Leonardo Misuraca

A Prospective Randomized Trial of Thrombectomy Versus No Thrombectomy in Patients With ST-Segment Elevation Myocardial Infarction and Thrombus-Rich Lesions: MUSTELA (MUltidevice Thrombectomy in Acute ST-Segment ELevation Acute Myocardial Infarction) Trial

OBJECTIVES The aim of this study was to evaluate whether thrombectomy during primary percutaneous coronary intervention (pPCI) in patients with high thrombus burden improves myocardial reperfusion and reduces infarct size. BACKGROUND Thrombectomy aims at reducing distal thrombotic embolization during pPCI, improving myocardial reperfusion and clinical outcome. METHODS We randomized 208 patients with high thrombus burden in a 1:1 ratio to either pPCI with thrombectomy (Group T) or standard pPCI (Group S). Thrombectomy was performed with either rheolytic or manual aspiration catheters. Three-month magnetic resonance imaging was performed to assess infarct size and transmurality and microvascular obstruction (MVO). The primary endpoints were ST-segment elevation resolution (STR) >70% at 60 min and 3-month infarct size. RESULTS The baseline profile was similar between groups, except for a higher rate of initial Thrombolysis In Myocardial Infarction flow grade 3 in Group S (p = 0.002). Group T showed a significantly higher rate of STR (57.4% vs. 37.3%; p = 0.004) and of final myocardial blush 3 (68.3% vs. 52.9%; p = 0.03). Group T and Group S did not differ with regard to infarct size (20.4 ± 10.5% vs. 19.3 ± 10.6%; p = 0.54) and transmurality (11.9 ± 12.0% vs. 11.6 ± 12.7%; p = 0.92), but Group T showed significantly less MVO (11.4% vs. 26.7%; p = 0.02) and a higher prevalence of inhomogeneous scar (p < 0.0001). One-year freedom from major adverse cardiac events was similar between groups. CONCLUSIONS Thrombectomy as an adjunct to pPCI in patients with high thrombus load yielded better post-procedural STR and reduced MVO at 3 months but was not associated with a reduction in infarct size and transmurality. Thromboaspiration in Patients With High Thrombotic Burden Undergoing Primary Percutaneous (Coronary Intervention; NCT01472718).

A very rare congenital abnormality: double right coronary artery. A case report

The incidence of coronary artery anomalies is about 0.6-1.3% in angiographic studies of the adult population. Double right coronary artery is one of the rarest abnormalities reported in the literature. We report a case of a double right coronary artery originating from a single orifice in a woman who underwent coronary angiography for a pathological transprosthetic aortic gradient.

Double right coronary artery or split right coronary artery: the same anomaly?

On the contrary, many authors keep describing the anatomical entity named ‘double RCA’ [2,3]. We think that this definition is not improper. A ‘split RCA’ is an anomalous RCA with the aforementioned features. ‘Double RCA’ describes a right coronary system formed of two distinct branches running very closely together in the atrioventricular groove, for at least the half of the entire course of the RCA. The two branches, showing a similar caliber, can originate from a single proximal trunk or arise from distinct orifices in the right sinus of Valsalva. The course of the two vessels can be totally split, with two distinct posterior descending arteries (PDAs), or only partially split, with a single PDA.

TCT-425 Bioresorbable vascular scaffold technology for small vessel coronary artery disease: results from the Italian multicenter RAI Registry

RESULTS A total of 207 patients with at least one SV were included in this analysis. Mean follow-up time was 22.4 months 14.9 with 85.8 % of patients having at least 1 year of follow-up. Clinical presentation of pts. (72.4% male, mean age 58.5 11.7 years, 16.4% diabetics, 25.6% with previous PCI and/or CABG) was ACS in 55.1%. Multivessel treatment was perfomed in 17,9% (37 pz). Mean lesion length by QCA was 23.7 11.0 mm and mean RVD was 2.2 0.3 mm with 14.5% of moderate/sever calcification lesions and 19.8 % of bifurcation treatment. Pre-dilatation was performed in 93.2% and post-dilatation in 57.9%. The mean scaffold length was 28.1 15.0 mm with 30.9% of cases using overlapping scaffolds. OCT or IVUS was used in 26.0%. Device success was 99.0% (failure to deliver in 2 pts). Over the entire follow-up period, death occurred in 3.4 % (7/207), myocardial infarction (MI) in 5.3% (11/207), target lesion revascularization in 7.2 % (15/207), target vessel revascularization (TVR) in 8.2% (17/207), non-target vessel revascularization in 2.9 (6/207) %. Overall MACE (death, MI, TVR) rate was 12.0% (25/207). Definite stent thrombosis (ST) occurred in 6 pts. (2.9%), of whom early ST occurred in 4 pts and late ST in 2 pts.

Design of the Rosuvastatin Pretreatment to Reduce Embolization during Carotid Artery Stenting trial

Background Carotid artery stenting (CAS) is a worldwide diffuse intervention, but may be associated with distal plaque component embolization, and sometimes major and minor stroke. Statin use has been demonstrated to reduce atherosclerotic plaque burden, but its effect in reducing distal embolization during carotid stenting has not yet been well validated. Aims With the Rosuvastatin Pretreatment to Reduce Embolization during Carotid Artery Stenting trial, we aim to discover if a pretreatement with high doses of rosuvastatin in dyslipidemic patients is able to reduce periprocedural cerebral ischemic complications following carotid stenting. Methods This is a phase III prospective, randomized controlled trial. All consecutive patients with asymptomatic carotid stenosis at least 80% will be randomized to a 6-week rosuvastatin treatment followed by carotid stenting, and to direct carotid stenting. Carotid stenting will be performed following common practice with distal or proximal embolic protection. The primary efficacy end point of the trial will be the prevalence of ‘relevant’ embolization during CAS, as a surrogate end point for cerebral ischemic complications. Other laboratory and clinical data will be registered and patients will be followed up to 1 year. In order to obtain the expected superiority of statin pretreatment on primary end point, a population of 130 patients will be enrolled into the study. Conclusion In conclusion, with the Rosuvastatin Pretreatment to Reduce Embolization during Carotid Artery Stenting trial, we want to evaluate whether a high dose of rosuvastatin for 6 weeks before CAS in asymptomatic patients with severe carotid stenosis is able to reduce the rate of plaque embolization during the procedure, thus suggesting a possible reduction in cerebral ischemic complications.

Left main compression by an aortic root abscess.

A 79-year-old man with severe aortic stenosis, history of coronary artery disease and a recent hospitalization for sepsis presented at our institution following a syncope and angina at rest. Coronary angiography and aortography showed an aortic root abscess, causing left main coronary artery compression. This life-threatening complication of aortic valve endocarditis is rare and requires immediate surgical correction.

OCT-guided stenting of a spontaneous coronary artery dissection

We present the case of a 67 year-old patient that presented to our institution with acute and severe chest pain. Optical coherence tomography high-resolution images of the coronary lumen, allowed us to confirm diagnosis of spontaneous coronary artery dissection, guide treatment, and verify the results of our intervention.

TCT-408 Thirty-day Outcome Following Polymeric Bioresorbable Scaffold Implantation in 347 STEMI Patients Enrolled in the Multicenter “Registro Absorb Italiano” (RAI Registry)

2.5-27; p<0.001), quantitative coronary angiography-derived reference vessel diameter less than 2.4 mm (HR 2.4; C.I. 1.9-18; p1⁄4 0.002), diabetes mellitus (HR 3.7; C.I. 1.2-11; p1⁄40.02) and lack of predilatation (HR 5.26; C.I. 1.1-25; p 0.03) were associated with increased DOCE. In OCT-guided cases (n1⁄4201), operators used larger predilatation balloons (2.86 0.40 vs 2.75 0.36 mm; p1⁄40.01), more 1:1 predilatation (55% vs 30%; p<0.001) and higher scaffold deployment pressures (14.37 1.76 atm vs 13.72 1.71 atm; p<0.001). Similar postdilatation rates (90%) were achieved in both groups. Use of OCT was associated with a significant increase in procedural time (80 18 vs 60 18 min.), x-ray exposure (10808 5131 vs 747

History of vasomotor symptoms, extent of coronary artery disease, and clinical outcomes after acute coronary syndrome in postmenopausal women

Objective: Vasomotor symptoms (VMS) during menopausal transition have been linked to a higher burden of cardiovascular risk factors, subclinical vascular disease, and subsequent vascular events. We aim to investigate the association of VMS with the extent of coronary disease and their prognostic role after an acute coronary syndrome. Methods: The Ladies Acute Coronary Syndrome study enrolled consecutive women with an acute coronary syndrome undergoing coronary angiography. A menopause questionnaire was administered during admission. Angiographic data underwent corelab analysis. Six out of 10 enrolling centers participated in 1-year follow-up. Outcome data included the composite endpoint of all-cause mortality, recurrent myocardial infarction, stroke, and rehospitalization for cardiovascular causes within 1 year. Results: Of the 415 women with available angiographic corelab analysis, 373 (90%) had complete 1-year follow-up. Among them, 202 women had had VMS during menopausal transition. These women had the same mean age at menopause as those without VMS (50 years in both groups), but were younger at presentation (median age 71 vs 76 years; P < 0.001), despite a more favorable cardiovascular risk profile (chronic kidney dysfunction 4.5% vs 15.9%; P = 0.001; prior cerebrovascular disease 4.5 vs 12.2%; P = 0.018). Extent of coronary disease at angiography was similar between groups (mean Gensini score 49 vs 51; P = 0.6; mean SYNTAX score 14 vs 16; P = 0.3). Overall cardiovascular events at 1 year did not differ between groups (19% vs 22%; P = 0.5). Conclusions: In postmenopausal women with an acute coronary syndrome, a history of VMS was associated with younger age at presentation, despite a lower vascular disease burden and similar angiographically defined coronary disease as compared with women without VMS. No difference could be found in terms of overall clinical outcomes. These results should be interpreted cautiously as all analyses were unadjusted and did not account for risk factor differences between women with and without a history of VMS.

Sequential spontaneous coronary artery dissection in a female patient on oral ephedrine

Spontaneous coronary artery dissection (SCAD) is an infrequent, but not rare, cause of acute coronary syndrome. It mainly affects young women, often with few or no traditional cardiovascular risk factors. In the case described, a 57-year-old woman experienced a first episode of SCAD involving a distal branch of the circumflex coronary artery--treated conservatively--followed, after a few hours, by a second episode of SCAD involving the left anterior descending coronary artery, complicated by hemodynamic instability and treated with emergency angioplasty. During the previous months, the patient was taking a slimming drug containing ephedrine. Dual spontaneous coronary dissection of different type and involving two different vessels, which occurred in the same patient within a few hours, testifies the heterogeneity of the clinical picture of this syndrome and of the therapeutic approach.