/- 1 months) and at follow-up (16 +/- 5 months) after HTx. Endothelial function was studied by selective infusion of serial doses of acetylcholine (ACh) (10(-8), 10(-7)and 10(-6) mol/l) in the left anterior descending coronary artery. Changes in mean luminal diameter after the infusion of each dose were evaluated by quantitative coronary angiography (QCA). RESULTS At early study, 17 patients (34%) showed a vasoconstriction after maximal dose of ACh (-13.3 +/- 13%) indicative of endothelial dysfunction. Logistic regression analysis identified the following variables as independent predictors of early endothelial dysfunction: donor inotropic support (p = 0.004), female donor (p = 0.04) and rejection at the time of the study (p = 0.01). Forty-one patients were re-studied at follow-up. Nine of them (22%) presented endothelial dysfunction. Early endothelial dysfunction was restored in 6 patients (43%) at follow-up. The number of episodes of rejection was the only variable associated to late endothelial dysfunction. CONCLUSIONS Endothelial dysfunction is a common finding after cardiac transplantation. The pathogenesis of this functional disturbance appears to be donor-related and immune-mediated. The reversibility of this phenomenon observed at follow-up suggests the episodic nature of the immunologic injury.

Minor Myocardial Damage During Percutaneous Coronary Intervention Does Not Affect Long-Term Prognosis

INTRODUCTION AND OBJECTIVES To determine whether long-term prognosis is affected by myocardial damage taking place during percutaneous coronary intervention (PCI). METHODS The study included consecutive patients undergoing PCI. Those with elevated baseline cardiac marker levels were excluded. Cardiac markers were evaluated and an ECG was recorded before and 12 and 24 hours after PCI. Patients were divided into three groups after PCI according to their cardiac marker levels: no myocardial damage (i.e. normal troponin and creatine kinase MB fraction [CK-MB]), minor damage (elevated troponin with normal CK-MB), and myonecrosis (elevated troponin and CK-MB). The occurrence of death, myocardial infarction or repeat revascularization during follow-up was recorded. RESULTS Minor myocardial damage associated with PCI was observed in 127 (16.8%) of the 757 patients included in the study and myonecrosis, in 46 (6.1%). During a follow-up of 45+/-14 months, cardiac events occurred in 151 (19.1%) patients. Mortality during follow-up was significantly higher in patients with myonecrosis (13%) than in the other two groups (4.8% and 3.9%; log rank, 6.83; P=.032). No difference was observed in the rate of myocardial infarction or repeat revascularization during follow-up. CONCLUSIONS Minor myocardial damage during PCI had no effect on long-term prognosis. In contrast, myonecrosis was associated with increased mortality. Consequently, the CK-MB level should be measured after all PCIs because of its prognostic implications, and strategies for reducing the risk of myonecrosis developing should be implemented.

Endothelial-Dependent Vasoconstriction in the Infarct-Related Artery Early After Myocardial Infarction Is Smaller Following Primary Angioplasty Than Thrombolytic Therapy

INTRODUCTION AND OBJECTIVES In patients with ST-elevation acute myocardial infarction treated by thrombolysis, both early endothelial dysfunction and long-term improvement in the infarct-related artery have been reported. Our aims were to assess the degree of endothelial dysfunction present after primary angioplasty and to compare it with that after thrombolysis. METHODS Endothelial function was assessed 9 days after infarction by infusing acetylcholine, at an increasing concentration, and subsequently nitroglycerine into the infarct-related artery in 16 patients who had undergone primary angioplasty and bare-metal stent implantation. In addition, endothelial function was compared with that in a group of 16 patients treated by thrombolysis in a different time period. The mean change in the diameters of segments distal to the culprit lesion or the treated lesion were evaluated by quantitative coronary angiography. RESULTS Baseline characteristics were similar in the two groups, except that patients in the primary angioplasty group were treated with clopidogrel and there were differences in residual stenosis in the infarct-related artery (3% in the primary angioplasty group compared with 62% in the thrombolysis group). At the maximum acetylcholine concentration, the degree of vasoconstriction was less in the primary angioplasty group than in the thrombolysis group (-4+/-5% vs. -20+/-21%; P=.018). CONCLUSIONS Early endothelium-dependent vasoconstriction in the infarct-related artery was lower in acute myocardial infarction patients treated by primary angioplasty and bare-metal stent implantation than in those treated by thrombolysis.

El daño miocárdico mínimo durante el intervencionismo coronario percutáneo no influye en el pronóstico a largo plazo

Introduccion y objetivos Evaluar el pronostico a largo plazo del dano miocardico producido durante el intervencionismo coronario percutaneo (ICP). Metodos Incluimos una serie de pacientes consecutivos a quienes se practico ICP, excluyendo a los que ya presentaban basalmente elevacion de marcadores cardiacos. El ECG y los marcadores de dano miocardico se evaluaron antes y a las 12 y 24 h tras el procedimiento. Segun el valor de dichos marcadores, se clasifico a los pacientes en tres grupos: ausencia de dano miocardico (troponina y CK-MB normal), dano miocardico minimo (elevacion del valor de troponina, con CK-MB normal) y mionecrosis (elevacion de troponina I y CK-MB). Muerte, infarto de miocardio y nueva revascularizacion fueron evaluados durante el seguimiento. Resultados De 757 pacientes incluidos, en 127 (16,8%) se detecto dano miocardico minimo asociado al procedimiento y en 46 (6,1%) mionecrosis. Durante un seguimiento de 45 ± 14 meses, 151 (19,1%) pacientes sufrieron eventos cardiacos. Los pacientes que presentaron mionecrosis tuvieron un significativo incremento de la mortalidad durante el seguimiento (13%) respecto a los otros dos grupos (el 4,8 y el 3,9%; log rank test, 6,83; p = 0,032). No se detectaron diferencias en la tasa de IAM o nueva revascularizacion en el seguimiento. Conclusiones El dano miocardico minimo durante el intervencionismo no influye en el pronostico a largo plazo. Por contra, la mionecrosis se asocia a un incremento de mortalidad. Este hecho implica la necesidad de determinar la CK-MB tras todo ICP debido a su implicacion pronostica y la aplicacion de estrategias que disminuyan la aparicion de mionecrosis.

Tratamiento de la reestenosis intra-stent. Situación actual y perspectivas futuras

In-stent restenosis is an increasing problem due to the frequent use of coronary stent as a form of percutaneous revascularization. The global incidence is near to 28%, and it is well document that a neointimal hyperplasia is its principal mechanism. The most commonly related factors for its appearance are diabetes mellitus, a longer length of the original lesion, a smaller diameter of the reference vessel, the left anterior descending artery location and a smaller luminal diameter at the end of the procedure. Due to a different long term evolution in-stent restenosis has been classified as focal or diffuse, according to the length of the restenotic lesion (focal or = 10 mm). Some strategies have been proven for its treatment, but no randomized-controlled trials have been published comparing these different treatments. In focal in-stent restenosis the practice of a conventional balloon angioplasty is associated with high initial clinical success with a favourable long term evolution (target lesion revascularization between 11-15%). But on the contrary, in diffuse in-stent restenosis, in spite of a high initial success rate, an elevated target lesion revascularization has been detected at the follow-up (up to 43%). Other proved such as atherectomy or excimer laser are associated with a significant procedural non-Q-wave infarction (near to 9%) and a long term target lesion revascularization during follow-up (23-31%). The implantation of an additional stent has been performed with low procedural complications and with a long term target lesion revascularization near to 27%. Patients treated with intracoronary radiation as a complementary technique seem to have a better long term evolution than those having had the other strategies alone. In conclusion, in-stent-restenosis is a new and progressively more frequent problem, requiring complex treatment and of which as been established. Comparative controlled studies need to be performed in order to determine the best treatment for this new entity.

Elevated troponin I levels in patients with acute coronary syndrome without ST elevation are associated with increased complexity of the culprit lesion

INTRODUCTION The prognosis in patients with acute coronary syndrome without persistent ST segment elevation (NSTEACS) differs depending on cardiac troponin levels. Clinical practice guidelines published by the Spanish Society of Cardiology and the ACC/AHA consider patients with NSTEACS and markedly elevated troponin levels as high risk patients. The aim of this study was to identify factors related to markedly elevated troponin I levels in NSTEACS. PATIENTS AND METHOD We measured troponin I levels in 219 consecutive patients with NSTEACS and normal CK-MB values, and identified 2 groups: patients with markedly elevated troponin levels (more than 10-fold the normal upper limit), and patients with normal or slightly elevated troponin levels (less than a 10-fold increase above the normal limit). We also analyzed clinical and angiographic variables. Logistic regression was used to calculate age- and sex-adjusted associations for the main variables. RESULTS Forty-one patients (19%) had markedly elevated troponin levels, and 178 (81%) showed normal or slightly elevated troponin I levels. Patients with markedly elevated levels had more frequently prolonged angina, class IIb angina, more severe ECG changes, a higher number of diseased vessels on coronary angiography, and greater severity of the culprit lesion. The culprit stenosis in these patients was more often characterized as ulcerated, showing visible thrombus, and excentric, bifurcated and irregular. Class IIIb angina (odds ratio [OR] = 3.1; CI 95%, 1.1-8.6), bifurcation (OR=6.04; CI 95%, 2.5-14.3), ulceration (OR=3.2; CI 95%, 1.07-9.7) and visible thrombus (OR=2.7; CI 95%, 1.1-6.3) in the culprit lesion were predictive factors associated with markedly elevated levels of troponin I independently of age or sex. CONCLUSIONS Markedly elevated troponin I levels in patients with NSTEACS are associated with a more severe clinical presentation and increased complexity of the culprit lesion on coronary angiography.

Las elevaciones importantes de troponina I en el síndrome coronario agudo sin elevación del segmento ST se asocian a estenosis coronarias más complejas

Introduccion. Los pacientes con sindrome coronario agudo sin elevacion persistente del segmento ST (SCASEST) presentan un pronostico distinto segun los valores de troponina. Las Guias de Practica Clinica (SEC y ACC/AHA) estratifican a los pacientes con SCASEST y marcada elevacion de troponinas como pacientes de alto riesgo. El objetivo del estudio ha sido identificar los factores asociados a las elevaciones importantes de los valores de troponina en estos pacientes. Pacientes y metodo. Se ha analizado a 219 pacientes con SCASEST y valores de la isoenzima MB de la creatincinasa normales en los que se determinaron los valores de troponina I. Segun estos valores, se diferenciaron en pacientes con troponina marcadamente elevada (= 10 veces el limite superior de la normalidad) y pacientes con troponina normal o ligeramente elevada (< 10 veces el limite normal). Se analizo una serie de variables clinicas y angiograficas. Los analisis principales se realizaron mediante regresion logistica ajustando por sexo y edad. Resultados. Un total de 41 pacientes (19%) presento valores de troponina marcadamente elevados y 178 (81%) mostraron valores normales o ligeramente elevados. Los pacientes con valores marcadamente elevados presentaban con mas frecuencia angina prolongada, angina de clase IIIb, cambios electrocardiograficos mas severos, un mayor numero de vasos afectados en la coronariografia con una mayor gravedad en la lesion causal. Dichas lesiones mostraban una mayor incidencia de ulceracion, trombo visible, excentricidad, localizacion en bifurcacion e irregularidad. La presencia de angina clase IIIb (odds ratio [OR] = 3,1; intervalo de confianza [IC] del 95%, 1,1-8,6), la localizacion en bifurcacion (OR = 6,04; IC del 95%, 2,5-14,3), la presencia de ulceracion (OR = 3,2; IC del 95%, 1,07-9,7) y trombo (OR = 2,7; IC del 95%, 1,1-6,3) en las estenosis causantes fueron factores independientes de la edad y el sexo asociados a valores de troponinas marcadamente elevados. Conclusiones. Las elevaciones importantes de troponina I en pacientes con SCASEST se asocian a presentaciones clinicas mas graves y a estenosis causantes mas complejas en la coronariografia.