Magdalena Łanocha

Percutaneous coronary intervention for chronic total occlusion of the coronary artery with the implantation of bioresorbable everolimus-eluting scaffolds. Poznan CTO-Absorb Pilot Registry.

AIMS Data concerning the use of bioresorbable vascular scaffolds (BVS) for chronic total occlusion (CTO) lesions are limited. The aim of this study was to evaluate the early and midterm clinical outcomes of CTO stenting with BVS. METHODS AND RESULTS Forty consecutive patients (male 78%, mean age 59.9±8.3 years, diabetics 30%) with CTO treated with BVS were enrolled. Patients with a reference vessel diameter >4 mm, metallic stents, excessive calcium and tortuosity were excluded. Mean J-CTO score was 1.6. A total of 63 BVS were implanted with an average number of 1.6 per patient, and an average scaffold length of 42.4±21.5 mm. Procedural success was achieved in all patients with no device-related complications. At follow-up (median time 556 days), there were no deaths, one patient experienced subacute and late scaffold thrombosis (ST), and another one developed symptomatic in-scaffold focal restenosis treated with repeat PCI. At control angiography, performed at a median time of 329 days in 27 patients (68%), no more restenosis or vessel reocclusion was found. CONCLUSIONS CTO stenting with BVS is feasible with good acute performance, and good early and midterm clinical outcomes.

Comparison of diffusion-weighted with T2-weighted imaging for detection of edema in acute myocardial infarction

BackgroundRecent studies, performed with the use of a commercially available diffusion weighted imaging (DWI) sequence, showed that they are sensitive to the increase of water content in the myocardium and may be used as an alternative to the standard T2-weighted sequences. The aim of this study was to compare two methods of myocardial edema imaging: DWI and T2-TIRM.MethodsThe study included 91 acute and post STEMI patients. We applied a qualitative and quantitative image analysis. The qualitative analysis consisted of evaluation of the quality of blood suppression, presence of artifacts and occurrence of high signal (edema) areas. On the basis of edema detection in AMI and control (post STEMI) group, the sensitivity and specificity of TIRM and DWI were determined. Two contrast to noise ratios (CNR) were calculated: CNR1 - the contrast between edema and healthy myocardium and CNR2 - the contrast between edema and intraventricular blood pool. The area of edema was measured for both TIRM and DWI sequences and compared with the infarct size in LGE images.ResultsEdema occurred more frequently in the DWI sequence. A major difference was observed in the inferior wall, where an edema-high signal was observed in 46% in T2-TIRM, whereas in the DWI sequence in 85%. An analysis of the image quality parameters showed that the use of DWI sequence allows complete blood signal suppression in the left ventricular cavity and reduces the occurrence of motion artifacts. However, it is connected with a higher incidence of magnetic susceptibility artifacts and image distortion. An analysis of the CNRs showed that CNR1 in T2-TIRM sequence depends on the infarct location and has the lowest value for the inferior wall. The area of edema measured on DWI images was significantly larger than in T2-TIRM.ConclusionsDWI is a new technique for edema detection in patients with acute myocardial infarction which may be recommended for the diagnosis of acute injuries, especially in patients with slow-flow artifacts in TIRM images.

Impact of the presence of chronically occluded coronary artery on long-term prognosis of patients with acute ST-segment elevation myocardial infarction

BACKGROUND Multivessel disease (MVD) is a significant risk factor in patients with acute ST-segment elevation myocardial infarction (STEMI). Whether the presence of chronic total occlusion (CTO) poses an additional hazard is still unknown. The objective of this study was to evaluate the impact of CTO on survival in STEMI patients. METHODS The study group consisted of 836 STEMI patients treated with primary percutaneous coro-nary intervention (PCI). MVD was diagnosed in 52.3%, and CTO in 17.5% of patients. RESULTS In MVD patients, 30-day mortality was 4.8% (6.8% in the CTO and 3.8% in the non-CTO group, p = 0.167). After 6 years, of the 437 patients with MVD, 56 (38.6%) died in the CTO group, and 74 (25.4%) in the non-CTO group (p = 0.0055). CTO was an independent predictor of long-term mortality (OR 2.07, 95% CI 1.30-3.28, p = 0.002), whereas triple vessel disease was not (OR 1.27, 95% CI 0.78-1.97, p = 0.358). The other independent predictors of mortality were: age, anterior myocardial infarction, and PCI failure. CONCLUSIONS The presence of CTO is an independent predictor of the long-term mortality in STEMI patients treated with primary PCI. (Cardiol J 2017; 24, 2: 117-124).

Distal coronary artery wire perforation: a simple method for infrequent complication

Coronary artery perforations (CAPs) are rare (around 0.3%) in patients undergoing routine percutaneous coronary interventions (PCIs) and they are associated with an increased risk of adverse outcomes. Complex lesion procedures, e.g. chronic total occlusion, bifurcation lesion, and rotablation procedures, increase the possibility of CAP occurrence. Treatment of perforations depends on their severity, graded by the Ellis type classification, and the presence of complications, such as tamponade. Early recognition and proper treatment of different perforation types are crucial. Potential therapies include the use of prolonged balloon occlusion, deployment of covered stents, or even cardiac surgery. For distal wire perforation, the treatment option comprises a variety of embolic approaches including mechanical coils, natural clot (thrombus and fat) or synthetic glue injections. Due to uncommon occurrence of CAP, interventional cardiologists infrequently perform such rescue procedures as coil embolisation for distal vessel perforation. Therefore, familiarity with the technique and equipment is essential to ensure patients’ safety. We describe a case of distal artery wire perforation successfully treated using coil embolisation. A 68-year-old man was scheduled for PCI of the left anterior descending and the first diagonal branch (1,1,1 Medina) (Fig. 1A). After difficulties with crossing the side branch we used guidewire with a hydrophilic coating (SION, ASAHI) (Fig. 1B). The bifurcation was treated successfully with two stents (Culotte technique). Final contrast injection revealed distal diagonal wire perforation (Fig. 1C). When it occurred, the patient was asymptomatic, and no signs of pericardial effusion were noticed. Initially, the patient did not receive any invasive treatment. Throughout the next days he remained haemodynamically stable. Bedside echocardiography confirmed no pericardial effusion on repeat imaging. Two days later the patient revealed atypical chest pain without any satisfactory relief after standard analgesic treatment. Control coronary angiography showed a large cavity formation with visible communication with the cardiac vein (Fig. 1D, E). We decided to provide definitive treatment for distal artery perforation by coil embolisation through a microcatheter. We used a regular 6-F guiding catheter and a dedicated microcatheter (Headway 17, Terumo), which was advanced to the distal diagonal branch, allowing delivery of the first coil (MicroPlex10 1.5 mm/1 cm, Terumo) (Suppl. Fig. 1A — see journal website). Repeat contrast injection revealed ongoing distal bleeding. Implantation of two additional coils (MicroPlex10 2 mm/2 cm and MicroPlex10 2 mm/4 cm) helped to achieve complete haemostasis (Suppl. Fig. 1B, C — see journal website). The patient remained haemodynamically stable throughout the procedure. Because of the presence of some minor symptoms, elective angiography was performed the following day, revealing properly placed coils without any signs of residual leakage (Suppl. Fig. 1D — see journal website). After further uneventful recovery, the patient was discharged from hospital in good clinical condition. Nine months later a control angiography was scheduled, which confirmed good results of the procedure. The patient has been stable and uneventful for three and a half years of follow-up. A distal coronary artery perforation caused by the tip of a guidewire usually does not have such a dramatic presentation as main vessel perforation. Initially, it may remain unnoticed. Small vessel perforations usually cause slow bleeding, not leading to tamponade until hours after the procedure. Spontaneous closure usually occurs with drainage and restoration of haemostasis. Even in the case of small perforation, a close monitoring of haemodynamic status is necessary. However, prevention is the most important issue. During the procedure, guidewire position should be continually monitored and polymer-jacketed or stiff guidewires should be exchanged for soft, workhorse guidewires as soon as possible after lesion crossing. Secondly, early detection and familiarity with treatment options are essential for the patient safety. In our case, the patient was initially managed conservatively due to lack of symptoms. However, when symptoms appeared later, even without any signs of tamponade, we decided to intervene by using brain coils. Coil embolisation through a microcatheter is a relatively simple and effective method for a distal coronary artery wire perforation. Knowledge of this technique seems to be necessary for the interventional cardiologists performing complex lesion PCIs.

Optical coherence tomography reveals the mechanisms of balloon pulmonary angioplasty in inoperable chronic thromboembolic pulmonary hypertension

Figure 1. Angiography and optical coherence tomography (OCT) cross-sections of the eighth segmental branch of the left pulmonary artery, before and after balloon pulmonary angioplasty (BPA). A 6-French right Judkins guiding catheter was introduced to the ostium of the artery and 0.0014” coronary guidewire was placed distally in the vessel. Then optical coherence tomography (OCT) catheter (DragonFly, St. Jude Medical, USA) was advanced. Iodinated contrast was infused at a flow rate of 5 mL/s over 4 s at 400 psi of pressure and OCT images were acquired. Subsequently the vessel was accurately measured in several locations and the proper size of the balloon was selected. OCT images revealed the potential mechanisms of BPA: expansion of internal lumen of the artery was achieved by breaking the meshwork lesions inside the artery lumen and by compression of the boundary white thrombus. A 76-year-old female patient with chronic thrombo-embolic pulmonary hypertension (CTEPH) as a result of previous pulmonary embolism was admitted for balloon pulmonary angioplasty. Right heart catheterization showed mean pulmonary artery pressure of 61 mm Hg. Selective pulmonary angiography revealed subtotal occlusion of the A8 segmental branch of the left pulmonary INTERVENTIONAL CARDIOLOGY

Optical coherence tomography improves the resultsof balloon pulmonary angioplasty in inoperable chronicthrombo-embolic pulmonary hypertension

Corresponding author: Aleksander Araszkiewicz MD, Department of Cardiology, Poznan University of Medical Sciences, 1/2 Długa St, 61-848 Poznan, Poland, phone: +48 608 574 375, fax: +48 618 549 094, e-mail: aaraszkiewicz@interia.pl Received: 23.12.2016, accepted: 12.02.2017. Optical coherence tomography improves the results of balloon pulmonary angioplasty in inoperable chronic thrombo-embolic pulmonary hypertension

Left ventricle pseudoaneurysm in a transplanted heart from a car crash victim donor

BACKGROUND Pseudoaneurysm is a very rare and unusual form of myocardial rupture, with complications such as chest trauma, inflammation, acute myocardial infarction, and infection. Although this rare complication has already been reported, it has never been found in a transplanted patient. CASE REPORT We present the case of a 54-year-old women waiting on the urgent list who underwent heart transplantation. The donor of the organ died in a car accident. Although preoperative echocardiography had not revealed any signs of heart injury, a superficial small (3 × 3 mm hematoma) was detected on harvesting. After implantation, intraoperative echocardiography was satisfactory, with no signs of wall motion disturbances, and left ventricle ejection fraction was estimated at 50%. The postoperative period was uneventful. Three weeks after surgery, a left ventricle pseudoaneurysm was found on routine MRI. The aneurysm wall consisted of only an epicardial layer. There was an 8-mm-wide gap in the myocardial wall next to the endocardium and with the width of 4 mm beneath the epicardium. On repeated MRI performed 3 months thereafter, the pseudoaneurysm was filled by thrombus. CONCLUSIONS The presented case illustrates the necessity of careful inspection of the organ reported for transplantation from a donor who died from high-speed motor vehicle crash injuries. Additional diagnostic steps like MRI imaging are obligatory after transplantation, especially when the organ was harvested from a motor vehicle crash victim.

Evaluation of bioresorbable vascular scaffolds in acute coronary syndrome: A two-center, one-year follow-up analysis

BACKGROUND Bioresorbable vascular scaffolds (BVS) have emerged as a new treatment option in cardiovascular medicine. Nonetheless, there is still limited data on the use of these novel devices in patients with acute coronary syndromes (ACS). The purpose of this study was to evaluate the feasibility and efficacy of BVS implantation in patients with ACS. METHODS The present report is a prospective, two-center registry that involved 165 consecutive patients hospitalized with the diagnosis of ACS and treated with the Absorb BVS (Abbot Vascular, Santa Clara, USA). During 1-year, all patients were monitored for the following endpoints: death, myocardial infarction (MI), scaffold thrombosis (ST), target lesion revascularization (TLR), target vessel revascularization (TVR) and target vessel failure (TVF), defined as cardiac death, target vessel MI, and TVR. RESULTS A total of 165 patients underwent 179 BVS implantations. 94 patients were diagnosed with unstable angina (UA; 57.6%), 45 with non-ST-segment elevation myocardial infarction (NSTEMI; 27.3%) and 26 with ST-segment elevation myocardial infarction (STEMI; 15.7%). Procedural success was achieved in all patients with thrombolysis in myocardial infarction flow 3. During a follow-up of 14.1 ± 8.5 months (median 12.4 months, IQR 8.7 [8.4 to 12.1] months) death occurred in 4 (2.4%) patients, including 2 (1.3%) cardiac deaths. There was only 1 case of subacute ST (0.66%), without late ST. The incidence of MI, TLR, TVR and TVF were: 2.65%, 2.65%, 7.95%, 9.3%, respectively. CONCLUSIONS The present results suggest that BVS implantation in ACS patients is feasible and safe in highly experienced centers. One-year clinical results are encouraging with a low rate of stent thrombosis.