Francesco Marzà

Transient Impairment of Vasomotion Function After Successful Chronic Total Occlusion Recanalization

OBJECTIVES The aim of our study was to assess coronary vasomotion after successful revascularization of chronic total occlusion (CTO). BACKGROUND It is largely unknown whether the recovery of anterograde flow after CTO recanalization with drug-eluting stent implantation affects vascular function in distal coronary segments. METHODS One hundred consecutive CTOs successfully treated with drug-eluting stents underwent coronary diameter measurement after intracoronary nitroglycerin injection 5, 20, and 35 mm distal to the stented coronary segment using 3-dimensional quantitative coronary angiography. In a subgroup of 14 patients, coronary vasomotion was tested in distal segments: incremental atrial pacing for endothelium-dependent cases; and intracoronary nitroglycerin injection for endothelium-independent cases. In another subgroup of 13 patients, distal vessels were assessed by intracoronary ultrasounds. RESULTS Vessel diameters significantly increased at follow-up as compared to baseline values (2.0 ± 0.52 mm vs. 2.25 ± 0.50 mm, 1.76 ± 0.49 mm vs. 2.05 ± 0.58 mm, 1.54 ± 0.53 mm vs. 2.04 ± 0.58 mm, at each segment analyzed; p < 0.001). At baseline, distal segments failed to respond to both endothelium-dependent and -independent stimuli. At follow-up, atrial pacing induced vasoconstriction, whereas nitroglycerine administration resulted in significant vasodilation (p < 0.05). Intracoronary ultrasounds failed to show changes of the cross-sectional area of distal segments at follow-up angiography. CONCLUSIONS Recanalization of CTO is followed by a hibernation of vascular wall at distal coronary segments that fail to respond to endothelium-dependent and -independent stimuli. Distal vessel diameter increases over time in the absence of positive remodeling and in spite of persistent endothelial dysfunction. This severe impairment of vasomotor tone after CTO reopening suggests that intracoronary ultrasound assessment is of paramount importance for the selection of stent size.

Management strategies in patients affected by chronic total occlusions: results from the Italian Registry of Chronic Total Occlusions

BACKGROUND Through contemporary literature, the optimal strategy to manage coronary chronic total occlusions (CTOs) remains under debate. OBJECTIVES The aim of the Italian Registry of Chronic Total Occlusions (IRCTO) was to provide data on prevalence, characteristics, and outcome of CTO patients according to the management strategy. METHODS The IRCTO is a prospective real world multicentre registry enrolling patients showing at least one CTO. Clinical and angiographic data were collected independently from the therapeutic strategy [optimal medical therapy (MT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG)]; a comparative 1-year clinical follow-up was performed. RESULTS A total of 1777 patients were enrolled for an overall CTO prevalence of 13.3%. The adopted therapeutic strategies were as follows: MT in 826 patients (46.5%), PCI in 776 patients (43.7%), and CABG in the remaining 175 patients (9.8%). At 1-year follow-up, patients undergoing PCI showed lower rate of major adverse cardiac and cerebrovascular events (MACCE) (2.6% vs. 8.2% and vs. 6.9%; P < 0.001 and P < 0.01) and cardiac death (1.4% vs. 4.7% and vs. 6.3%; P < 0.001 and P < 0.001) in comparison with those treated with MT and CABG, respectively. After propensity score-matching analysis, patients treated with PCI showed lower incidence of cardiac death (1.5 vs. 4.4%; P < 0.001), acute myocardial infarction (1.1 vs. 2.9%; P = 0.03), and re-hospitalization (2.3 vs. 4.4% P = 0.04) in comparison with those managed by MT. CONCLUSIONS Our data showed how CTO PCI might significantly improve the survival and decrease MACCE occurrence at 1 year follow-up in comparison with MT and/or CABG.

Incidence, treatment, and in-hospital outcome of bifurcation lesions in patients undergoing percutaneous coronary interventions for chronic total occlusions.

Background Bifurcation lesions represent a distinct lesion subset associated with an increased risk of procedural complications. Data on the incidence, treatment, and outcome of bifurcation lesions associated with chronic total occlusions are limited. Methods Among chronic total occlusion procedures performed by a single experienced operator, patients with a bifurcation lesion within the chronic total occlusion vessel and a side branch reference diameter greater than or equal to 2.0 mm were enrolled. Results A total of 905 patients (mean age 61.1±9.5 years, men 89.4%) were treated for 922 chronic total occlusion lesions. Among these, 244 bifurcation lesions were observed (26.5%). The procedural time was significantly longer in bifurcation lesions (139±67 vs. 124±68 min; P=0.003), with greater use of contrast load (470±193 vs. 436±227 ml; P=0.04) and higher number of stents (3.1±1.5 vs. 2.9±1.4; P=0.035). Overall, an angiographic success was achieved in 91.1% of cases with a higher rate in nonbifurcation lesions (92.5 vs. 87.3%; P=0.04). Coronary perforations were more often observed in bifurcation lesions (4.9 vs. 1.7%; P<0.001), resulting in more tamponades (2.4 vs. 0.2%; P<0.001). True bifurcations were encountered in the majority of cases (86.8%) and required more two-stent techniques than false bifurcations (50 vs. 18.8%; P=0.001). Conclusion The incidence of bifurcation lesions in chronic total occlusions is higher than that reported in continuous lesions. The presence of a bifurcation lesion increases the complexity of the procedure and may lead to less angiographic success and more periprocedural complications.

Prognostic value of exercise myocardial scintigraphy in patients with coronary chronic total occlusions.

OBJECTIVES To evaluate the prognostic value of exercise myocardial scintigraphy in patients undergoing incomplete revascularization by means of percutaneous coronary intervention (PCI) with at least a residual chronic total occlusion (CTO) left untreated. METHODS Of 569 consecutive patients with multivessel disease undergoing myocardial scintigraphy after incomplete revascularization by PCI between March 1997 and December 2004, 126 (79% male, 64+/-10 years) with >or= 1 residual CTO fulfilled the eligibility criteria and entered in the study. Hard events defined as cardiac death and myocardial infarction, soft events defined as incidence of unstable angina and PCI procedures, and their composite were assessed at a median follow-up period of 44 months. RESULTS Hard events were observed in six patients (4.8%). All of them had severely abnormal perfusion defects detected by myocardial scintigraphy. Soft events occurred in 0 (0%), 10 (7.9%), and 15 (11.9%) patients with normal, mildly abnormal, and severely abnormal perfusion, respectively. In the Kaplan-Meier analysis, the log-rank test was statistically significant across patients stratified by summed stress score either in terms of hard, soft and hard, or soft events. Univariate and multivariate Cox proportional-hazards showed an incremental significant information when the scintigraphic variables were added to clinical, angiographic, left ventricular ejection fraction, and Duke treadmill score, for prediction of the composite of hard and soft cardiac events (P < 0.006). CONCLUSIONS Among patients with a residual CTO left untreated after PCI, myocardial perfusion imaging provides significant independent information concerning the subsequent risk of cardiac events.

Recanalization of Complex Coronary Chronic Total Occlusions Using High-Frequency Vibrational Energy CROSSER Catheter as First-Line Therapy: A Single Center Experience

BACKGROUND Several studies have illustrated the safety and the procedural outcome of high-frequency vibrational energy in guidewire refractory chronic total occlusions (CTOs). AIM To evaluate the advantage of high-frequency vibrational energy device (CROSSER Catheter) use in coronary complex CTO revascularization as primary strategy. METHODS CROSSER was used as a primary approach if four or more unfavorable angiographic features were observed in the CTO lesions. RESULTS From May 2007 to February 2009, a CTO percutaneous intervention attempt was performed in 178 lesions of 171 patients (60.1 +/- 8.9 age with 49.4 +/- 7.2% in ejection fraction). Among these, the CROSSER was used in 46 complex CTO lesions of 45 patients (25.8% of cases) and in the remaining cases, typical CTO percutaneous coronary intervention techniques were employed. Clinical success was 84.8% in CROSSER group. Moreover, in the CROSSER group, no periprocedural myocardial infarction, perforation, or 30 days MACE was observed. In addition, the use of CROSSER was associated with lower time of procedure, time of fluoroscopy, and contrast load administration as compared with conventional techniques [88 +/- 27 minutes vs 109 +/- 38 minutes (P = 0.045), 39 +/- 12 minutes vs 50 +/- 27 minutes (P = 0.032), and 334 +/- 122cc vs 408 +/- 198cc (P = 0.05), respectively]. CONCLUSION In the present study, the CROSSER System was safe and obtained a high rate of success in complex CTO similar to conventional dedicated guidewire techniques for noncomplex CTO; however, the CROSSER Catheter obtained CTO recanalization with lower contrast load administration, less time of procedure, and lower fluoroscopy exposure.

Percutaneous Coronary Interventions for Chronic Total Occlusions: More Benefit for the Patient or for the Interventionist's Ego?

Chronic total occlusions (CTOs) represent a common lesion subset observed in patients who undergo coronary angiography. During the past decade, the interest of the interventionist community in CTOs has exponentially grown with fast advancement in dedicated equipment and techniques, which has resulted in high rates of procedural success and low rates of complications. Although different observational studies have shown that CTO revascularization was associated with good clinical outcome, its real benefit for patients remains to be determined, particularly in the absence of randomized trials. In addition, compared with non-CTO lesions, the American and European guidelines downgraded percutaneous coronary intervention in the setting of CTOs. In this viewpoint, we try to identify patients who would benefit from CTO recanalization, and discuss the issues that might improve the appropriateness of CTO percutaneous coronary intervention.

Iatrogenic Aortic Dissection Complicating Percutaneous Coronary Intervention for Chronic Total Occlusion

BACKGROUND We aimed to determine the prevalence of iatrogenic aortic dissection in chronic total occlusion (CTO) recanalization procedures, and to assess the management strategy and outcome of such a complication. METHODS This study was a retrospective analysis of CTO percutaneous coronary intervention (PCI) cases performed by a single CTO experienced operator. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root. RESULTS Among 956 CTO PCI cases, iatrogenic aortic dissection occurred in 8 patients for an overall frequency of 0.83%. The right coronary artery was the CTO involved vessel in all cases with ostial location and severe calcifications in 37.5% and 62.5% of cases, respectively. Four patients underwent the antegrade approach and a retrograde strategy was adopted in the remaining 4 patients. The iatrogenic aortic dissection started from the right sinus of Valsalva in 87.5% of cases and catheter trauma was the presumed mechanism of dissection in most cases. Stenting of the entry point was performed in all cases, and dissection was limited (< 40 mm) in all patients. No patients required emergency surgery. One cardiac death was observed 12 days after the index procedure (12.5%), and a mean follow-up of 31.5 months was uneventful in the remaining 7 patients. CONCLUSIONS CTO recanalization procedures might be associated with a greater incidence of iatrogenic aortic dissection than non-CTO PCI. The therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment.

Usefulness of SYNTAX score II in complex percutaneous coronary interventions in the setting of acute coronary syndrome

Background SYNTAX score II (SS II) integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality. Aims We sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes (ACS) population with severe coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). Methods From August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 (13.6%) showed severe CAD (three-vessel disease and/or left main involvement). Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events (MACCE) were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization. Results The median SS II was 29 (range, 14–59). Overall, MACCE occurred in 25% of patients (cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%). The 1-year MACCE-free survival was significantly lower in patients with SS (⩾29), than in those with SS II (<29) (64.2% vs. 87.2%, respectively; p = 0.007). In multivariate Cox regression analysis, the presence of unprotected left main stenosis [hazard ratio 2.52, 95% confidence interval (CI): 1.02–5.85; p = 0.031] and SS II ⩾29 (hazard ratio 2.74, 95% CI: 1.30–8.21; p = 0.011) were the only predictors of MACCE at 1-year clinical follow-up. The c-index of SS score II was 0.70 (95% CI: 0.58–0.81). For patients who experienced MACCE, the SS II reclassification improved by 36%, while in nonevent patients the reclassification improved by 22%. The net reclassification index was 0.24 (p = 0.09). Conclusion SS II might represent a useful tool to predict clinical events in not only ideal stable patients, but also an unrestricted, real world population of patients with ACS and severe CAD undergoing PCI.

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization.

Coronary Heart Disease in Postmenopausal Women with Type II Diabetes Mellitus and the Impact of Estrogen Replacement Therapy: A Narrative Review

Coronary heart disease is the main cause of death in postmenopausal women (PMW); moreover its mortality exceeds those for breast cancer in women at all ages. Type II diabetes mellitus is a major cardiovascular risk factor and there is some evidence that the risk conferred by diabetes is greater in women than in men. It was established that the deficiency of endogenous estrogens promotes the atherosclerosis process. However, the impact of estrogen replacement therapy (ERT) on cardiovascular prevention remains controversial. Some authors strongly recommend it, whereas others revealed a concerning trend toward harm. This review tries to underlines the different components of cardiovascular risk in diabetic PMW and to define the place of ERT.