M. Ciardetti

Contrasting effects of acute and chronic cigarette smoking on skin microcirculation in young healthy subjects.

Objective The aim of our study was to assess the effects of acute and chronic smoking on skin microvascular properties of young healthy subjects. Design An observational study, using a totally non-invasive approach, employing continuous palmar microvascular flow (laser Doppler) and arterial pressure measurements, to compute estimates of microvascular resistive (Z0) and oscillatory (impedance, i.e. ZC) properties. Measures were obtained at baseline and after iontophoretic administration of acetylcholine (ACh), an endothelium-dependent vasodilator and of sodium nitroprusside (NP), an endothelium-independent vasodilator. Participants A total of 20 healthy male subjects (nine habitual smokers and 11 non-smokers; aged 27 ± 1 and 29 ± 2 years, respectively) in resting conditions and during administration of ACh and of NP (in two different days), before and after smoking one cigarette were evaluated. Results Smokers showed significant lower baseline Z0 and ZC than non-smokers. In non-smokers, ACh and NP iontophoresis induced a significant decrease of both Z0 and ZC, before and after smoking one cigarette (P < 0.02). Conversely, in smokers, both Z0 and ZC were not affected by ACh iontophoresis before acute smoking, while, after smoking, a significant decrease of both Z0 and ZC (P < 0.02) was detected after ACh challenge. In smokers, both Z0 and ZC were not affected by NP iontophoresis, either before or after smoking a cigarette. Conclusions Smokers appeared characterized by a complex disruption of peripheral microcirculatory regulation, including inappropriate resting vasodilation, impaired endothelium-dependent and independent vasodilation, paradoxical recovery of endothelium-dependent vasodilation in response to acute smoking.

Drug Eluting Balloon: A Multipurpose Tool for Coronary Revascularization With Optimal Long‐Term Follow‐Up Results

AIMS This study aimed to evaluate safety and efficacy of drug-coated balloon (DCB) at long-term follow-up; a large series of real-life patients underwent revascularization with DCB for a wide spectrum of clinical and angiographic situations. METHODS AND RESULTS One hundred ten patients underwent percutaneous revascularization using paclitaxel eluting balloon (Sequent Please, Braun, Germany). End-points were major adverse cardiac events (MACE; all-cause death, myocardial infarction [MI], target vessel revascularisation [TVR], and vessel thrombosis). DCB were used for stable angina (58%), unstable angina/nonST elevation MI (31%) and ST elevation MI (11%). DCB were used for in-stent restenosis (61%), small vessel disease (25%), with bare metal stent (BMS) to avoid long dual antiplatelet therapy (10%) or for impossibility to place a stent (4%). Cumulative MACE at follow-up (median 23 months, IQR 13-32) was 12.7%, with 8.2% all-cause death (1 fatal MI), 4.5% TVR, 3.6% TLR, and no vessel thrombosis. Three of four TLRs occurred in patients who received DEB for DES restenosis. CONCLUSIONS DCB are a very effective tool for a variety of clinical and angiographic situations. DCB use seems to be affected by a low rate of complications and adequate results at long-term follow-up.

Self-expanding stent for complex percutaneous coronary interventions: A real life experience

AIM Self-expanding stents represent a re-emerging option for percutaneous coronary interventions. Their application covers a wide spectrum of angiographic situations, i.e., coronary bifurcations, acute coronary syndromes with large thrombotic burden and stenosis of ectatic coronaries. We review our experience with self-expanding stents for different clinical and angiographic indications, with long clinical follow-up. METHODS From 2011 to 2013 we used self-expanding STENTYS® stents in 40 consecutive patients followed-up for death from any cause and from cardiovascular cause, myocardial infarction, target lesion revascularization (TLR), stent thrombosis (mean 21±13months). We also revised rate of procedural outcomes, acute stent thrombosis and TLR in patients treated with conventional stents for similar clinical/angiographic situations, in the same period at our institution. RESULTS We identified three anatomical settings of STENTYS® use: coronary bifurcations with proximal/distal main branch diameter discrepancy (55% of cases), massive thrombotic burden in the setting of acute coronary syndrome (35% of cases) and stenosis of ectatic coronaries (15%). We observed one death related to acute heart failure and 1 case (2.5%) of acute stent thrombosis (2.5% in the control group). During follow-up 2 cases of stent restenosis leading to TLR (5%) occurred (6.25% in the control group). CONCLUSIONS According to our real life experience, self-expanding STENTYS® stents appear to be an effective tool for different angiographic situations in which they may be preferable to balloon-expandable stents, showing a low rate of complications and good results at long term follow-up.

Surgical correction of left coronary artery origin from the right coronary artery.

We describe the case of a patient with limiting angina pectoris and anomalous origin of the left coronary artery from the right coronary artery, with a retroaortic course. Myocardial ischemia in the left anterior descending territory was documented by positron emission tomography, confirmed by fractional flow reserve, and relieved by surgical coronary reimplantation. This patient did not have coronary atherosclerosis or any other significant anatomic abnormality, such as myocardial bridging or compression between the aorta and the pulmonary artery. We attempt to describe the mechanisms of myocardial ischemia that contributed to the clinical manifestations in our patient.

Contrast medium nephrotoxicity after renal artery and coronary angioplasty

Background: Renal dysfunction induced by iodinated contrast medium (CM) administration can minimize the benefit of the interventional procedure in patients undergoing renal angioplasty (PTRA). Purpose: To compare the susceptibility to nephrotoxic effect of CM in patients undergoing PTRA with that of patients submitted to percutaneous coronary intervention (PCI). Material and Methods: A total of 33 patients successfully treated with PTRA (PTRA group, mean age 70±12 years, 23 female, basal creatinine 1.46±0.79, range 0.7–4.9 mg/dl) were compared with 33 patients undergoing successful PCI (PCI group), matched for basal creatinine (1.44±0.6, range 0.7–3.4 mg/dl), gender, and age. In both groups postprocedural (48 h) serum creatinine was measured. Results: Postprocedural creatinine level decreased nonsignificantly in the PTRA group (1.46±0.8 vs. 1.34±0.5 mg/dl, P=NS) and increased significantly in the PCI group (1.44±0.6 vs. 1.57±0.7 mg/dl, P<0.02). Changes in serum creatinine after intervention (after-before) were significantly different between the PTRA and PCI groups (−0.12±0.5 vs. 0.13±0.3, P=0.014). This difference was not related to either a different clinical risk profile or to the volume of CM administered. Conclusion: In this preliminary study patients submitted to PTRA showed a lower susceptibility to renal damage induced by CM administration than PCI patients. The effectiveness of PTRA on renal function seems to be barely influenced by CM toxicity.

How should I treat a perimembranous interventricular defect following aortic valve replacement surgery

BACKGROUND A 73-year-old man was admitted to our Institute for repeated episodes of congestive heart failure. The patient was affected by arterial hypertension, dyslipidaemia, severe chronic obstructive pulmonary disease, and recurrent atrial fibrillation. Two months earlier he had undergone aortic valve replacement with a biological prosthesis for severe stenosis. Echocardiography showed a left-to-right shunt localised in the left ventricular outflow tract, normal morphology and function of the aortic valve prosthesis, and a hyperkinetic left ventricle. INVESTIGATION Physical examination, electrocardiography, transthoracic and transoesophageal echocardiography, right heart catheterisation, left ventricular angiography. DIAGNOSIS Post-surgical perimembranous interventricular defect with a clinically significant left-to-right shunt. MANAGEMENT Percutaneous closure with a ventricular septal defect occluder.

Quantitative analysis of epicardial fat volume: effects of scanning protocol and reproducibility of measurements in non-contrast cardiac CT vs. coronary CT angiography

BACKGROUND Several studies have focused on the role of epicardial fat in the pathogenesis of cardiovascular disease (CVD). The main purpose of the study was to evaluate a computerized method for the quantitative analysis of epicardial fat volume (EFV) by non-contrast cardiac CT (NCT) for coronary calcium scan and coronary CT angiography (coronary CTA). METHODS Thirty patients (61±12.5 years, 73% male, body mass index (BMI) =25.9±6.3 kg/m2) referred to our Institution for suspected coronary artery disease (CAD) underwent NCT and coronary CTA. Epicardial boundaries were traced by 2 experienced operators (operator 1, operators 2) on 3 and 6 short-axis (SA) slices. EFV was computed with a semi-automatic method using an in-house developed software based on spherical harmonic representation of the epicardial surface. In order to analyze the inter-observer variability both the Coefficient of Repeatability (CR) and Intra Class Correlation (ICC) were computed. RESULTS The total EFV was 103.62±50.97 and 94.96±67.91 cc in NCT and coronary CTA with non-significant difference (P=0.292). CR error was 10.22 cc for operator 1 and 11.31 cc for operator 2 in NCT and 7.99 cc for operator 1 and 7.75 cc for operator 2 in coronary CTA. To analyze the inter-observer variability CR and ICC were computed. CR was 8.17 and 8.39 cc with NCT and 7.07 and 7.21 cc with CTA for 6 and 3 SA slices respectively. ICC values >0.99 were obtained in all cases. The right ventricular EFV was 67.23±31.4 and 57.41±34.3 cc for NCT and coronary CTA respectively; the corresponding values for left ventricular EFV were 38.01±19.1 and 35.27±25.9 cc. CONCLUSIONS Both NCT and coronary CTA can be used with low intra- and inter-observer variability for computer-assisted measurements of EFV. Cardiac CT may allow a fast and reliable computation of EFV in clinical setting.

Endothelium-dependent vasodilation at peripheral microvascular level in hypertensive patients before and after therapy with nebivolol

Background: Nebivolol is a new beta-adrenergic blocking agent which has been shown to cause vasodilation when infused in the forearm vascular bed both in normotensive and in hypertensive subjects, and this effect is probably mediated by the activation of the L-arginine/NO pathway. Aim of the study: to investigate cutaneous microvascular function in hypertensive (HT) patients before and after treatment with Nebivolol. Methods: in 11 never treated essential mild to moderate HT patients (mean age 48 69 years, 8 males, mean SBP/DBP 150 68/10064 mmHg) and in 20 normotensive controls (NT, mean age 50 67 years, mean SBP/DBP 118612/7269 mmHg), skin blood flow (SBF) was studied by means of laser doppler flowmetry (LDF) at baseline and after administration by iontophoresis of stepwise doses of Acetylcholine (ACh) and Sodium Nitroprusside (SNP), in order to explore the endothelium-dependent and independent vasodilation. In the HT group, the same protocol was repeated after 15 to 21 days of treatment with Nebivolol (5mg/die). Results: SBF significantly increased with ACh and SNP in NT and HT(p,.05 vs basal). During Nebivolol, blood pressure significantly decreased in all patients (mean SBP/DBP 129 612/8169 mmHg, p,.05 vs baseline). SBF response to both vasoactive agents did not significantly differ after therapy in the overall population. However, when the doseresponse curves to ACh in HT patients were compared to those obtained in NL, we could point out two subgroups: A) with a similar to normal, or enhanced response to ACh (SBFmax-SBFbasal .SBFmean-1sd than NT), B) with a depressed response to ACh (SBFmaxSBFbasal #SBFmean-1sd than NT). After therapy, group B showed significantly increased vasodilatory response to ACh, while group A showed a decreased one, as compared to pre-treatment response (ANOVA, p.,.05 vs pre-treatment). No differences were present when comparing SNP dose-response curves before and after Nebivolol. Conclusion: in patients with arterial hypertension, Nebivolol selectively improves endothelium-dependent microcirculatory vasodilation in patients with basally blunted response. By contrast, patients with basally normal response to ACh show a reduction in microcirculatory response, probably related to prevalence of peripheral beta-blocking effect when pre-treatment endothelium dependent vasodilation is preserved.