Luís Leite

Bioresorbable Scaffolds in Cardiac Allograft Vasculopathy—Searching for the Holy Grail

We read with great interest the article by Pighi et al. [1] that presented the Cardiac Allograft Reparative Therapy (CART) study, a prospective multicenter clinical trial to evaluate the performance of the AbsorbTM bioresorbable scaffold (BVS) for treating cardiac allograft vasculopathy (CAV). Determining the best approach to treating CAV—the leading cause of death after heart transplantation—is a serious, yet unmet, need [2]. Introducing BVS into treatment might produce a paradigm shift in focal CAV management. A platform that provides transient arterial support, delivers an antiproliferative drug, and can avoid chronic local inflammatory reactions due to a permanent Bmetallic cage^ is a potentially revolutionary approach to focal CAV. The Absorb BVS is the most studied platform [3]. It is composed of a fully bioresorbable polymeric scaffold with a coating that elutes everolimus, which is an immunosuppressive agent that reduces the incidence and progression of CAV [2]. In our institution, we recently performed routine coronary angiography on a 69-year-old man, who had undergone heart transplantation 3 years earlier. The angiography revealed intermediate stenosis in the mid-segment of the left anterior descending artery (LAD). To assess the physiological impact of the epicardial disease, an invasive LAD coronary flow study was performed and revealed a fractional flow reserve (FFR) of 0.78. Optical coherence tomography (OCT) showed focused concentric intimal hyperplasia (Fig. 1a). After lesion preparation, an Absorb BVS (2.50 × 23 mm) was implanted at the mid-LAD. The post-implant OCT evaluation revealed well-apposed and expanded scaffolds (Fig. 1b). The patient was discharged with dual antiplatelet therapy and optimized immunosuppression treatment. Eleven months later, routine coronary angiography and OCT revealed significant BVS restenosis (Fig. 1c). Revascularization was successfully performed with a paclitaxel-coated balloon (2.50 × 20 mm). What can be said about the role of BVS in the management of CAV? In the presence of focal intimal thickening leading to significant luminal obstruction and a drop in flow reserve, PCI is the intuitive solution, despite the lack of evidence for a survival advantage. BVS appears to be particularly appealing in this setting, providing anatomical and functional vascular restoration with a reduced inflammatory reaction. The feasibility of BVS implantation for treatment of CAV has been demonstrated in some case reports [4], with excellent angiographic results at 6-month [5] and 1-year [6] follow-up. However, our case strengthens the possibility that the restenosis rate might be a major drawback to the use of BVS. Before the promising widespread use of BVS in CAV management becomes a reality, we believe that further investigation is necessary. Therefore, the randomized CART study [1] will be crucial in determining the safety and efficacy of BVS therapy in the cardiac transplant population. Associate Editor Emanuele Barbato oversaw the review of this article

Subclinical thrombosis of a chronically lost stent

A 69-year-old man presented with stable angina and ischaemia on a treadmill test. He had a left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass graft seven years earlier. After 4 years, he had a percutaneous coronary intervention (PCI) of the right coronary artery (RCA). Coronary angiography showed LAD occlusion and patent LIMA graft. The RCA was calcified with good result of the previous ostial intervention but there was a linear radiopaque image in the mid segment (Panels A and A’, arrows; Supplementary ma terial online, Video S1). We suspected an unexpanded stent was lost inside the RCA and performed optical coherence tomography (OCT) to clarify the situation. OCT revealed the presence of a metallic tubular structure suggestive of an ‘abandoned’ stent (Panel B; Supplementary material on line, Video S2). Noticeably, there was red thrombus (Panel C, asterisk) adherent to the distal part of the unexpanded stent (Panel C, arrow) resulting in significant decrease of luminal area. Therefore, we decided to crush the stent to the arterial wall with a drug eluting stent (Panel D, arrows; Supplementary material online, Video S3). Patient angina was relieved and subsequent follow-up was uneventful. Unnoticed loss of an unexpanded stent is a known infrequent complication of PCI. This case emphasizes that, after three years, a lost coronary stent will not lead to endothelialization and may have adherent thrombus, even in a non-acute setting. Therefore, crushing the stent should be considered to relieve symptoms and to reduce the risk of stent thrombosis.

Pulse pressure can predict mortality in advanced heart failure

INTRODUCTION Pulse pressure (PP) is the difference between systolic and diastolic blood pressure (BP). PP rises markedly after the fifth decade of life. High PP is a risk factor for the development of coronary heart disease and heart failure. The aim of this study was to assess whether PP can be used as a prognostic marker in advanced heart failure. METHODS We retrospectively studied patients in NYHA class III-IV who were hospitalized in a single heart failure unit between January 2003 and August 2012. Demographic characteristics, laboratory tests, and cardiovascular risk factors were recorded. PP was calculated as the difference between systolic and diastolic BP at admission, and the patients were divided into two groups (group 1: PP >40 mmHg and group 2: PP ≤40 mmHg). Median follow-up was 666 ± 50 days for the occurrence of cardiovascular death and heart transplantation. RESULTS During follow-up 914 patients in NYHA class III-IV were hospitalized, 520 in group 1 and 394 in group 2. The most important difference between the groups was in left ventricular dysfunction, which was greater in patients with lower PP. On Kaplan-Meier analysis, group 2 had higher mortality (38 vs. 24 patients, log-rank p=0.002). CONCLUSIONS PP is easily calculated, and enables prediction of cardiovascular death in patients with advanced heart failure.

Heart transplant coronary artery disease: Multimodality approach in percutaneous intervention

Coronary artery disease is the most important cause of late morbidity and mortality after heart transplantation. It is usually an immunologic phenomenon termed cardiac allograft vasculopathy, but can also be the result of donor-transmitted atherosclerosis. Routine surveillance by coronary angiography should be complemented by intracoronary imaging, in order to determine the nature of the coronary lesions, and also by assessment of their functional significance to guide the decision whether to perform percutaneous coronary intervention. We report a case of coronary angiography at five-year follow-up after transplantation, using optical coherence tomography and fractional flow reserve to assess and optimize treatment of coronary disease in this challenging population.

Bioresorbable scaffolds for primary angioplasty: Optical coherence tomography follow-up

A 44-year-old female was admitted for an anterior ST-segment elevation myocardial infarction (STEMI) and emergency coronary angiography revealed total occlusion of the mid segment of the left anterior descending artery (LAD). After thrombus aspiration, intracoronary nitrate administration and balloon predilatation, two overlapping Absorb bioresorbable vascular scaffolds (BVS) (3 mm× 18 mm and 2.5 mm×28 mm; Abbott Vascular, Santa Clara, CA, USA) were implanted in the proximal, mid and distal LAD segments. A more distal obstructive lesion was treated with a 2.5 mm×18 mm Absorb BVS (Abbott Vascular, Santa Clara, CA, USA). Seven months later, the patient was admitted with anemia (hemoglobin 7.9 g/dl) associated with subacute genital tract bleeding. In order to improve risk stratification of temporary discontinuation of dual antiplatelet therapy (DAPT),

Aortic Valve Disease and Vascular Mechanics: Two‐Dimensional Speckle Tracking Echocardiographic Analysis

Degenerative aortic valve disease (AVD) is a complex disorder that goes beyond valve itself, also undermining aortic wall. We aimed to assess the ascending aortic mechanics with two‐dimensional speckle tracking echocardiography (2DSTE) in patients with aortic regurgitation (AR) and hypothesized a relationship with degree of AR. Aortic mechanics were then compared with those of similarly studied healthy controls and patients with aortic stenosis (AS); finally, we aimed to assess the prognostic significance of vascular mechanics in AVD.