Gaetano Palma

Inflammation and Cardiovascular Disease: From Pathogenesis to Therapeutic Target

Atherosclerosis represents the most common pathological substrate of coronary heart disease (CHD), and the characterization of the disease as a chronic low-grade inflammatory condition is now largely accepted. A number of mediators of inflammation have been widely studied, both as surrogate biomarkers and as causal agents, in the pathophysiological network of atherogenesis and plaque vulnerability. The epidemiological observation that biomarkers of inflammation are associated with clinical cardiovascular risk supports the theory that targeted anti-inflammatory treatment appears to be a promising strategy in reducing residual cardiovascular risk on the background of traditional medical therapy. A large number of randomized controlled trials have shown that drugs commonly used in cardiovascular disease (CVD), such as statins, may be effective in the primary and secondary prevention of cardiovascular events through an anti-inflammatory effect. Moreover, several anti-inflammatory drugs are being tested for their potential to reduce residual cardiovascular risk on the background of validated medical therapy for atherosclerotic disease. In this paper, we review relevant evidence with regard to the relationship between inflammation and CVD, from pathogenesis to therapeutic strategies.

Technetium-99m methoxy isobutyl isonitrile simultaneous evaluation of ventricular function and myocardial perfusion in patients with congenital heart disease.

The authors evaluated the clinical applications of Tc- 99m methoxy isobutyl isonitrile (MIBI) in the simultaneous assessment of ventricular function and myocardial perfusion in patients with congenital heart disease. Global ventricular function was assessed by first-pass ECG gated study. Myocardial perfusion was evaluated on images performed 1 hour after the injection of the tracer. Regional wall motion and systolic thickening were assessed by gated study acquired after the perfusion study. Two young patients were studied after a surgical Glenn procedure. The first patient, with a history of transposition of the great vessels and univentricuiar heart, had an ejection fraction of 44%. The left ventricle was dilated and the right ventricle was not appreciable. The septal and inferoapical regions showed reduced perfusion and reduced systolic thickening. The second patient, with a history of pulmonary atresia, septal defect and left ventricular hypoplasia, had a right ventricular ejection fraction of 37%. Regional wall motion, systolic thickening, and myocardial perfusion were normal. The right ventricle was hypertrophic and larger than the left ventricle. Thus, a single injection of Tc-99m MIBI allows noninvasive simultaneous assessment of global and regional ventricular function and myocardial perfusion in young patients with complicated congenital heart disease

First experience with sildenafil after Fontan operation: short-term outcomes.

Background We conducted a retrospective study to determine the effect of oral sildenafil administrated as monotherapy after Fontan operation in single ventricle physiology. Methods From January 2008 to March 2012, during two different periods, a total of 30 pediatric patients undergoing Fontan operation by extracardiac conduit were included in this study. Thirteen patients were in the sildenafil group and exclusively treated with sildenafil given at the dose of 0.35 mg/kg through a nasogastric tube and then orally every 4 h, at the start of cardiopulmonary bypass and for the first postoperative week; then we reduced and discontinued the therapy. The other 17 patients were in the control group. No other vasodilator was administered in both groups. We analyzed intraoperative and postoperative outcomes of sildenafil administration. Results There were no differences in mortality or operative time. The total and relative drainage loss was lower in the sildenafil group (P = 0.0003 and 0.0045). The hemodynamic parameters showed a better condition in the sildenafil group, with a lower mean pulmonary artery pressure (mPAP) (P = 0.0001) and better mPAP to mean systemic blood pressure (mSBP) ratio (P = 0.0043), whereas there was no difference in peripheral oxygen saturation (P = 0.31). The sidenafil group patients showed other additional positive differences as well as lower inotropic score (P = 0.0005) and intubation time (P = 0.0004). No complications related to the use of sildenafil were noted in any of the children studied. Conclusion This initial experience provides evidence that sildenafil may be used in postoperative Fontan operation with positive effectiveness.

Transradial versus transfemoral ancillary approach in complex structural, coronary, and peripheral interventions. Results from the multicenter ancillary registry: A study of the Italian Radial Club

to understand the role of a transradial (TR) secondary approach during complex percutaneous interventions.

Pulmonary atresia with intact ventricular septum: Is it possible to improve survival?

Between February 1986 and December 1991, 41 patients with pulmonary atresia and intact ventricular septum were treated in our institution following a multistage protocol of management. In all cases, the first step was to construct a right modified Blalock-Taussig shunt during the neonatal period regardless of the right ventricular anatomy. Then, in patients with well-developed right ventricles possessing all three components, we proceeded to early surgical repair. In contrast, in patients with right ventricles having obliteration of some components, yet deemed to be recoverable, the next step was to provide palliative relief of obstruction in the right ventricular outflow tract followed, if possible, by subsequent repair. Fontans operation was performed in patients with right ventricles considered unsuitable from the outset to support the pulmonary circulation. Only one patient died following the initial shunt procedure (mortality of 2.43%). The subsequent program of treatment has now been concluded in 22 patients. In all those deemed to have favorable native anatomy (10 cases), the subsequent complete repair was successful. Among the 24 patients who required palliation of the outflow tract, five died while total repair was subsequently performed in eight. Fontans operation was performed without mortality in five patients with small right ventricles, although one patient died while waiting for surgery. In all, 89 procedures were performed with an overall mortality of 14%.

First experience of drug-coated balloons for treatment of bioresorbable vascular scaffold restenosis

OBJECTIVES The aim of this study is to evaluate the role of drug-coated balloons (DCB) for the management of bioresorbable vascular scaffold (BVS) restenosis. METHODS AND RESULTS In a series of 25 BVS restenosis discovered during systematic angiographic follow up of 246 consecutive BVS implantations at our institution, DCB was used as a primary therapeutic tool in 9 patients and 3 different types of DCB were used. Follow-up coronary angiography at 12months after DCB treatment was performed to all the patients. Among the 9 patients treated with DCB, angiographic follow up revealed failure in two patients that experienced type III restenosis (both of them treated with the same type of DCB). Both patients were treated with drug eluting stent implantation. CONCLUSIONS In this case series of consecutive patients with BVS restenosis, the use of certain types of DCB is safe and effective in order to maintain vessel patency at mid-term follow up. Despite the small sample size and the study limitations, DCB can provide therefore an alternative treatment option in this setting, avoiding the implantation of further metallic stents in a patient where a different strategy was initially planned.

Immediate and short-term performance of a novel sirolimus-coated balloon during complex percutaneous coronary interventions. The FAtebenefratelli SIrolimus COated-balloon (FASICO) registry

BACKGROUND AND PURPOSES Drug-coated balloons (DCB) currently represent an alternative to drug-eluting stents (DES) for the treatment of in-stent restenosis and they are also variably used for small coronary vessel and bifurcation lesion management. All DCB variably elute paclitaxel as an anti-proliferative drug. The first sirolimus coated balloon (SCB) received the CE mark in 2016, but its clinical performance has not been shown yet. METHODS AND RESULTS FASICO in an all-comer registry of the first consecutive patients with at least one lesion treated with SCB between March and July 2016 at the first European centre that used this device. All patients were prospectively enrolled in a dedicated database. Primary endpoint was procedural success; co-primary endpoint was the rate of major adverse cardiac events at short-term follow-up. The 32 patients (34 lesions) enrolled had at least 6-month clinical follow up available. Forty-five percent had diabetes and indication to PCI was ISR in 47% of the cases. Lesions were always pre-dilated and device deployment was successful in all the cases. Procedural success was achieved in 100% of patients. We observed 3 cases of TLR at follow-up. CONCLUSIONS SCB shows high immediate technical performance and adequate short-term efficacy and safety. The ongoing EASTBOURNE registry will shed light on mid-and long-term performance of this device in an adequately powered population.

Coronary sinus perforation during reducer implantation

Coronary Sinus Reducer (Neovasc, Inc., Richmond B.C., Canada) has shown to be an effective and safe treatment option for the treatment of refractory angina. Until now, a few number of complications related to its implantation have been reported. Coronary sinus perforation is a rare complication, more often related to cardiac surgery procedures. We report the first case of coronary sinus perforation after a sinus Reducer implantation.

Clinical and angiographic outcome of a single center, real world population treated with a dedicated technique of implantation for bioresorbable vascular scaffolds. The FAtebenefratelli Bioresorbable Vascular Scaffold (FABS) registry

OBJECTIVES With this prospective study we aim at investigating the long-term outcome of a consecutive cohort of patients successfully treated with bioresorbable scaffold (BVS) implantation. BACKGROUND It is not clearly understood if there is a relation between the technique of BVS implantation and the outcome. METHODS Between December 2012 and December 2014, all consecutive patients treated with BVS were included in this registry and received an angiographic follow-up. After a run-in phase, all BVS were implanted using a specific technique consisting of aggressive predilation, correct scaffold sizing, visually determined, and high-pressure post-dilation with a noncompliance balloon. Primary endpoint was late lumen loss (LLL) at 1-year angiographic follow-up and ischemia-driven target-lesion revascularization (ID-TLR) at 2-year clinical follow-up. Secondary endpoints were the occurrence of binary restenosis, major adverse cardiac events (MACE), and every single component of MACE (cardiac death, myocardial infarction, TLR) at 2 years. RESULTS A total of 144 lesions in 122 patients treated consecutively with BVS, were enrolled. Diabetics were 29.5% and acute coronary syndrome at presentation occurred in 29.5% of patients. At the angiographic follow-up LLL was 0.38 ± 0.9. At 2-year clinical follow-up, ID-TLR occurred in eight patients (5.6%). We observed two cases of scaffold thrombosis (1.38%, one early and one very late). At multivariate statistical analysis, STEMI presentation remained a significant predictor for TLR. CONCLUSIONS In a complex, all-comers real world population, BVS implantation with a specific, and standardized technique showed to be feasible, with acceptable mid-term angiographic and long-term clinical outcome.

True Competitor of Femoral Access for Iliac Endovascular Interventions: A Radial Appraisal

To the editors: We read with much interest the article “Efficacy and Safety of Transbrachial Access for Iliac Endovascular Interventions,” which related the results of a retrospective study that enrolled 201 patients treated via transbrachial access for iliac artery disease. This study concluded that brachial access enables endovascular treatment of iliac artery disease in the majority of patients, although an adjunctive transfemoral access may be required. However, a significant limitation of this route was the high incidence of access site complications and strokes, which, as correctly stated by the authors, favored the use of the transfemoral route. We believe that something is missing here: 20 to 25 cm away is the radial artery, which has become the most important route for coronary angioplasty, now used in >70% of these interventions in Europe. In a recent multicenter study coordinated by the Italian Radial Force, we investigated the role of a transradial approach for endovascular iliac interventions in 149 consecutive patients at radial expert centers. Procedure success was achieved in 98.7% of the population, and an ancillary transfemoral approach was required only in 13%. No major bleedings or strokes were recorded during hospitalization. In addition, 1-month freedom from symptoms was achieved in 97.3% of patients, and the rate of radial occlusion (assessed in 60% of the patients) was as low as 2.7%. Moreover, there were no major cardiac or cerebrovascular events. We have to admit that currently available devices have been developed for transfemoral use. Although some of them have increased shaft length and low profile, allowing the iliac arteries to be accessed from the wrist, we believe that endovascular device companies should continue developing dedicated equipment for a transradial approach to peripheral interventions. In summary, as regards the transbrachial approach for iliac interventions, we would like to underline that radial access is a safe and efficient alternative to a transfemoral approach, at least in selected cases and in expert hands.