Francesca Sanguineti

Meta-Analysis of the Impact on Mortality of Noninfarct-Related Artery Coronary Chronic Total Occlusion in Patients Presenting With ST-Segment Elevation Myocardial Infarction

Several observational studies have compared clinical outcome in patients with a co-existing noninfarct-related artery chronic total occlusion (n-IRA CTO) versus those without, suggesting increased all-cause mortality. The goal of this study was to provide a systematic review and meta-analysis evaluating the impact of the presence of an n-IRA CTO on short- and long-term mortality after primary percutaneous coronary intervention. Studies published from January 1980 to January 2014 that compared the incidence of all-cause mortality in patients with ST-segment elevation myocardial infarction with co-existing n-IRA CTO versus those without were identified using an electronic search and reviewed using meta-analytical techniques. Seven studies (5 observational studies and 2 observational analyses of randomized controlled trials) comprising 14,117 patients and 1,554 patients (11.7%) with n-IRA CTO were included. The presence of n-IRA CTO was associated with increased incidence of all-cause mortality at a median follow-up of 25.2 months (interquartile range 24 to 60) compared with no CTO (absolute risk 23.5% vs 9.0%; odds ratio [OR] 2.90, 95% confidence interval [CI] 2.09 to 4.01; p <0.0001). This finding was consistent in the analysis of studies reporting 30-day follow-up (absolute risk 17.2% vs 4.7%; OR 3.79, 95% CI 3.13 to 4.59; p <0.0001). Co-existing n-IRA CTO was also associated with increased mortality in a subanalysis of patients with multivessel disease only (absolute risk 24.2% vs 11.3%; OR 2.23, 95% CI 1.90 to 2.63; p <0.0001). In conclusion, coronary CTO in the nonculprit artery in patients presenting with ST-segment elevation myocardial infarction is associated with increased short- and long-term all-cause mortality.

The effect of Platelet Lysate on osteoblast proliferation associated with a transient increase of the inflammatory response in bone regeneration

Platelet Lysate (PL) contains a cocktail of growth factors and cytokines, which actively participates in tissue repair and its clinical application has been broadly described. The aim of this study was to assess the regenerative potential of PL for bone repair. We demonstrated that PL stimulation induces a transient increase of the inflammatory response in quiescent human osteoblasts, via NF-kB activation, COX-2 induction, PGE2 production and secretion of pro-inflammatory cytokines. Furthermore, we showed that long-term PL stimulation enhances proliferation of actively replicating osteoblasts, without affecting their differentiation potential, along with changes of cell morphology, resulting in increased cell density at confluence. In confluent resting osteoblasts, PL treatment induced resumption of proliferation, change in cell morphology and increase of cell density at confluence. A burst of PL treatment (24-h) was sufficient to trigger such processes in both conditions. These results correlated with up-regulation of the proliferative and survival pathways ERKs and Akt and with cell cycle re-activation via induction of CyclinD1 and phosphorylation of Rb, following PL stimulation. Our findings demonstrate that PL treatment results in activation and expansion of resting osteoblasts, without affecting their differentiation potential. Therefore PL represents a good therapeutic candidate in regenerative medicine for bone repair.

The EUROpean and Chinese cardiac and renal Remote Ischemic Preconditioning Study (EURO-CRIPS CardioGroup I): A randomized controlled trial

BACKGROUND The potential protective effects of remote ischemic preconditioning (RIPC) on contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) remain to be defined. METHODS AND RESULTS A double blind, randomized, placebo controlled multicenter study was performed. Patients younger than 85years old, with a renal clearance of 30-60ml/min/1.73m2, who were candidates for PCI for all clinical indications except for primary PCI, were allocated 1:1 to RIPC or to standard therapy. The primary endpoint was incidence of CIN. The secondary endpoint was incidence of peri-procedural myocardial infarction (PMI). From February 2013 to April 2014, 3108 patients who were scheduled for coronary angiography were screened for the study. 442 fulfilled the inclusion criteria and 223 received PCI. These patients were randomized to sham RIPC (n=107) or treatment group (n=116). The only pre-specified subgroup of diabetic patients included 85 (38%) cases. RIPC significantly reduced CIN incidence in the overall population (12.1% vs. 26.1%, p=0.01, with a NNT=9) and in non-diabetic patients (9.2% vs. 25.0%, p=0.02), but showed no benefit in diabetics (16.7% vs. 28.2%, p=0.21). A trend for lower PMI was seen in the intervention arm (creatine kinase - muscle brain >5 URL; 8.4% vs. 16.4%, p=0.07; troponin T >5 URL; 27% vs. 38%, p=0.21). CONCLUSIONS Remote ischemic preconditioning significantly reduces the incidence of acute kidney injury in non-diabetic patients undergoing PCI. Larger sample size is presumably needed to assess the effect of RIPC for patients with diabetes mellitus. Clinical Trial number:NCT02195726https://www.clinicaltrial.gov/.

The EUROpean and chinese cardiac and renal Remote ischemic Preconditioning study (EURO-CRIPS): Study design and Methods

Aims Contrast-induced nephropathy (CIN) and periprocedural myocardial infarction (PMI) represent frequent complications of percutaneous coronary intervention (PCI) and negatively impact subsequent length of hospitalization, costs of adjunctive diagnostic–therapeutic measures and mid-term cardiovascular events. The aim of the EURO-CRIPS trial is to test whether remote ischemic preconditioning (RIPC) may reduce the incidence of these complications and improve mid-term outcome. Methods This will be a double-blind, randomized, placebo-controlled multicentre study. Patients will be allocated 1 : 1 to RIPC or standard therapy if they were younger than 85 years old, with a renal clearance in the interval 30–60 ml/min/1.73 m2 and candidate to PCI for all clinical indications except for primary PCI in ST segment elevation myocardial infarction (STEMI), unstable haemodynamic presentations or ongoing severe arrhythmias. Incidence of CIN will be the primary end point and the amount of periprocedural cardiac enzyme leakage will be the secondary end point. In addition, we will evaluate whether the preconditioned patients will have a reduction of MACCE at 6 months (major adverse cardiac and cerebrovascular event). Conclusion The EURO-CRIPS Study will be the first large-scale, multicentre clinical trial to test the role of RIPC in current clinical practice. The results of this randomized trial will provide important insights to optimize management strategy of patients undergoing PCI and to improve their outcome.

Petrified Myocardium The Age of Stone

A 55-year-old woman with a history of type 1 multiple endocrine neoplasia and primary hyperparathyroidism was referred for exertional dyspnea. She had been hospitalized 18 months earlier with septic shock caused by acute peritonitis, and she underwent subtotal parathyroidectomy 1 year before admission. She presented with New York American Heart Association class II dyspnea and no palpable neck mass. Her ECG showed diffuse negatives T waves (Figure 1A). Chest radiograph revealed moderate calcifications at the left ventricular (LV) apex (Figure 1B). Plasmatic albumincorrected calcium and phosphorus levels were 2.7 mmol/L (normal range, 2.1–2.7 mmol/L) and 0.8 mmol/L (normal range, 1.0–1.5), respectively, and parathyroid hormone was 240 pg/mL (range, 17–70 pg/mL). The patient’s echocardiogram showed marked asynergy of the LV apical and posterior walls, and a large acoustic shadow at the LV apex with myocardial calcifications embedded in the LV apical and posterior walls (Figure 2). LV ejection fraction was 49%

Vie chirurgiche d’accesso al gomito in traumatologia

The elbow is a complex anatomical structure. The increasing amount of high energy trauma-related injuries has required the development of several surgical approaches to allow for restoration of the anatomical joint surface and to obtain good clinical outcomes. In this article, we describe the main surgical approaches needed for the treatment of such a complex pattern of traumatic lesions.

Outcome after Combined Lateral Extra-articular Tenodesis and Anterior Cruciate Ligament Revision in Professional Soccer Players

We report the functional outcome after combined anterior cruciate ligament (ACL) reconstruction and lateral extra-articular tenodesis (LET) for ACL re-rupture and high-grade pivot shift in professional soccer players. For this retrospective review, the medical records of 24 professional soccer players were analyzed. The mean age at surgery was 23.8 ± 4.2 years and the mean follow-up was 42.2 ± 16.9 months. Pre- and postoperative assessment included the KT-1000 Lachman test, pivot shift test, International Knee Documentation Committee (IKDC) subjective knee evaluation, Tegner activity scale (TAS), and Lysholm score. The rate of return to sports and the level of play at final follow-up were recorded. ACL revision was performed with an autologous bone-patellar tendon-bone autograft or a hamstring graft. LET was performed using an extra-articular MacIntosh procedure as modified by Arnold-Coker. Anterior-posterior laxity was significantly reduced at the final clinical assessment (p < 0.0001): 22 patients (91.7%) had a negative pivot shift and 2 (8.3%) had residual glide (+), with significant improvement (p < 0.0001). The mean subjective IKDC and Lysholm score improved from 69.5 ± 11.1 (range: 56-90) to 88.4 ± 8.9 (range: 62.1-100) and from 58.1 ± 11.7 (range: 33-72) to 97.4 ± 3.2 (range: 88-100), respectively, with significant improvement (p < 0.0001) over preoperative values. The overall failure rate was 8.3%. There were no differences between mean preinjury and final TAS scores (p > 0.05). The rate of return to sports at the same level was 91.7% and the mean time to return to sports was 9.2 ± 2.2 months. Mid-term functional outcome after combined extra-articular reconstruction and ACL revision surgery was satisfactory, with a reduction in residual postoperative rotatory instability and degree of pivot shift.

Coronary Artery Fenestration

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed clinical entity with a severe prognosis. Whereas conservative management is followed in asymptomatic patients with reassuring hemodynamic status and TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 on angiography, high-risk

TCT-375 Comparison of Long Term Outcome After First- and Second-Generation Drug-Eluting Stents in the Treatment of Chronic Total Occlusions: Insights From a Large Registry of 1,343 Consecutive Patients

exercise capacity and reduction of mortality. Up to date no adequate information on stent strut endothelialisation after CTO treatment is available. In particular, the duration of dual antiplatelet therapy (DAPT) remains an issue of debate. Following CTO treatment, patients are at risk for restenosis as well as stent thrombosis. DAPT is able to sufficient reduce frequency of stent thrombosis, but keeps an increased risk of major bleeding in case of unnecessarily prolonged ingestion. Intracoronary optical coherence tomography (OCT) is a novel invasive method, which is able to precisely analyse stent strut endothelialisation. We tested the hypothesis, that OCT detects delayed endothelialisation after CTO treatment compared to non-CTO PCI. Methods: We performed diagnostic OCT measurements following successful CTO treatment (n 1⁄4 22) as well as non-CTO DES PCI of complex lesions (n 1⁄4 29). All Patients had been treated with 2nd generation DES. Mean time point of OCT analysis was 7.8 months and 6.5 months, respectively (p 1⁄4 0.83). Results: The two groups were well matched and similar concerning characteristics. Stent struts (in total n 1⁄4 13629) were analysed and classified by OCT according to previously described methods (CTO recanalization vs. non-CTO DES; mean +/SEM): covered struts: 81.65 +/2.9% vs. 97.34 +/0.78%, p<0.0001; protruding/uncovered struts: 10.1 +/1.7% vs. 1.4 +/0.4%, p<0.0001; malapposed/uncovered struts: 7.9 +/2.0 % vs. 1.3 +/0.5 %, p<0.001. We performed subgroup analysis concerning CTO recanalization by antegrade vs. retrograde approach as well as subintimal tracking vs. non-subintimal tracking methods. No significant differences were found concerning subgroup analysis. No MACE events were detected in this series. Conclusions: Here we describe delayed stent endothelialisation after CTO treatment. Our results suggest an urgent need to extend the DAPT after CTO treatment to reduce the risk of late stent thrombosis. OCT allows interventional cardiologists to safe and precisely perform follow-up examinations in patients after CTO recanalization with the ability of individualise the duration of DAPT.

TCT-368 Long-Term Clinical Outcome in Elderly Patients (≥75 years) Versus Younger Patients (<75 years) Undergoing PCI for Chronic Total Occlusion

P O S T E R S 70.8% (p1⁄40.46). Coronary perforations (10.5 vs 3.0%, p<0.01) and need for pericardial drainage (3.6 vs 1.0%, p1⁄40.02) were more frequent among retrograde compared to antegrade approach. However, need for emergency cardiac surgery were similar (0 vs 0.9%,p1⁄40.57).RetrogradeCTOPCIwas relatedwith longer procedure time (149.7 58.6 vs 80.7 40.2 min. p<0.01), fluoroscopy time (75.8 39.1 vs 42.5 99.8 min. p<0.01) and higher contrast dose (385 180 vs 257 158ml, p<0.01). The incidence of in-hospital non Q-wave myocardial infarction (0.7 vs 0.1%, p1⁄40.20) and death were similar (0.7 vs 1.1%, p1⁄40.66). The 3-year cumulative incidence ofmyocardial infarction (2.6% vs 1.3%, p1⁄40.81) and cardiac death (4.8% vs 4.7%, p1⁄40.83) were similar between retrograde and antegrade approach. Among patients with successful CTO PCI, the 3-year cumulative target lesion revascularization (TLR) rate was significantly higher in retrograde approach compared with antegrade (12.6% vs 6.9%, p1⁄40.045). Conclusions: Higher incidences of coronary perforation and pericardial drainage, but no emergency cardiac surgery were observed after retrograde CTO PCI. Although long-term TLR rate was higher, retrograde CTO PCI was associated with acceptable procedural success rate and similar short and long-term adverse events compared with antegrade CTO PCI.