Keir McCutcheon

HIV and Nonischemic Heart Disease

Human immunodeficiency virus (HIV)-associated heart disease encompasses a broad spectrum of diseases. HIV infection may involve the pericardium, myocardium, coronary arteries, pulmonary vasculature, and valves, as well as the systemic vasculature. Access to combination antiretroviral therapy, as well as health resources, has had a significant influence on the prevalence and severity of the effects on each cardiac structure. Investigations over the recent past have improved our understanding of the epidemiology and pathophysiology of HIV-associated cardiovascular disease. This review will focus on our current understanding of pathogenesis and risk factors associated with HIV infection and heart disease, and it will discussxa0relevant advances in diagnosis and management of these conditions.

5-Year clinical follow-up of the COBRA (complex coronary bifurcation lesions: Randomized comparison of a strategy using a dedicated self-expanding biolimus A9-eluting stent vs. a culotte strategy using everolimus-eluting stents) study

We evaluated healing responses with optical coherence tomography, and long‐term clinical outcomes after treatment with a dedicated stent versus a conventional culotte technique.

Etiology and Long‐Term Outcome of Patients Undergoing Pericardiocentesis

Background Pericardial effusions can be caused by a variety of disorders. The frequency of the underlying diseases varies with patient population; therefore, previously reported series are not necessarily representative of other populations. Our purpose was to examine the etiology of pericardial effusions and the survival of patients requiring pericardiocentesis at a tertiary center. Methods and Results We performed a retrospective observational study of 269 consecutive patients who underwent percutaneous pericardiocentesis at our university hospital between 2006 and 2016 and had prospective follow‐up for up to 10 years. The most frequent etiologies were idiopathic (26%), malignancy (25%), and iatrogenicity (20%), whereas bacterial causes were very rare. The most frequent malignancies originated from the lung (53%) or breast (18%). A new cancer was diagnosed with malignant pericardial effusion as the presenting complaint for 9% of patients, whereas the pericardium was the first metastatic site of a known malignancy in 4% of patients. Survival was significantly poorer in malignancy‐related versus non–malignancy‐related effusions (P<0.001) and in cytology‐positive versus cytology‐negative effusions in the overall cohort (P<0.001). Among cancer‐only patients, however, there was no significant difference in long‐term survival between cytology‐positive and ‐negative effusions. Conclusions In this contemporary tertiary‐center cohort, pericardial effusions often represent the primary instance of a new malignancy, underscoring the importance of cytological analyses of noniatrogenic effusions in patients without known cancer, as survival is significantly worse. In cancer patients, however, the presence of pericardial malignant cytology does not appear to affect outcome significantly.

Long-term outcomes after percutaneous revascularization of complex coronary bifurcation lesions using a dedicated self-expanding biolimus-eluting stent system

BACKGROUNDnTo evaluate long-term clinical outcomes after treatment of complex bifurcation lesions with the AXXESS dedicated self-expanding biolimus A9-eluting bifurcation stent.nnnMETHODSnBetween 2004 and 2013, 123 patients with complex bifurcation lesions were treated in a single-center with the AXXESS stent in the proximal main vessel (MV) and additional drug-eluting stents in branches when required. Median follow-up was 5 years. Primary endpoint was the rate of major adverse cardiac events (MACE). Secondary endpoints included MACE components (cardiac death, non-periprocedural clinical myocardial infarction [MI], target lesion revascularization [TLR] and definite/probable stent thrombosis [ST]) as well as all-cause death, target vessel revascularization (TVR) and non-TVR.nnnRESULTSnDuring follow-up, 11 (8.9%) patients experienced a MACE, of whom 2 (1.6%) suffered cardiac death, 2 (1.6%) had a non-periprocedural clinical MI requiring TLR, and 7 (5.7%) underwent elective TLR. No definite/probable ST was observed. All-cause death occurred in 9 (7.3%) patients, TVR in 11 (8.9%) and non-TVR in 11 (8.9%). Patients treated for left main (LM) bifurcation lesions were more likely to experience MACE than non-LM bifurcation lesions (25% vs. 6.5%, p = 0.04).nnnCONCLUSIONSnPercutaneous revascularization of complex bifurcation lesions with the AXXESS stent is safe and provides excellent long-term results, especially in non-LM lesions.

Early collapse causing stenosis in a resorbable magnesium scaffold

We report a case of early in‐stent restenosis due to collapse of a Magmaris resorbable magnesium scaffold.

Major adverse cardiovascular events while awaiting staged non-culprit percutaneous coronary intervention after ST-segment elevation myocardial infarction

Abstract Background: The optimal therapeutic strategy for ST-segment elevation myocardial infarction (STEMI) patients found to have multi-vessel disease (MVD) is controversial but recent data support complete revascularisation (CR). Whether CR should be completed during the index admission or during a second staged admission remains unclear. Our main objective was to measure rates of major adverse cardiovascular events (MACEs) during the waiting period in STEMI patients selected for staged revascularisation (SR), in order to determine the safety of delaying CR. For completeness, we also describe 30-day and long-term outcomes in STEMI patients with MVD who underwent in-hospital CR. Methods: A single-centre retrospective analysis of 931 STEMI patients treated by primary percutaneous coronary intervention (PCI) identified 397 patients with MVD who were haemodynamically stable and presented within 12 hours of chest pain onset. Of these, 191 underwent multi-vessel PCI: 49 during the index admission and 142 patients undergoing a strategy of SR. Results: Our main finding was that waiting period MACE were 2% (three of 142) in patients allocated to SR (at a median of 31 days). In patients allocated to in-hospital CR, 30-day MACE rates were 10% (five of 49). During a median follow up of 39 months, all-cause mortality was 7.0% vs. 28.6%, and cardiac mortality was 2% vs. 8%, in patients allocated to SR or CR, respectively. Conclusions: Patients with STEMI and MVD who, based on clinical judgement, were allocated to a second admission SR strategy had very few adverse events during the waiting period and excellent long-term outcomes.

Unusually aggressive immature neo-intimal hyperplasia causing in-stent restenosis

This image illustrates a very unusual pattern of early and aggressive immature neo-intimal hyperplasia in a 52-year-old man with unstable angina, two months after deployment of a drug-eluting stent in the proximal left anterior descending artery.

Long-term intravascular follow-up of coronary bifurcation treatment with Absorb bioresorbable vascular scaffold

The feasibility of using the Absorb bioresorbable vascular scaffold (BVS) in complex bifurcation techniques has been investigated in ex and in vivo investigations. However, long-term clinical evaluations of different approaches are still ongoing. We present the longterm intravascular follow-up of a patient treated with modified-T stenting of a true bifurcation lesion. A 53year-old male smoker underwent PCI of a LAD/diagonal lesion (Medina 1,1,1) following presentation with stable angina. Using a modified-T technique, the bifurcation lesion was successfully treated with implantation of 2.5 18mm BVS in D1 and 3.0 18mm BVS in LAD, with good bifurcation coverage and stent apposition on optical coherence tomography (OCT). The patient remained angina free at 30 months. Baseline (preand post-PCI) and (planned) 30-month angiography and OCT (Figure 1) revealed complete restoration of the bifurcation anatomy and excellent vessel-wall healing characteristics at 30 months. When considering which two-stent technique to use when treating complex bifurcation lesions with Absorb BVS, modified T-stenting seems to be more favourable than Culotte or TAP-stenting based on in vivo investigations. Nevertheless, in view of worrying reports of intraluminal scaffold dismantling and very late scaffold thrombosis, the long-term performance of bifurcation procedures with Absorb BVS has to be further investigated. The presented images highlight that modified T-stenting is a promising technique with excellent healing characteristics at 30 months, provided an optimal result post-PCI has been obtained. Although recent data from the Absorb II and III studies have shown an increased risk of target lesion failure with the Absorb BVS, the modified-T approach may warrant re-evaluation in future generation bioresorbable scaffolds.

Left main coronary artery stenosis due to a protruding calcified nodule.

A 59-year-old diabetic man with a history of pulmonary endarterectomy due to chronic thromboembolic disease presented with typical angina and syncope. Coronary angiography unveiled an area of haziness in the left main coronary artery (LMCA) (Figure 1, Panel A, arrow). Optical coherence tomography (OCT) illustrated an irregular high-backscattering structure with signal attenuation compatible with a protruding calcified nodule in the LMCA (Figure 1, Panel B, asterisk), covered by mural thrombus (Figure 1, Panel B, arrow). The calcified nodule was causing significant narrowing of the LMCA (Figure 1, Panel C) whereas the rest of the LMCA wall appeared almost normal (Figure 1, Panel A, arrowhead & Panel D). Taking into consideration the patients’ history of previous thoracotomy, percutaneous treatment was favoured. A drug-eluting stent (4.5mm 12mm) was implanted in the LMCA followed by post dilatation with a non-compliant balloon (4.5mm 8mm), with an excellent angiographic result (Figure 1, Panel E, arrow). Haziness in the LMCA is a rare condition, commonly considered as plaque rupture. Calcified nodules have been described as a rare cause of acute coronary syndrome. Etiologically, calcified nodules might be associated with previous intra-plaque haemorrhage or healed plaque rupture and their pathology is strikingly different to that of non-nodular calcification. Intravascular ultrasound illustrates calcium as an intense structure with dark shadowing but given its lower spatial resolution compared to OCT, is inferior in differentiating a protruding calcified nodule from a calcified burden in the vessel wall. In these cases OCT can elucidate the diagnosis, differentiate between underlying pathology and guide treatment.