Nicola Viceconte

Immediate Results of Bifurcational Stenting Assessed With Optical Coherence Tomography

Background: A tubular stent may adapt with difficulty to coronary bifurcation lesions (CBLs). Methods: Time domain or frequency domain (FD) optical coherence tomography (OCT) was performed to assess strut apposition immediately after stent implantation across four segments inside the bifurcation, in a consecutive series of patients. OCT pullbacks were performed in the main vessel (MV). Results: A total of 13,142 struts in 45 CBL in 41 patients were assessed. Strut malapposition was significantly more frequent in the half bifurcation facing the side‐branch (SB) ostium (42.9%) than in the proximal segment of the bifurcation 11.8%, half bifurcation opposite the SB 6.7%, or the distal segment 5.7% (all P < 0.0001). Lesions (n = 15) treated with stenting of both MV and SB had a total higher rate of malapposition than those (n = 30) treated with stenting of the MV only (17.6% vs. 9.5%; P = 0.0014). In latter group, lesions treated with FD‐OCT‐guided stent implantation (n = 13) presented a lower rate of malapposition than those treated with conventional angiographic‐guided stent implantation (n = 17) (7.1% vs. 17.5%; P = 0.005). Conclusions: In CBL, strut malapposition is particularly high at the SB ostium. However, a strategy of stenting MV only with adjunctive FD‐OCT guidance is associated with lower rates of malapposition.

Laser “explosion” technique for treatment of unexpanded coronary stent

fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369–429. [5] Wann LS, Curtis AB, January CT, et al. ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011;57:223–42. [6] Shewan LG, Coats AJ. Ethics in the authorship and publishing of scientific articles. Int J Cardiol 2010;144:1–2.

Sudden death and physical exercise: timely diagnosis of congenital anomalies of the coronary arteries with the new 320-slide multi-detector computed tomography.

Congenital abnormalities of the coronary arteries here described are an uncommon form of structural heart disease. Nevertheless, they deserve attention because may cause chest pain and, in some cases, sudden cardiac death even during exercise. Traditional angiography has limitations due to its projectional and invasive nature. The recent development of the 320-slide multi-detector computer tomography with low radiation exposure has the potential to modify the current diagnostic work-up, as it allows even in young people a timely identification of clinical significant coronary anomalies minimizing the risks related to radiation exposure.

STEMI guidelines: from formulation to implementation

Introduction In general, guidelines reflect scientific evidence already acquired and follow, rather than anticipate, new developments in diagnostic and therapeutic practice. This applies to STEMI guidelines. Failure to apply the guidelines is rarely caused by the lack of knowledge of their content. Resistance is invariably due to scepticism as to the true advantage of the treatment proposed, financial concerns or organisational difficulties. In the last 10 years the guidelines surrounding STEMI treatment have evolved from a list of drugs able to respond to the various needs of STEMI patients (from pain relief to haemodynamic stabilisation and antithrombotic treatment) to an integrated strategy describing in detail the response to this primary cardiovascular emergency (from the first diagnosis and treatment in the ambulance to rehabilitation and secondary prevention). This article reports the key messages of the guidelines addressing STEMI treatment in the past 10 years and reviews how these messages have informed key changes in clinical practice.

Early beneficial effects of drug-eluting stents in vein grafts wane during long term follow-up: a case-control study.

The aim of the study was to compare outcomes of drug‐eluting stents (DES) versus bare‐metal stents (BMS) in saphenous vein graft (SVG) interventions in a case–control study with a long‐term follow‐up.

Randomized study on provisional stenting with sirolimus-eluting stent vs. bare metal stent for the treatment of true coronary bifurcations: The PROSUMER (PROvisional with sirolimus-eluting vs. bare metal stents in truE bifuRcations) study

⁎ Corresponding author. Via Tommaso Inghirami 85, 00179 Rome, Italy. Tel.: +39 348 3392006; fax: +39 06 330 62516. E-mail address: f.pelliccia@mclink.it (F. Pelliccia). Percutaneous treatment of coronary bifurcations with stent implantation is still a matter of debate [1]. Despite the implementation of numerous techniques to stent both branches, none has shown clinical and angiographic superiority to the main branch (MB) stent technique with provisional T-stenting of the side branch (SB) in case of dissection or residual severe disease [2]. In addition, concerns have been raised about safety of drug-eluting stents (DES) because of the greater late and very late [3] stent thrombosis and mortality as compared to bare metal stents (BMS). Also, technical characteristics of stents (i.e. high radial force, favorable vessel wall covering percentage and larger patency of SBs) seem to be crucial factors in case of provisional T-stenting strategy [2,4]. To address these issues, we designed the PROSUMER (PROvisional with sirolimus-eluting vs. bare metal stents in truE bifuRcations) study in order to prospectively and randomly compare the safety and efficacy of sirolimus-eluting stent (SES) vs. a BMS in case of treatment of true coronary bifurcation lesions with provisional T-stenting. The studywasdesigned as a prospective, single-center pilot trial, and included consecutive angina patients with a de novo true coronary arterybifurcation lesion (Medina classifications1,1,1 or 1,0,1 or0,1,1)[5] who were allocated to SES (CypherTM, Johnson & Johnson, Miami Lakes, Fla) or a novel BMS (Horus S, International Biomedical Systems, Trieste, Italy). The BMS under investigation is made from 316 LVM stainless steel. The stent is a cylindrical helix with sinusoidal loops, consisting of medical-grade stainless-steel continuouswire, that has high radial force (1.5% diameter reduction at 200 mm Hg) with good scaffolding and favorable vesselwall coveragewith patency of SBs (covering percentage in the expanding state ranging between 19.1%—2.5 mm and 16.2%— 3.5 mm).All patientswere followedup to9 months. Theprimary clinical end point of the study was the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiac or noncardiac death, Q-wave or non-Q-wave myocardial infarction, or target vessel revascularization. The primary angiographic end point of the study was the insegment per cent diameter stenosis of the SB at 9 month follow-up. Coronary angiograms were analyzed off-line with the use of an automated edge-detection system (Cardiovascular Medical System, MEDIS Imaging Systems, Leiden). Sixty consecutive patients (age: 62±12 years) were randomized to a SES (N=30) or a BMS (N=30) in the MB. The two study groups did not show any significant difference in baseline clinical and angiographic characteristics. Procedural success after stenting the MB was similar in the two groups (97%), with 2 cases of periprocedural non-Q-wave myocardial infarction (1 in the SES group and in 1 in the BMS group) caused by periprocedural occlusion of the nonstented SB because of dissection. The primary clinical endpoint of the study, cumulative MACE at 9month follow-up, occurred in 6 patients of the SES group and in 4 patients of the BMS group (20 vs. 17%; P=1.00) (Table 1). During follow-up, no patient died, but one patient of the SES group had stent thrombosis. No significant differences in the rate of target lesion revascularization and target vessel revascularization occurred between the two groups (Table 1). The primary study angiographic endpoint did not differ significantly between the SES and BMS groups (20% vs. 34%, P=0.38). When restenosis rates were analyzed by restenosis site, the two groups showed similar rates of binary restenosis occurring in both MB and SB, in MB only and in SB only (Table 1). Quantitative data at follow-up angiography (Table 2) revealed that, as compared with the BMS group, the SES group had significantly larger minimal lumen diameter and percent diameter restenosis as well as lower late loss at MB. Conversely, no significant difference was found between the two study groups in any angiographic variable at SB. The PROSUMER study shows that good long-term results when treating coronary bifurcations can be achieved with a strategy of provisional stenting with BMS as compared with SES, provided that a stent with favorable technical characteristics for bifurcations coupled with an optimal delivery technique are adopted. The results of PROSUMER show that binary restenosis rate at 9-month control angiography did not differ significantly between the SES and BMS

Bi-Atrial Function before and after Percutaneous Closure of Atrial Septum in Patients with and without Paroxysmal Atrial Fibrillation: A 2-D and 3-D Speckle Tracking Echocardiographic Study

Our aim was to analyze atrial function with 2-D (2-D-STE) and 3-D (3-D-STE) speckle tracking echocardiography in patients with atrial septal devices and paroxysmal atrial fibrillation (PAF). One hundred sixteen patients and a subgroup of 22 patients who developed PAF after device insertion were studied. Left atrial and right atrial peak longitudinal strain and standard deviations of time to peak strain (TPS) were calculated using 2-D-STE. The left atrial/right atrial emptying fraction and expansion index were determined using 3-D-STE. By multivariate analysis, pre-closure 3-D right atrial expansion index, left atrial time to peak strain, and 3-D left atrial expansion index were independently associated with PAF. Compared with the other indices, receiver operating characteristic analysis revealed better diagnostic accuracy for the combination of pre-closure time to peak strain and 3-D expansion index in detecting PAF. Patients with atrial septal devices have pre-existing left and right atrial dilation and dysfunction as assessed by 2-D-STE and 3-D-STE that appear sensitive for the stratification of PAF risk in this population.

Early metabolic response to acute myocardial ischaemia in patients undergoing elective coronary angioplasty

Objective Balloon-induced transient coronary ischaemia represents a model of myocardial ischaemia and reperfusion. We are interested in the very early systemic metabolic response to this event. Methods Blood samples of patients with stable angina (SA) were collected before and after coronary angioplasty. Serum metabolic profiles were obtained using nuclear magnetic resonance spectroscopy. Univariate and multivariate analyses were used to investigate changes in metabolite concentrations. Results Thirty-four consecutive patients with SA, undergoing elective coronary angioplasty at Policlinico Umberto I of Rome, were included in this study. Changes in metabolites concentration induced by balloon occlusion in venous and arterial sera were detected. In both serum types, a significant increase in ketone bodies, 2-hydroxybutyrate, glutamine and O-acetylcarnitine concentration is observed, while alanine, lactate, phenylalanine and tyrosine decreased after intervention. Most significant metabolic changes were detected in arterial serum. Conclusions Our study points out two main global metabolic changes in peripheral blood after balloon-induced coronary ischaemia: ketone bodies increase and lactate decrease. Both could be related to compensation mechanisms finalised to fulfil heart’s needs after short period of myocardial ischaemia and probably after reperfusion.

Interplay between Oxidative Stress and Platelet Activation in Coronary Thrombus of STEMI Patients

Background: Platelet activation and oxidative stress seem to play a key role in coronary thrombus formation and are associated with thrombus burden in ST-elevation myocardial infarction (STEMI). However, the interplay between oxidative stress and platelet activation has not been fully elucidated. Materials and Methods: For 32 patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) and 10 patients with stable angina (SA) and oxidative stress, as assessed by NADPH isoform 2 activity (soluble Nox2-derived peptide, sNox2-dp), levels of oxidized low-density lipoproteins (oxLDLs) and platelet activation markers such as soluble CD40 Ligand (sCD40L) and soluble P-selectin (sP-selectin) were measured in the retrieved material (coronary thrombi plus blood waste) of STEMI patients and in intracoronary blood of SA patients, respectively, and in peripheral blood samples of both groups. Results: In aspirated thrombi and blood waste of STEMI patients we found higher serum levels of sNox2-dp, oxLDLs, sCD40L, and sP-selectin, as compared to the intracoronary blood samples of SA patients. Moreover, in thrombi and blood waste of STEMI patients, a direct correlation between markers of oxidative stress and of platelet activation was found. Also, in STEMI patients a progressive increase of oxidative stress and platelet activation markers was observed according to the thrombus score burden. STEMI patients showed higher peripheral blood Nox2 activity and oxLDL levels as compared to SA patients. Conclusion: This study shows a close relationship between oxidative stress and platelet activation in the intracoronary blood waste and aspirated thrombi of STEMI patients, suggesting a role of oxidative stress in promoting thrombus formation and growth.

Glutathione sodium salt as a novel adjunctive treatment for acute myocardial infarction

Timely recanalization of infarct related artery along with effective myocardial cell reperfusion represents a major challenge in the management of STEMI. The reperfusion of coronary arteries can induce further cardiomyocyte death by generating oxidative stress, which itself can mediate myocardial damage through a number of different mechanisms. Based on experimental and clinical studies, interventions to treat reperfusion injury by antioxidants were considered to be an appropriate therapeutic option. We emphasize the hypothesis that glutathione sodium salt, a physiologic antioxidant, may be of value when administered to STEMI patients both at an early stage of myocardial reperfusion by primary angioplasty and for up to three days after the procedure, in addition to standard treatment.