Joan García-Picart

Non-Invasive Coronary Angiography With 16 Multidetector-Row Spiral Computed Tomography: a Comparative Study With Invasive Coronary Angiography

INTRODUCTION AND OBJECTIVES Non-invasive coronary artery angiography by 16 multidetector-row spiral computed tomography is a novel diagnostic tool whose reliability is still unclear. The aim of our study was to compare this technique with invasive coronary angiography. PATIENTS AND METHOD A total of 31 selected patients were examined with both angiographic methods. Non-invasive studies were performed with a helical computer tomography system (Toshiba Aquilion 16-slices). A contrast agent was injected into a peripheral vein, and cross-sectional images were reconstructed with a slice thickness of 0.5 mm or 1.0 mm. Findings from both techniques were analyzed according to a predetermined segmented anatomical model of the coronary artery. The detection and relevance of coronary artery lesions were evaluated, and lesions with a reduction in diameter of more than 50% were considered significant. RESULTS Non-invasive coronary angiography yielded an appropriate assessment in 88.4% of the coronary artery segments. The reasons that prevented correct segment evaluation were extensive coronary calcifications, inappropriate breath-hold, motion artefacts and small vessel size. Sensitivity and specificity for the detection of significant coronary lesions with the non-invasive method were 75% and 91%, respectively. Sensitivity and specificity for individual coronary artery segments were as follows: proximal, 89% and 93%; medial, 87% and 90%; distal, 50% and 90%; and secondary branches, 62% and 92%. CONCLUSIONS Non-invasive coronary artery angiography with 16 multidetector-row computed tomography is a powerful diagnostic tool, especially for the evaluation of the proximal and medial segments of the major coronary arteries.

Endothelial progenitor cell capturing stent and short dual antiplatelet therapy in patients on chronic anti-vitamin k regimen undergoing percutaneous coronary interventions: long-term outcomes of a single centre registry.

AIMS To evaluate outcomes of the endothelial progenitor cell (EPC) capture stent in patients on chronic anti-vitamin K (AVK) regimen, requiring percutaneous coronary intervention (PCI). METHODS AND RESULTS Between February 2007 and February 2008, 78 consecutive patients under chronic AVK treatment undergoing PCI were enrolled in the registry and received an EPC capture stent. The incidence of comorbid conditions was analysed by the Charlson index. Dual antiplatelet therapy (DAT, aspirin and clopidogrel) was prescribed for one month only together with the AVK treatment, after PCI. Major adverse clinical events (MACE) rate, included death, acute myocardial infarction (MI) or target lesion revascularisation (TLR), incidence of stent thrombosis and rate of haemorrhagic events were collected. A?Charlson index >3 was present in 89% of patients. At 14±8 months the cumulative rate of MACE was 22%: 10 deaths (six cardiac deaths), and six TLR. No MI or definitive/probable stent thromboses occurred during follow-up. Four major haemorrhagic episodes occurred during follow-up, all of them after the first month. CONCLUSIONS Patients on AVK treatment represent a highly comorbid population with a high event rate after PCI. The strategy of PCI with an EPC capture stent and short duration of DAT may be used in patients who need a short-term DAT.

Intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration

Aim: Massive intracoronary thrombus is associated with adverse procedural results including failed aspiration and unfavourable reperfusion. In this scenario the best treatment remains unknown. We aim to evaluate the effect of low dose intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction (STEMI) presenting with a large thrombus burden and failed aspiration. Methods and results: In this study 30 STEMI patients with a large thrombus burden and failed manual aspiration were included in the registry. Local fibrinolysis with low dose (one-third of systemic) tenecteplase (27%) or alteplase (73%) was administered via a 6F-infusion catheter. A thrombus was qualified as large when its maximal dimension was ≥2 vessels (thrombolysis in myocardial infarction (TIMI) thrombus grade 4 and 5). Altogether 33% of patients received delayed invasive therapy (>12 h) guided by the presence of recurrent symptoms and/or ischaemia. A total of 17% of patients presented with cardiogenic shock and half of the population received glycoprotein IIb/IIIa inhibitors. A post-lysis thrombus grade 4–5 was found in just one patient. TIMI flow grade improved from 0/1 at baseline (93%) to ≥2 in most patients (97%). Blush grade 2–3 was observed in 85% and we observed a similar percentage (82%) of more than 50% ST-segment resolution. In-hospital mortality was 10% (three patients with cardiogenic shock). No major bleeding events were observed. At a median follow-up of 14 (6–35) months, only one new clinical event was reported (1 target lesion revascularization, (TLR)). Conclusions: In STEMI patients with a large thrombus burden and failed manual aspiration, administration of low dose intracoronary thrombolysis is safe and reduces trhombus burden, as a result improving in epicardial flow and myocardial reperfusion.

Evaluación de la permeabilidad de los injertos de arteria mamaria interna izquierda mediante análisis de la velocidad del flujo por técnica Doppler transcutánea

Objetivo El objetivo del estudio fue analizar las caracteristicas de la curva de velocidad del flujo Doppler de los injertos coronarios con arteria mamaria interna en relacion con su permeabilidad determinada por angiografia selectiva. Metodos Se estudiaron 25 pacientes consecutivos portadores de un injerto de arteria mamaria interna izquierda. Se les practicaron coronariografia y estudio Doppler transcutaneo. Se cuantificaron las velocidades maximas y las integrales velocidadtiempo de los componentes sistolico y diastolico de las senales obtenidas. En la coronariografia se analizo la permeabilidad del injerto, asi como las caracteristicas angiograficas de la arteria coronaria distal a la anastomosis. Resultados Se obtuvo senal de flujo por Doppler en 23 de los 25 pacientes analizados (92%). En 17 de los 25 casos (68%) el injerto era angiograficamente permeable, siendo el flujo de predominio diastolico en 15 (88%) y sistolico en 2 (12%). En los 8 pacientes (32%) con injerto ocluido angiograficamente, 6 (75%) presentaban una senal de predominio sistolico y estaba ausente en 2 (25%). La sensibilidad y la especificidad de la presencia de un patron Doppler de predominio diastolico para la deteccion de permeabilidad del injerto fueron del 88 y del 100%, respectivamente, con un valor predictivo positivo del 100% y negativo del 80%. Conclusiones Las caracteristicas de la curva de velocidad del flujo de los injertos coronarios con arteria mamaria interna estan relacionadas con la permeabilidad del injerto, siendo la presencia de un flujo predominantemente diastolico altamente indicativa de la misma.

Radial versus femoral access for angioplasty of ST-segment elevation acute myocardial infarction with second-generation drug-eluting stents.

INTRODUCTION AND OBJECTIVES Invasive and pharmacological treatment of ST-segment elevation acute myocardial infarction reduces the rate of ischemic events but not bleeding complications. The objective of this study was to compare clinical results and bleeding complications between femoral and radial access routes in patients with ST-segment elevation acute myocardial infarction. METHODS An evaluation was performed of the population of the Examination study, a randomized, multicenter, clinical trial that included 1498 patients with ST-segment elevation acute myocardial infarction who underwent emergency angioplasty. Subanalysis of this population was conducted to compare patients by type of access (femoral vs radial). The primary end point was a composite of: all-cause death, myocardial infarction, revascularization, and bleeding. RESULTS Femoral and radial access routes were used in 825 (55%) and 673 (45%) patients, respectively. More bleeding complications (major and minor) were seen with femoral access than radial access (5.9% vs 2.8%; P<.004), largely due to a greater incidence of minor bleeding with femoral access (4.6% vs 1.9%; P=.005). After adjustment for confounders, survival analysis showed a reduction in the primary composite end point in patients with radial access (hazard ratio=0.73; 95% confidence interval, 0.56-0.96; P=.022). CONCLUSIONS In patients with ST-segment elevation acute myocardial infarction, the radial approach is an effective technique that improves prognosis and reduces bleeding complications.

Unusual case of new‐onset heart failure due to cor triatriatum sinister

We report the case of a 30‐year old man who came to the emergency department of our hospital with acute left heart failure, and was diagnosed with a rare congenital anomaly (cor triatriatrum sinister), which can mimic a severe mitral stenosis. Cor triatriatum sinister is a rare anomaly (0.1% of all cases of congenital heart disease) that is seldom diagnosed in adult patients. The hallmark of this congenital defect is the presence of a fibromuscular membrane that divides the left atrium (LA) into two chambers: a postero‐superior chamber into which the pulmonary veins drain and an infero‐anterior chamber (true LA) containing the mitral valve and atrial appendage. Both chambers communicate through a membrane in which one or more drain holes can be found. When the hole is significantly obstructive, it results in increased venous and arterial pressures. Even though the definitive treatment of cor triatriatum is the surgical excision of the membrane, we present a balloon dilatation case with a good response to percutaneous therapy, both initially and in the ensuing months.

Adequate antiplatelet regimen in patients on chronic anti-vitamin K treatment undergoing percutaneous coronary intervention

AIM To investigate the impact of dual antiplatelet therapy (DAT) in patients on anti-vitamin K (AVK) regimen requiring percutaneous coronary intervention (PCI). METHODS Between February 2006 and February 2008, 138 consecutive patients under chronic AVK treatment were enrolled in this registry. Of them, 122 received bare metal stent implantation and 16 received drug eluting stent implantation. The duration of DAT, on top of AVK treatment, was decided at the discretion of the clinician. Adequate duration of DAT was defined according to type of stent implanted and to its clinical indication. RESULTS The baseline clinical characteristics of patients reflect their high risk, with high incidence of comorbid conditions (Charlson score ≥ 3 in 89% of the patients). At a mean follow-up of 17 ± 11 mo, 22.9% of patients developed a major adverse cardiac event (MACE): 12.6% died from cardiovascular disease and almost 6% had an acute myocardial infarction. Major hemorrhagic events were observed in 7.4%. Adequate DAT was obtained in only 44% of patients. In the multivariate analysis, no adequate DAT and Charlson score were the only independent predictors of MACE (both P = 0.02). CONCLUSION Patients on chronic AVK therapy represent a high risk population and suffer from a high MACE rate after PCI. An adequate DAT regimen and absence of comorbid conditions are strongly associated with better clinical outcomes.

Coronary stenting after failure of conservative treatment for spontaneous coronary dissection: Usefulness of the intravascular ultrasound

Spontaneous coronary dissection of a coronary artery is a rare cause of acute coronary syndrome. Optimal treatment has not yet been established. We describe a woman with spontaneous dissection of the left anterior descending artery who presented transitory angina and electrocardiographic ST segment elevation in precordial leads. Conservative treatment was carried out. The angina and electrocardiographic changes recurred 3 days later. An intravascular vascular ultrasound was performed and the patient was stabilized following stenting. Stress testing was negative at 6‐month follow‐up and she remained asymptomatic at 18 months. We discuss the usefulness of an intravascular ultrasound study to establish the therapeutic strategy.

High-Sensitivity Troponin T and Soluble Form of AXL as Long-Term Prognostic Biomarkers after Heart Transplantation

Antecedents Cardiac allograft vasculopathy (CAV) is a frequent complication limiting the long-term (>1 year) survival after heart transplantation (HTx). CAV is initiated by endothelial dysfunction and can lead to severe cardiovascular (CV) complications. Since CAV is often clinically silent, biomarkers could help identifying HTx patients at risk of CAV and their severe complications. Aim Evaluate the clinical yield of high-sensitivity cardiac troponin T (hs-cTnT), marker of cardiomyocyte damage, and the soluble form of AXL (sAXL), biomarker of endothelial dysfunction, to assess the prognosis of long-term cardiovascular (CV) events occurring after HTx. Methods 96 patients were evaluated at least > 1 year after HTx. CAV was evaluated by coronary angiography or multisliced tomography, and hs-cTnT and sAXL measured 6 months before or after CAV evaluation. Patients were followed during 42 ± 15 months for a combined end point including cardiac death, angina or acute myocardial infarction, left ventricular ejection fraction < 50%, or heart failure not due to an acute rejection. Results 51 patients (53%) presented CAV at evaluation; 21 of them had CV events. Hs-cTnT (56 ± 45 versus 20 ± 18 ng/L; p = 0.04) and sAXL concentrations (98 ± 51 versus 26 ± 26 ng/L; p = 0.01) were significantly higher in patients with CV events. Hs-cTnT (HR 1.03; 95% CI 1.015–1.042, p = 0.0001) and sAXL (HR 1.01; 95% CI 1.001–1.019, p = 0.02) were independent predictors of CV events. A hs-cTnT concentration < 21 ng/L, detected by AUC ROC, predicted the absence of CV events with a predictive value of 91%; sAXL did not add more predictive value to hs-cTnT. Survival free of CV events was 92% in patients with hs-cTnT < 21 ng/L and 57% in those with hs-cTnT > 21 ng/L (p < 0.001). Conclusion Hs-cTnT, but not sAXL, measured during the long-term follow-up of HTx patients appears as a helpful biomarker to identify patients at low risk of adverse CV outcomes.

Síndrome coronario agudo por embolismo distal de un trombo localizado en el tronco común

A 54-year-old man with exertional angina of 2 months’ evolution came to the hospital for pain that had lasted 1.45 h. The electrocardiogram showed ST segment elevation of 2 mm in leads I and aVL. Clopidogrel and acetylsalicylic acid were administered. Angiography disclosed a filling defect in the left main coronary artery (LMCA) consistent with a large thrombus, occlusion of the first diagonal artery, and slow flow in the second diagonal. Furthermore, severe stenosis was observed in the left anterior descending artery after the second diagonal (Fig. 1). Sodiumheparin (1mg/kg bodyweight) and abciximab (0.25mg/kg bolus and 0.125mg/kg/min perfusion) were administered. A guidewire was advanced to the first diagonal and repeated thrombectomy was performed in the LMCA and first diagonal using a 6F Export XT aspiration catheter (Medtronic, Inc., Minneapolis, Minnesota, United States). The ischemia time (initiation of pain to thrombectomy) was 3 h. The following angiogram showed improvement of the LMCA image, patency of the first diagonal, and increased flow in the second diagonal. On intracoronary ultrasound, an image consistent with complicated plaque was seen between 10 and 3 o’clock (Fig. 2). Stent implantation was not performed. Enoxaparin 1 mg/kg body weight/day was prescribed. Five days later, the LMCA image had completely resolved and elective angioplasty of the left anterior descending artery with stent implantation was carried out (Fig. 3). The favorable results were maintained on follow-up coronary angiography and intracoronary ultrasound at 6 months, with no restenosis of the LMCA or the stent. Rev Esp Cardiol. 2011;64(7):614