Salvatore Azzarelli

Clinical findings of Takotsubo cardiomyopathy: results from a multicenter international study.

Background Takotsubo cardiomyopathy consists of reversible systolic left ventricular apical ballooning associated with chest pain. Electrocardiographic abnormalities and the minimal rise of serum cardiac markers are similar to those in acute myocardial infarction, but without evidence of myocardial ischemia or injury. To date, many reports concerning this kind of acute reversible heart failure have been published, but the information available about the management of affected patients is scarce and the clinical data are incomplete. Aims In the present study, we report a collection of 40 patients who were affected by Takotsubo cardiomyopathy obtained in a multicentric international study, aiming to investigate the origins, and the clinical and instrumental patterns, and to establish the best diagnostic criteria for this syndrome. Methods and Results In the analysed group, the mean age was 68 years, of whom 85% were women. On admission to hospital, 68% of patients reported chest pain. An electrocardiogram (ECG) showed anterolateral (34%) or anterior (36%) ST segment elevation. The ECG demonstrated hyperkinesis of the basal segments with a severe hypokinesis of the other segments. Mean ejection fraction was 42.53%. Three patients died within the first 24 h from acute heart failure. The remaining 37 patients showed a complete resolution of symptoms and a complete normalization of the kinesis deficiency. Sixteen patients underwent myocardial scintigraphy, nine cases underwent myocardial biopsy and two patients received an ergonovine test. Conclusion Our results demonstrate a good course of Takotsubo cardiomioathy, after the initial phase. An echocardiogram is an important tool for improving the diagnosis.

Incidence, treatment, and in-hospital outcome of bifurcation lesions in patients undergoing percutaneous coronary interventions for chronic total occlusions.

Background Bifurcation lesions represent a distinct lesion subset associated with an increased risk of procedural complications. Data on the incidence, treatment, and outcome of bifurcation lesions associated with chronic total occlusions are limited. Methods Among chronic total occlusion procedures performed by a single experienced operator, patients with a bifurcation lesion within the chronic total occlusion vessel and a side branch reference diameter greater than or equal to 2.0 mm were enrolled. Results A total of 905 patients (mean age 61.1±9.5 years, men 89.4%) were treated for 922 chronic total occlusion lesions. Among these, 244 bifurcation lesions were observed (26.5%). The procedural time was significantly longer in bifurcation lesions (139±67 vs. 124±68 min; P=0.003), with greater use of contrast load (470±193 vs. 436±227 ml; P=0.04) and higher number of stents (3.1±1.5 vs. 2.9±1.4; P=0.035). Overall, an angiographic success was achieved in 91.1% of cases with a higher rate in nonbifurcation lesions (92.5 vs. 87.3%; P=0.04). Coronary perforations were more often observed in bifurcation lesions (4.9 vs. 1.7%; P<0.001), resulting in more tamponades (2.4 vs. 0.2%; P<0.001). True bifurcations were encountered in the majority of cases (86.8%) and required more two-stent techniques than false bifurcations (50 vs. 18.8%; P=0.001). Conclusion The incidence of bifurcation lesions in chronic total occlusions is higher than that reported in continuous lesions. The presence of a bifurcation lesion increases the complexity of the procedure and may lead to less angiographic success and more periprocedural complications.

Prognostic value of exercise myocardial scintigraphy in patients with coronary chronic total occlusions.

OBJECTIVES To evaluate the prognostic value of exercise myocardial scintigraphy in patients undergoing incomplete revascularization by means of percutaneous coronary intervention (PCI) with at least a residual chronic total occlusion (CTO) left untreated. METHODS Of 569 consecutive patients with multivessel disease undergoing myocardial scintigraphy after incomplete revascularization by PCI between March 1997 and December 2004, 126 (79% male, 64+/-10 years) with >or= 1 residual CTO fulfilled the eligibility criteria and entered in the study. Hard events defined as cardiac death and myocardial infarction, soft events defined as incidence of unstable angina and PCI procedures, and their composite were assessed at a median follow-up period of 44 months. RESULTS Hard events were observed in six patients (4.8%). All of them had severely abnormal perfusion defects detected by myocardial scintigraphy. Soft events occurred in 0 (0%), 10 (7.9%), and 15 (11.9%) patients with normal, mildly abnormal, and severely abnormal perfusion, respectively. In the Kaplan-Meier analysis, the log-rank test was statistically significant across patients stratified by summed stress score either in terms of hard, soft and hard, or soft events. Univariate and multivariate Cox proportional-hazards showed an incremental significant information when the scintigraphic variables were added to clinical, angiographic, left ventricular ejection fraction, and Duke treadmill score, for prediction of the composite of hard and soft cardiac events (P < 0.006). CONCLUSIONS Among patients with a residual CTO left untreated after PCI, myocardial perfusion imaging provides significant independent information concerning the subsequent risk of cardiac events.

Apical thrombus in a patient with takotsubo cardiomyopathy.

We report a case of apical thrombus formation among a group of 15 patients with takotsubo cardiomyopathy who were referred for a suspected acute coronary syndrome over a 2.5-year period. To the best of our knowledge, no data are available regarding the treatment of this syndrome. According to current literature and our reported experience, the use of anticoagulant therapy administered until complete resolution of wall motion abnormalities appears to be appropriate to treat apical thrombus formation and any possible subsequent embolism.

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization.

Iatrogenic left main coronary artery dissection: a single-center case series.

Age, years 55 60 64 69 72 72 Sex, (M1⁄4male, F1⁄4 female) F M F F M M Family history Yes No Yes No No No Diabetes mellitus No No No No No No Hypertension No No Yes Yes Yes No Hypercholesterolemia Yes Yes No Yes No Yes Current smoking Yes Yes No No No Yes Previous myocardial infarction No No No No Yes No Previous PCI/CABG No Yes No No Yes No Previous stroke/TIA No Yes No No No No PAD No No No No No No LVEF, % 47 56 60 55 48 60 Clinical presentation Stable angina – Yes – – – – Unstable angina – – Yes Yes Yes – NSTEMI – – – – – Yes STEMI – – – – – – AMI<15 days Yes – – – – –

A case of transient left mid ventricular ballooning.

We describe a case of an 85-year-old woman who presented with chest pain after a crisis of bronchial asthma. On admission, the electrocardiogram showed ST-segment elevation in leads II, III, and aVF. Peak troponin I level was 3.0 ng/dl (normal value <0.4 ng/dl). Angiography demonstrated ballooning of the mid portion of the left ventricle without involvement of the apex. No obstructive epicardial coronary artery disease was present. After 8 days, left ventricular wall motion improved and returned completely to normal at 1-month echocardiographic follow-up.

Which are the Best Follow-Up Strategies for Patients Who Undergo Percutaneous Coronary Interventions?

Percutaneous coronary intervention has become a mainstay in the treatment of patients with coronary artery disease in recent years. However, restenosis, incomplete revascularization, and progression of disease continue to cause a need for a clinical functional assessment in order to reduce morbidity. Angiographic systematic follow-up should nowadays be considered a valuable approach only to monitor small groups of very high risk patients. Although coronary CT angiography seems able to non-invasively image the coronary artery lumen, but the presence of a stent could limit visualization of coronary morphology. Recurrence of symptoms itself has low sensitivity and specificity for detection of restenosis and myocardial ischemia. Exercise testing may provide useful information on symptoms and functional capacity of the patient; however, it is poorly diagnostic of restenosis and myocardial ischemia with a low level of sensitivity and specificity. Conversely, the significantly increased sensitivity and specificity obtained by stress nuclear, echocardiographic or magnetic resonance imaging provide great advantage for clinical assessment of these patients. Additional advantages of stress imaging are the ability to assess location and extent of myocardial ischemia regardless of symptoms as well as to evaluate patients who are unable to exercise or who have an uninterpretable electrocardiogram. Furthermore, the clear superiority of stress imaging with regard to specificity and predictive value for postrevascularization events makes this functional approach of paramount importance for assessing prognosis of such patients.

Residual SYNTAX Score II: a Combination of the Assessment of the Revascularization Degree and the Clinical Evaluation after Percutaneous Coronary Intervention

Please cite this article in press as: Boukhris M. et al., Residual SYNTAX score II: A combination of the assessment of the revascularization and the clinical evaluation after percutaneous coronary intervention, J Saudi Heart Assoc (2017), https://doi.org/10.1016/j.jsha.2017.11.003 Marouane Boukhris a,⇑, Farouk Abcha , Salvatore D. Tomasello , Simona Giubilato , Salvatore Azzarelli , Alfred R Galassi c,d

Role of Stress Myocardial Scintigraphy in the Evaluation of Incompletely Revascularized Post-PCI Patients

Percutaneous coronary intervention (PCI) is actually the most used method of revascularization. Although complete revascularization remains a desirable goal, it may not be possible or not easy to plan in many patients. Thus, incomplete revascularization might be a preferred treatment strategy in selected patient categories. Stress myocardial scintigraphy, because of its high diagnostic accuracy and prognostic value and its ability to assess location and extent of myocardial ischemia regardless of symptoms as well as to evaluate patients who are unable to exercise or who have uninterpretable electrocardiogram, is of paramount importance for clinical decision making in patients with multivessel disease and incomplete revascularization.