Francesco Meucci

Long-term invasive follow-up of the everolimus-eluting bioresorbable vascular scaffold: Five-year results of multiple invasive imaging modalities

AIMS Invasive imaging modalities have shown restoration of vasomotion, prevention of restenosis and, most importantly, increase in lumen area between six months and two years after first-generation everolimus-eluting bioresorbable vascular scaffold (Absorb BVS) implantation. Our aim was to assess whether these positive findings were sustained in the long term. METHODS AND RESULTS Patients included in the ABSORB cohort A from the Thoraxcenter Rotterdam cohort underwent coronary catheterisation including angiography, intravascular ultrasound (IVUS), virtual histology, optical coherence tomography (OCT) and vasomotion testing at five years. Eight out of 16 patients underwent catheterisation and scaffold assessment with multiple imaging modalities. A trend towards an increase in minimum luminal diameter was observed between two and five years by angiography (1.95±0.37 mm vs. 2.14±0.38 mm; p=0.09). IVUS data showed an increase in mean lumen area at five years (6.96±1.13 mm2) compared to six months (6.17±0.74 mm2; p=0.06) and two years (6.56±1.16 mm2; p=0.12), primarily due to a persistent reduction in plaque area size between six months and five years (9.17±1.86 mm2 vs. 7.57±1.63 mm2; p=0.03). The necrotic core area was reduced at five years compared to post-procedural results. In OCT, an increase in mean and minimal luminal area was observed. Moreover, no scaffold struts could be identified and a smooth endoluminal lining was observed. The scaffolded coronary segment did not show signs of endothelial dysfunction with acetylcholine testing. CONCLUSIONS At five years, the Absorb BVS is no longer discernible by any invasive imaging method and endothelial function is restored. Late luminal enlargement persists up to five years of follow-up without adaptive vessel remodelling.

Tools and Techniques Clinical: transcatheter closure of left atrial appendage using the Amplatzer™ Cardiac Plug.

Background Since chronic oral anticoagulation cannot be administered in a substantial proportion of patients with atrial fibrillation, the endovascular exclusion of the left atrial appendage (LAA), which represents the source of atrial-derived emboli in the majority of cases, has been proposed as a valuable alternative in selected patients. In this article we briefly summarise the basic steps to perform an effective and safe implantation procedure using the AmplatzerTM Cardiac Plug (ACP; St. Jude Medical, Plymouth, MN, USA). Methods First, both cardiac computed tomography and transoesophageal echocardiography should be complementarily performed to study LAA anatomy and size accurately (Figure 1). LAA dimensions must be validated and confirmed during the procedure either by TEE or intracardiac echo (ICE) and angiographic measurements. It is recommended that the AmplatzerTM Cardiac Plug be oversized by about 2 to 3 mm with respect to the LAA measurements. Second, a transseptal puncture, using either the Mullins sheath (Medtronic AVE, Galway, Ireland) or the SL1 sheath (St. Jude Medical, Plymouth, MN, USA), should be performed in the lower part of the fossa ovalis. Third, after the advancement of a marker pigtail catheter (5 Fr, 100 cm long) through the transseptal sheath and the localisation of the pigtail catheter inside the LAA, perform an LAA angiogram to size the LAA ostium and “neck” angiographically. Fourth, prepare the LAA device accurately in

Comparison between drug-eluting and bare metal stent on ST-elevation myocardial infarction outcome: Should second-generation drug-eluting stent be preferred?

BACKGROUND AND PURPOSE Although several studies reported that drug-eluting stents (DES) are able to reduce restenosis incidence without increasing mortality, concerns still exist about their safety in ST-segment elevation myocardial infarction (STEMI) patients mainly for a possible higher rate of in-stent thrombosis. Recent evidence suggests a better safety profile of second-generation DES, but data on their outcome in STEMI are still poor. In this study we evaluated the impact on mortality and target lesion revascularization (TLR) of DES or bare metal stent (BMS) implantation in STEMI patients submitted to primary angioplasty. METHODS AND SUBJECTS We analyzed mortality and TLR in 1150 STEMI patients during a mean 43-month follow-up after DES (44.6%) or BMS (55.4%) implantation. A propensity score method was used to minimize bias. During follow-up, 223 deaths occurred. ESSENTIAL RESULTS Unadjusted for potential confounders, DES implantation was associated with a significant reduction in all-cause mortality [hazard ratio (HR) 0.40; 95%CI 0.30-0.54] and TLR (HR 0.55; 95%CI 0.36-0.86); this latter was confirmed after propensity score analysis (HR 0.39; 95%CI 0.21-0.67). Second- (n=179) vs. first- (n=337) generation DES showed a further reduction in TLR (HR 0.17; 95%CI 0.05-0.57). Adjusted analyses showed a significant reduction in the combined end-point of all-cause mortality or TLR after both first- and second-generation DES vs. BMS implantation with a trend to a lower risk for second- vs. first-generation DES. PRINCIPAL CONCLUSIONS DES implantation in STEMI patients showed a significant reduction in TLR and in the combined endpoint of TLR or mortality. Second-generation DES showed a more protective effect on the combined endpoint, suggesting that they would be preferred in this setting.

Thrombus aspiration in elderly STEMI patients: A single center experience

No data is so far available on the impact of thrombus aspiration onoutcome in the elderly patients with ST elevation myocardial infarc-tion (STEMI) submitted to primary PCI (pPCI9) [1–4].We aimed at assessing the factors influencing the decision to usethrombus aspiration and its prognostic impact at short and long termsin404elderly(>/=75 yearold)STEMIpatientssubmittedtopPCI,con-secutively admitted to our Intensive Cardiac Care Unit (ICCU) from 1stJanuary2004to31thDecember2010(theFlorenceSTEMIregistry)[5–7].According to our Cath Labs policy, thrombus aspiration wasperformed in presence of:a) Thrombolysis In Myocardial Infarction (TIMI) grade 0 to 1 flow.b) TIMI thrombus grades 3 to 5 [8–11].c) An infarction-related artery minimal reference diameter of at least2.5 mm [12–14].Mechanical (Export Medtronic device) or Rheolytic (AngioJetrheolytic thrombectomy System, Medrad Interventional/Possis,Minneapolis, Minnesota) thrombus aspiration was performed accordingto the interventional cardiologists discretion [12,14].Theprimaryoutcomeswere mortalityrateduring ICCUstay andatfollow-up. One-year post discharge mortality was computed as previ-ously described [15].ThestudyprotocolwasinaccordancewiththeDeclarationofHelsinkiand approved by the local Ethics Committee. Informed consent wasobtained in all patients before enrollment.Ap-valueb0.05 was considered statistically signi ficant. Continuousvariableswerereportedasmean ± SD;categoricalvariablesaredepictedas frequency (percentage). For continuous variables, between-groupcomparisons were performed with Students t-test; categorical vari-ables were compared with chi-square.Multivariablecorrelationofthromboaspirationwithin-ICCUmortal-itywasinvestigatedwithlogisticregressionanalysis:candidatevariablewascarefullychosenamongthoseknowntobeclinicallyrelatedtoout-comeinordertoavoidmodeloverfitting.One-yearpost-dischargemor-talitywasinvestigated,afterassessmentofhazardproportionality,withmultivariable Cox regression analyses, in which the thromboaspirationhas been adjusted for age of patients (1 year step), ejection fraction atdischarge (1% step) and eGFR (1 ml/min/1.73 m

Left atrial appendage closure using AMPLATZER™ devices: A large, multicenter, Italian registry

BACKGROUND Left atrial appendage occlusion (LAAO) has been proven to be effective for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF). We aim to assess the safety and efficacy of LAAO by AMPLATZER™ devices in a large, multicenter, single-nation cohort of NVAF patients at high-risk of stroke and bleeding. METHODS From December 2008 to April 2015 613 NVAF patients (75.1±8.0years, 62.5% male) underwent LAAO in 15 Italian centers by AMPLATZER™ devices. There were no restrictions on any personal/institutional protocols with respect to indications, pre-procedural planning, device implantation, drug therapy and follow-up. All the baseline characteristics, imaging, procedural and follow-up data were collected in a single dataset. RESULTS AMPLATZER™ devices were successfully implanted in 95.4% of cases. Major complications occurred during 38 procedures (6.2%) and included more frequently major bleeding (3.3%) and pericardial tamponade (2.0%). At a mean follow-up of 20months, the overall annual rates of stroke and thromboembolic events, including those periprocedural, was 1.67% and 2.90%, respectively, consisting in a reduction in the rate of stroke and TIA of 66% compared with the risk-based expectation. Among the 218 patients undergoing transesophageal echocardiography at 6months of follow-up, device thrombosis was present in 1.8% of the patients whilst a significant or mild to moderate peri-device leak was found in 0.5% and 11.9% of cases, respectively. CONCLUSIONS In this large, multicenter, single-nation study, LAAO with the AMPLATZER™ devices showed high procedural success, early safety and mid-term efficacy for the prevention of NVAF-related thromboembolism.

COmparison between COronary THrombus aspiration with Angiojet® or Export® catheter in patients with ST-elevation myocardial infarction submitted to primary angioplasty: The COCOTH Study

AIMS To compare the effects of two thrombus aspiration devices, the manual catheter Export® and the more complex and expensive mechanical Angiojet®, on several indices of reperfusion in acute ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS Clinical, hemodynamic and procedural characteristics of 185 STEMI patients, randomized to treatment with Export (n=95) or Angiojet (n=90) during primary percutaneous coronary intervention (PPCI) were analyzed. The primary endpoint was ST-segment elevation reduction 90 min after culprit vessel re-opening. Secondary endpoints included variations in some angiographic parameters (TIMI Flow, TIMI Frame Count and Myocardial Blush Grade) and Infarct Size and Severity at myocardial scintigraphy. A significant reduction in ST-elevation was observed in both groups after PPCI without significant differences between the two groups. No significant difference between Angiojet vs. Export was observed in ST-segment resolution >50% and ≥ 70%, in TIMI Flow, TIMI Frame Count and Myocardial Blush Grade before vs. after PPCI and in Infarct Size and Severity. CONCLUSIONS PPCI with thrombus aspiration was effective in both groups of patients, without differences in myocardial reperfusion and necrosis indices. These results could support the routine use of manual devices during PPCI, reserving the more expensive Angiojet in case of manual device failure and persistent or massive intracoronary thrombosis, with favorable implications in terms of cost containment.

Primary PCI in a patient with acute occlusion of native LAD beyond the LIMA graft anastomosis: first reported case, technical challenges and review of the literature

We present a case of a man with an anterior STEMI due to acute occlusion of the LAD, distally to the anastomosis with LIMA graft. We describe our treatment strategy with primary PCI and the difficulties we encountered: insufficient length of balloon and stent shafts and need for deep intubation of the graft with the guiding catheter. The procedure was complicated by graft dissection that was successfully treated with a DES. Afterwards we successfully stented the culprit lesion. We discuss technical possibilities for overcoming such difficulties and present brief review of literature on STEMI in patients with previous CABG.

Prospectively electrocardiogram-triggered high-pitch spiral acquisition coronary computed tomography angiography for assessment of biodegradable vascular scaffold expansion: Comparison with optical coherence tomography☆ , ☆☆

BVS polymeric struts are transparent to the light so that the vessel wall contour can be easily visualized using optical coherence tomography (OCT). Therefore OCT represents a unique tool for both the evaluation of the resorption process and for the assessment of acute BVS mechanical failure. Similarly, the metal-free struts allow unrestricted coronary computed tomography angiography (CCTA), thus this non invasive method might become the gold standard for a non invasive assessment of BVS. In this case we show the ability of CCTA, performed with a low X-Ray dose, to provide a good evaluation of scaffold expansion. The quantitative measurements were in agreement with those obtained with OCT.

Isolated Papillary Muscle Rupture Complicating Acute Pancreatitis

Papillary muscle rupture in the absence of coronary stenoses is a rare event. An isolated infarction of the papillary muscle is involved in most cases, but the pathogenesis is still debated. We describe an anterolateral papillary muscle rupture complicating acute pancreatitis in a patient without significant coronary stenoses and with evidence of coronary spasm. This suggests that an increased susceptibility to coronary spasm and thrombosis, triggered by an acute systemic inflammatory response, may represent a mechanism of selective papillary muscle infarction.

MitraClip Implantation to Treat Early Recurrence of Mitral Regurgitation After Percutaneous Direct Annuloplasty With Cardioband

An 80-year-old man presented with severe dyspnea (New York Heart Association functional class III/IV) due to severe left ventricular dysfunction (ejection fraction 35%) and severe functional mitral regurgitation (FMR). His medical history included chronic obstructive pulmonary disease, chronic renal