Giuseppe Andolina

Effect of Drug-Coated Balloons in Native Coronary Artery Disease Left With a Dissection.

OBJECTIVES The authors sought to understand the clinical and angiographic outcomes of dissections left after drug-coated balloon (DCB) angioplasty. BACKGROUND Second-generation DCB may be an alternative to stents in selected populations for the treatment of native coronary lesions. However, the use of these devices may be hampered by a certain risk of acute vessel recoil or residual coronary dissection. Moreover, stenting after DCB has shown limited efficacy. Little is known about when a non-flow-limiting dissection is left after DCB angioplasty. METHODS This was a prospective observational study whose aim was to investigate the outcome of a consecutive series of patients with native coronary artery disease treated with second-generation DCB and residual coronary dissection at 2 Italian centers. We evaluated patient clinical conditions at 1 and 9 months, and angiographic follow up was undertaken at 6 months. RESULTS Between July 2012 and July 2014, 156 patients were treated with DCB for native coronary artery disease. Fifty-two patients had a final dissection, 4 of which underwent prosthesis implantation and 48 were left untreated and underwent angiographic follow-up after 201 days (interquartile range: 161 to 250 days). The dissections were all type A to C, and none determined an impaired distal flow. Complete vessel healing at angiography was observed in 45 patients (93.8%), whereas 3 patients had persistent but uncomplicated dissections, and 3 had binary restenosis (6.2%). Late lumen loss was 0.14 mm (-0.14 to 0.42). Major adverse cardiovascular events occurred in 11 patients in the entire cohort and in 4 of the dissection cohort (7.2% vs. 8.1%; p = 0.48). We observed 8 and 3 target lesion revascularizations, respectively (5.3% vs. 6.2%; p = 0.37). CONCLUSIONS In this cohort of consecutive patients treated with new-generation DCB and left with a final dissection, this strategy of revascularization seemed associated with the sealing of most of dissections and without significant neointimal hyperplasia.

Angiographic Evaluation of Coronary Microvascular Dysfunction in Patients with Heart Failure and Preserved Ejection Fraction.

The aim of this study was to evaluate myocardial perfusion and coronary blood flow through validated angiography indices to assess whether there is greater MVD in patients with microvascular angina and HFPEF compared to those who do not have.

An uncommon presentation of eosinophilic granulomatosis with polyangiitis: a case report

IntroductionEosinophilic granulomatosis with polyangiitis is a rare and potentially fatal disease if not readily diagnosed. Cerebral involvement is extremely rare and clinical presentation as hemorrhagic stroke is even rarer.Case presentationA 58-year-old Caucasian man was admitted to our medical unit because of a computed tomography-diagnosed hemorrhagic stroke with right-sided hemiparesis and fever. A chest computed tomography scan also revealed multiple bilateral pulmonary infiltrates; coronary artery, and carotid and left vertebral artery calcifications were also observed. Empiric antimicrobial therapy with cephalosporins was promptly undertaken; low-molecular-weight heparin was introduced as prophylaxis for venous thromboembolism. Over the following days, magnetic resonance imaging scans showed a regression of the hemorrhagic framework, also revealing hypoxic areas consistent with acute ischemic lesions. With a computed tomography scan showing a worsening of his pulmonary framework, antimicrobial therapy was modified and corticosteroids were introduced. A new blood cell count revealed further increased leukocytosis (17.49×103μL), characterized by a surprising rise of eosinophilic cells (32.8%). Angiography of the coronary arteries found diffuse dilatations with severe signs of endothelial damage. Such an unexpected framework induced a strong suspicion that the stroke was the expression of a systemic vasculitis, which had triggered his cerebral, coronary, and pulmonary frameworks. The search for antineutrophil cytoplasmic antibody was positive for perinuclear antineutrophil cytoplasmic antibody, and eosinophilic granulomatosis with polyangiitis was diagnosed. Explaining to the patient the rarity of his disease, and what the most typical presentations of eosinophilic granulomatosis with polyangiitis were, he revealed that before admission he had had scalp injuries, in the nuchal region, and had taken corticosteroids as self-medication, with subsequent disappearance of the lesions. Therefore, high-dose corticosteroid treatment was started, and at discharge he was in good clinical condition with a slight right-sided hyposthenia.ConclusionsA diagnosis of eosinophilic granulomatosis with polyangiitis is often difficult, but we are convinced that intake of corticosteroids on a self-prescribed basis may have obscured the clinical presentation. Therefore, this case also suggests how the growing phenomenon of self-medication can be harmful, and that a careful investigation of clinical history is still an act of paramount importance.

Coronary bifurcation lesions: Some questions need an answer to make bioresorbable vascular scaffold technology more "coronary bifurcation-friendly"

In the last years, the use of bioresorbable vascular scaffold (BVS) has been increasing in daily interventional practice, especially in the setting of patients considered off-label until a few years ago as coronary bifurcation lesions (CBL). In these complex lesions, although the introduction of drug eluting stent (DES) has reduced the rate of complications, the incidence of instent restenosis (ISR) and/or stent thrombosis (ST) is still high in both provisional and double strategy [1]. According to the fully resorbable poly-L-lactide (PLLA) structure of BVS, this device might represent an optimal choice to revascularize CBL overcoming the limits of metallic DES struts, because of its temporary scaffold support without permanent metal layers allowing a bifurcation anatomy and vasomotion restoration, a normal flow pattern due to the resorption of the struts across the side branch (SB) with a natural remodeling. However the other side of the coin is the high thickness of its struts and the large profile that decreases the deliverability andmay induce an alteration of flow pattern with an anomalous endothelial shear stress and an unnatural alteration of the bifurcation integrity, due to the formation of tissue bridge called “neo-carina” after struts resorption [2].

Recurrent in-stent restenosis, certainty of its origin, uncertainty about treatment

Treatment of recurrent in-stent restenosis is a real brainteaser for the interventional cardiologist who cannot resort to the guidelines to have indications about the type of treatment to be preferred. The use of intracoronary imaging may provide insights into the underlying mechanisms of this complication and use of drug-coated balloons may be a valid alternative and especially a thoughtful treatment when the repeated and perseverant use of drug-eluting stents clearly fails. In this setting, we present a review of the literature about this interesting topic, going deep into the heart of the problem, its origin and possible treatment options.

STEMI patients and nonculprit lesions: To treat or not to treat? and when? A review of most recent literature.

Patients with ST segment elevation myocardial infarction and multivessel disease represent a high percentage of ischemic patient with a worse outcome than patient with single coronary artery disease. Therefore, initial management of these patients is of high importance, but unfortunately this is not clarified yet. We analyze the available literature trying to afford current doubts to determine which way of revascularization is to be preferred.

Coronary artery fistulas as a cause of angina: How to manage these patients?

Coronary artery fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the clinical presentation is mainly dependent on the severity of the left-to-right shunt. We describe a case of a 55-year-old man with history of chest pain and without history of previous significant chest wall trauma or any invasive cardiac procedures. A coronary multislice computed tomography showed two large coronary fistulas arising from the left anterior descending coronary artery and ending in an angiomatous plexus draining into the common pulmonary trunk. Coronary angiography confirmed the CT finding and showed a third fistulous communication arising from the sinus node artery. Although coronary fistulas are infrequent, they are becoming increasingly important because their management and treatment could prevent serious complications. The latest guidelines of the American College of Cardiology/American Heart Association indicate as Class I recommendation the percutaneous or surgical closure for large fistulas regardless of symptoms. In this manuscript, we provide a detailed review of the literature on this topic, focusing on the clinical management of these patients.

The percutaneous closure of patent foramen ovale (PFO): impact on the quality of life.

Patent foramen ovale (PFO) is an abnormal communication between the right and the left atriumdue to an incomplete fusion between septum primum and septum secundum [1]. It involves 25–30% of the general population [2]. PFO is often associated to cryptogenic cerebral vascular accident (CVA) [3,4] and migraine with aura [5]. PFO can be also associated with other anatomical abnormalities (Chiari network, septal aneurysm, eustachian valve) which can increase the shunt [1]. As the prevailing increase of PFO percutaneous interventions, we found interesting to assess the “Quality of Life” after percutaneous closure, intending to describe the state of physical, psychological and social well-being. In our center between July 2009 and July 2012, the percutaneous closure of PFO was performed in 34 patients: 20 women (58.8%) and 14 men (41.2%); mean age 46±9.67. The diagnosis of right to left shunt was achieved by the bubble test (9 ml of saline and 1 ml of air) with the transcranial Doppler (TCDc). Then a trans-thoracic echocardiography (TTE) confirmed the right to left shunt of micro-bubbles and allowed to find out the presence of atrial septal aneurysm (ASA) and other anatomical anomalies such as the Chiari network and the eustachian valve. The anatomical and functional characteristics of PFO were then better studied with transesophageal echocardiography (TEE)-(Fig. 1). The indications employed for percutaneous treatment, after careful echocardiographic studies and neurological consults, consist in the occurrence of ischemic events TIA/STROKE, classified as cryptogenic nature (65% of our treated patients), often recurrent, or the presence of multiple cerebral ischemic lesions detected with MRI, even if asymptomatic, for which no valid etiopathogenetic cause could be identified. Moreover 56% complained frequent and debilitating episodes of migraine with aura before treatment. Percutaneous PFO closure was performed under local anesthesia with intracardiac ultrasound guidance (9 MHz Ultra ICE, Boston Scientific Corporation, San Jose, California) to optimize the positioning of the devices. The PFO devices used up to now are: Amplatzer® (4 patients 11.8%), Cardia® (4 patients 11.8%), and Figulla® Flex PFO Occluder (26 patients 76.4%). All patients were then treated with acetylsalicylic acid 100–325 mg/die and Ticlopidine 500 mg/die or Clopidogrel 75 mg/die for the first six months and then only acetylsalicylic acid for another 6 months. The follow-up includes a Holter-ECG (7 days after closure) and then programmed controls: TTE at 1 and 3 months, TTE+TCDc at 6 months and at 1 year. After informed consent, our treated patients were subjected to a validated questionnaire, “Quality of Life” (QoL) SF 36 V1 standard [6], administered before PFO closure and then after 6 months. The questionnaire is a self-compile generic test on quality of life studying multiple aspects of the psycho-physical well-being of the subject through 36 questions. The result obtained from the responses is represented by 8 scales, which is a quantification of a specific aspect of health status. Among our 34 treated patients, 4 were excluded from the study for recent closure; 29 patients were subjected to QoL questionnaire while n=1 was unavailable. The mean values obtained on different fields, from the analysis of the questionnaires, before and after treatment administration, were compared using the Student t-test for paired samples, in order to assess the statistical significance of improvements on quality of life. The obtained values are expressed as mean±1 SD. A p value of b0.05 was considered statistically significant. The procedure was successfully performed in 34 treated patients. No complicationswere recorded during the procedure. The presence of newonset atrial fibrillation (AF) was excluded. A closure rate of 86.6% was obtained and no cerebrovascular symptomatic events occurred in treated patients, until now. The QoL SF-36 questionnaire reported a positive impact of the procedure on the quality of life by re-appropriation of normal daily activities; also from the psychological point of view. The comparison of the mean values obtained from the analysis on different fields of the questionnaire, before and after treatment, has suggested a statistically significant improvement in quality of life (Table 1). This result is reasonably related to the improvement of migraine patients which were confined below all aspects. Among our 19 patients which were affected from severe migraine with aura, 94.7% had in fact a significant benefit in health, due to an important reduction of the migraine frequency and severity or even their interruption (p=0.0001). In patients with cryptogenic stroke and PFO, the percutaneous closure treatment represents a possible and effective procedure and a possible alternative to the only antiplatelet or anticoagulant medical therapy conducted for a lifetime [7,8], even if the first randomized controlled trial, CLOSURE I,has not demonstrated the superiority of the percutaneous treatment against themedical therapy [9]. In our center the percutaneous technique was initiated relatively recently, however our results are encouraging. We considered only the presence of CVA as the main

Short-Term Prognosis of Juvenile Myocardial Infarction Role of Plasma Viscosity

In our early research regarding the hemorheological pattern in patients with acute myocardial infarction (AMI) with a mean age of 61.45 + 10.99 years, we showed that the major hemorheological parameters were almost normalized 2 weeks after the acute event. In the last decade, we focused on hemorheological parameters in juvenile myocardial infarction (JMI), defined as AMI in patients aged 45 years, in the ‘‘Sicilian study on juvenile myocardial infarction’’. Juvenile myocardial infarction is responsible for 2% to 10% of all cases with AMI in different surveys. Juvenile myocardial infarction presents a typical pattern of risk factors and shows clinical, angiographic, and prognostic characteristics. Regarding risk factors, cigarette smoking is by far the most common, followed by family history of coronary artery disease and hypercholesterolemia, while arterial hypertension and diabetes mellitus are less frequent. Juvenile myocardial infarction may be associated with the use of oral contraceptives, pregnancy, or cocaine abuse as well as with congenital coronary artery abnormalities. Concerning the clinical picture, patients with JMI reach hospital earlier than older patients, enhancing the effectiveness of revascularization procedures and treatment of complications. In JMI, the absence of coronary stenosis is often demonstrated or just 1 coronary vessel is affected; 2or 3vessel disease is infrequent. Generally, patients with JMI have a lower incidence of complications, such as early and late heart failure, angina, reinfarction, and atrioventricular block; mortality during hospitalization and after 6 months is significantly reduced. In the Sicilian study, we observed a pattern of inflammatory polymorphisms in patients with JMI. A higher prevalence of proinflammatory polymorphisms (SNP A2080G of pyrin gene, SNP Gly670Arg of PECAM gene, C1019T of Cx 37 gene, and SNP G1059C of PCR gene) and a lower prevalence of antiinflammatory polymorphisms (Asp299Gly of TLR4 gene, SNP – 1082 G/A of IL10 gene, CCR5D32) were present. We revisited plasma viscosity (PV) in our survey of patients with JMI and considered 2 aspects in particular. The first is the potential role played by PV in the dynamics of myocardial microcirculation (namely, in the phenomenon of coronary slow flow) that may be secondary to AMI; the second aspect was life expectancy. Plasma viscosity is dependent on the plasma protein concentration, although the contribution of different proteins (fibrinogen, a2-macroglobulin, immunoglobulins, haptoglobin, and ceruloplasmin) differs in relation to their molecular size and shape; the plasma protein composition can also change due to pathophysiological processes. The PV plays a pivotal role, together with erythrocyte deformability and platelets, in microcirculatory blood flow. In this editorial, we describe the behavior of PV in 120 patients with JMI (109 men; mean age 39.4 + 5.8 years); the time interval between AMI onset and the first hemorheological evaluation was 13 + 7 days. Using fasting venous blood, we measured PV at the shear rate of 450 s 1 using the cone-andplate viscometer Wells-Brookfield mod 1⁄2 LVT (Middleboro, Massachusetts). We reexamined this parameter 3 (n 1⁄4 83) and 12 (n 1⁄4 70) months after AMI. At the initial stage, PV was increased compared to controls (CS 1.259 + 0.125 vs JMI 1.519 + 0.108 mPas, P < .001). The PV did not differ between ST-segment elevation myocardial infarction (STEMI) and non-STEMI as well as in 3 subgroups of the patients with JMI subdivided according to the number of cardiovascular risk factors (39 had 0 or 1 risk factor, 39 had 2 risk factors, and 42 had 3). Coronary angiography was performed in 103 patients; no significant coronary stenosis was demonstrated in 23, 46 had a single vessel disease, and 34 had multi-vessel disease. The PV did not differ between the 3 subgroups. At 3 and 12 months after AMI, PV was persistently increased compared to controls (at 3 months 1.466 + 0.119 mPas and at 12 months 1.475 + 0.009 mPa-s, respectively). Although the literature has described a low incidence of cardiovascular complications in JMI, in our survey, followup carried out for as long as 18 months showed that 5 patients developed heart failure, 15 a new ischemic event (angina in 12

Score System Approach to Diagnose and Manage Spontaneous Coronary Artery Dissection

We have read with great interest the publication by Lezcano Gort et al. The authors have kindly reported their experience in which a 40-year-old postpartum woman with no relevant coronary risk factors was admitted for non–ST-segment elevation myocardial infarction in which optical coherence tomography and intravascular ultrasound images showed a multivessel spontaneous coronary artery dissection (SCAD).