Maurizio Viecca

Supported High-Risk Percutaneous Coronary Intervention With the Impella 2.5 Device: The Europella Registry

OBJECTIVES This retrospective multicenter registry evaluated the safety and feasibility of left ventricular (LV) support with the Impella 2.5 (Abiomed Europe GmbH, Aachen, Germany) during high-risk percutaneous coronary intervention (PCI). BACKGROUND Patients with complex or high-risk coronary lesions, such as last remaining vessel or left main lesions, are increasingly being treated with PCI. Because periprocedural hemodynamic compromise and complications might occur rapidly, many of these high-risk procedures are being performed with mechanical cardiac assistance, particularly in patients with poor LV function. The Impella 2.5, a percutaneous implantable LV assist device, might be a superior alternative to the traditionally used intra-aortic balloon pump. METHODS The Europella registry included 144 consecutive patients who underwent a high-risk PCI. Safety and feasibility end points included incidence of 30-day adverse events and successful device function. RESULTS Patients were older (62% >70 years of age), 54% had an LV ejection fraction < or = 30%, and the prevalence of comorbid conditions was high. Mean European System for Cardiac Operative Risk Evaluation score was 8.2 (SD 3.4), and 43% of the patients were refused for coronary artery bypass grafting. A PCI was considered high-risk due to left main disease, last remaining vessel disease, multivessel coronary artery disease, and low LV function in 53%, 17%, 81%, and 35% of the cases, respectively. Mortality at 30 days was 5.5%. Rates of myocardial infarction, stroke, bleeding requiring transfusion/surgery, and vascular complications at 30 days were 0%, 0.7%, 6.2%, and 4.0%, respectively. CONCLUSIONS This large multicenter registry supports the safety, feasibility, and potential usefulness of hemodynamic support with Impella 2.5 in high-risk PCI.

Myocardial blood flow and infarct size after CD133+ cell injection in large myocardial infarction with good recanalization and poor reperfusion: Results from a randomized controlled trial

Objective Large acute ST-elevation myocardial infarction (STEMI) sometimes leaves extensive ischemic damage despite timely and successful primary angioplasty. This clinical picture of good recanalization with incomplete reperfusion represents a good model to assess the reparative potential of locally administered cell therapy. Thus, we conducted a randomized controlled trial aimed at evaluating the effect of intracoronary administration of CD133+ stem cells on myocardial blood flow and function in this setting. Methods Fifteen patients with large anterior STEMI, myocardial blush grade 0–1 and more than 50% ST-elevation recovery after optimal coronary recanalization (TIMI 3 flow) with stenting were randomly assigned to receive CD133+ cells from either bone marrow (group A) or peripheral blood (group B), or to stay on drug therapy alone (group C). The cells were intracoronary injected within 10–14 days of STEMI. Infarct-related myocardial blood flow (MBF) was evaluated by NH3 positron emission tomography 2–5 days before cell administration and after 1 year. Results MBF increased in the infarct area from 0.419 (0.390–0.623) to 0.544 (0.371–0.729) ml/min per g in group A, decreased from 0.547 (0.505–0.683) to 0.295 (0.237–0.472) ml/min per g in group B and only slightly changed from 0.554 (0.413–0.662) to 0.491 (0.453–0.717) ml/min per g in group C (A vs. C: P = 0.023; B vs. C: P = 0.066). Left ventricular volume tended to increase more in groups B and C than in group A, ejection fraction and wall motion score index remained stable in the three groups. Conclusion These findings support the hypothesis that intracoronary administration of bone marrow-derived, but not peripheral blood-derived CD133+ cells 10–14 days after STEMI may improve long-term perfusion.

Comparative Effectiveness of Wide Antral Versus Ostial Pulmonary Vein Isolation A Systematic Review and Meta-Analysis

Background—For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented worldwide for the treatment of atrial fibrillation. Currently, 2 main approaches are used for PVI: ostial isolation of the PVs and wide antral PVI. The aims of this systematic review are to evaluate the relative merits of each technique with a pooled comparative analysis of efficacy and complications. Methods and Results—Studies were identified by searching electronic databases for studies on ostial versus antral PVI. Information was extracted from each included trial. Odds ratio was the primary measure of treatment effect or side effects. The proportion of patients with recurrences of atrial fibrillation or other atrial tachyarrhythmias was evaluated at the end of the follow-up periods in 12 trials, including 1183 patients. The recurrence rate of total supraventricular arrhythmias was significantly lower in wide antral than in segmental PVI group (odds ratio, 0.42; 95% confidence interval, 0.32–0.56; P<0.00001). Atrial fibrillation recurrence was significantly lower in the wide antral group (odds ratio, 0.33; 95% confidence interval, 0.24–0.46; P<0,00001). A trend toward a higher incidence of left atrial tachycardia occurrence in the wide antral circumferential ablation group was detected, which did not reach statistical significance (odds ratio, 1.53; 95% confidence interval, 0.88–2.69; P=0.13). Conclusions—Our primary finding is that PVI performed with a wide antral approach is more effective than ostial PVI in achieving freedom from total atrial tachyarrhythmia recurrence at long-term follow-up.

Remote magnetic with open-irrigated catheter vs. manual navigation for ablation of atrial fibrillation: a systematic review and meta-analysis

The aim of this study was to determine the efficacy and safety of remote magnetic navigation (RMN) with open-irrigated catheter vs. manual catheter navigation (MCN) in performing atrial fibrillation (AF) ablation. We searched in PubMed (1948-2013) and EMBASE (1974-2013) studies comparing RMN with MCN. Outcomes considered were AF recurrence (primary outcome), pulmonary vein isolation (PVI), procedural complications, and data on procedures performance. Odds ratios (OR) and mean difference (MD) were extracted and pooled using a random-effect model. Confidence in the estimates of the obtained effects (quality of evidence) was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. We identified seven controlled trials, six non-randomized and one randomized, including a total of 941 patients. Studies were at high risk of bias. No difference was observed between RMN and MCN on AF recurrence [OR 1.18, 95% confidence interval (CI) 0.85 to 1.65, P = 0.32] or PVI (OR 0.41, 95% CI 0.11-1.47, P = 0.17). Remote magnetic navigation was associated with less peri-procedural complications (Peto OR 0.41, 95% CI 0.19-0.88, P = 0.02). Mean fluoroscopy time was reduced in RMN group (-22.22 min; 95% CI -42.48 to -1.96, P = 0.03), although the overall duration of the procedure was longer (60.91 min; 95% CI 31.17 to 90.65, P < 0.0001). In conclusion, RMN is not superior to MCN in achieving freedom from recurrent AF at mid-term follow-up or PVI. The procedure implies less peri-procedural complications, requires a shorter fluoroscopy time but a longer total procedural time. For the low quality of the available evidence, a proper designed randomized controlled trial could turn the direction and the effect of the dimensions explored.

Does left atrial appendage closure with a cardiac plug system reduce the stroke risk in nonvalvular atrial fibrillation patients? A single-center case series.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and it is associated with an increased stroke risk, due mainly to cardiac embolism from the left atrial appendage (LAA). Percutaneous LAA closure is a method to reduce stroke risk in AF without using anticoagulant agents. In this study we report data from an Italian experience with the LAA occluder Amplatzer Cardiac Plug (ACP) device (Aga Medical Corporation, Plymouth, MN, USA).

Triggers of acute myocardial infarction: a neglected piece of the puzzle.

The existence of specific risk factors for the development of coronary heart disease, both chronic and acute, has been extensively investigated and is well understood by cardiology professionals. Diabetes, hypertension, hypercholesterolemia, psychological patterns and smoking are assumed to interact in a complex way with individual heritable predisposition, thus determining the long-term probability of coronary disease. However, the possibility that defined circumstances and activities may act as immediate triggers of acute coronary syndromes, particularly acute myocardial infarction, has not been given comparable attention in clinical research. For example, the recently issued 2012 European guidelines on cardiovascular disease prevention completely overlook the topic of triggers and their possible prevention. This review presents a picture of the most reliable evidence regarding the triggering of myocardial infarction and contributes to further investigation in the field.

Instrumental validation of percutaneous transmyocardial revascularization: follow-up data at one year

BACKGROUND Despite the clinical efficacy of percutaneous transmyocardial revascularization (PTMR), up to date there are still no instrumental validations to demonstrate both the improved perfusion of treated areas and cardiac function. METHODS During the first year of follow-up after PTMR, 27 patients (group A) underwent 99mTc MIBI exercise-single photon emission tomography (SPET), while 30 patients (group B) underwent serial transthoracic echocardiography (TTE) evaluations with analysis of cardiac volumes and subendocardial layer thickness in systole. RESULTS All 57 patients had a significant angina Canadian Cardiovascular Society (CCS) class improvement. Group A patients (75%) had improved exercise-SPET perfusion in treated areas at 12 weeks after PTMR, and at the next follow-up. Group B patients had non-significant reduction in global volume and no significant change in ejection fraction. However, there was an improvement in thickness of the subendocardial-treated areas in systole that persisted during follow-up. CONCLUSIONS The use of SPET and TTE validates the clinical efficacy of PTMR.

[Interatrial block: an under-recognized electrocardiographic diagnosis with important clinical-therapeutic implications].

Interatrial blocks, characterized by P-wave duration ≥120 ms, are a well described but poorly recognized cardiac rhythm disorder. They are caused by a conduction delay between the right and left atria and occur in pandemic proportions in unselected patients. Interatrial blocks correlate with atrial dysfunction and are a predictor of significant atrial arrhythmias, particularly atrial fibrillation, as well as embolic stroke, all-cause and cardiovascular mortality. Special attention to this cardiac rhythm disorder is required because of its pathologic implications.

Surgical timing in aortic regurgitation: left ventricular function analysis by contractility score.

In 32 patients with aortic regurgitation, angiographic evaluation of global left ventricular performance before and after aortic valve replacement was carried out by means of a computer-analyzed contractility scoring system. A strong correlation was detected between the preoperative and postoperative contractility score. Postoperatively, the score decreased in all but 3 patients, becoming normal or near normal in 21 of 27 patients whose preoperative value had been less than 40. However, all 5 patients with a preoperative contractility score of 40 or greater exhibited a persistently elevated score after operation that indicated the presence of irreversible contractile dysfunction. Patients in groups A and B (preoperative score, 0 to 40) experienced a good surgical outcome, and at 5-year follow-up were in New York Heart Association functional class I. Patients in group C (preoperative score, > 40) altogether had a very poor surgical outcome, although they did experience a short to midterm period of symptomatic relief. It is important to offer aortic valve replacement to patients with aortic regurgitation before their chances for a good functional result are lost. The computer-analyzed contractility score may be a useful index for determining the optimal timing of operation in these patients, particularly those who show features consistent with impaired left ventricular function but are asymptomatic and who should undergo aortic valve replacement before symptoms of definitive left ventricular failure develop.

Primary PCI is associated with different cardiac autonomic patterns in relation to the site of myocardial infarction.

AIM Reflex alterations of cardiac autonomic modulation have been described after acute myocardial infarction (AMI). The non-homogeneous autonomic innervation of the heart gives reason of different patterns of autonomic modulation depending upon the site of AMI. Conflicting data are available on cardiac autonomic modifications after primary percutaneous coronary intervention (pPCI). We evaluated cardiac autonomic changes in patients with ST-elevation myocardial infarction (STEMI) after pPCI, either within 24h after revascularization (T0) and at clinical stability (T1, 6±2days), taking into account the site of infarction. METHODS AND RESULTS We enrolled 33 consecutive patients with STEMI treated with pPCI (25 males, mean age 61±12.1yr); 15 had an anterior wall STEMI (ANT) and 18 had an inferior wall STEMI (INF). ECG and respiration were recorded at T0 and at T1. Cardiac autonomic modulation was evaluated by means of symbolic analysis of heart rate variability. At T0, At T0, 0V% (marker of sympathetic modulation) was higher in INF compared to ANT [31% (18-43) vs 18% (7-32), p=0.014]. Moreover, ANT had a higher 2LV%, index of vagal modulation, compared to INF [8% (7-15) vs 5% (2-8), p=0.006]. CONCLUSION After pPCI, these preliminary results suggest that patients with INF were characterized by a sympathetic predominance, while ANT by a predominant vagal modulation. Our data suggest that pPCI can be associated with specific autonomic patterns, which are different for ANT and INF STEMI, according to the different autonomic innervation. Future ad hoc studies are needed to confirm these preliminary observations.