In high risk hypertensive subjects with incidental and unilateral renal artery stenosis percutaneous revascularization with stent improves blood pressure control but not glomerular filtration rate.

AIM: In high-risk hypertensive subjects (HTs) with incidental unilateral renal artery stenosis (RAS), the effectiveness of percutaneous revascularization with stent (PR-STENT) on blood pressure (BP) and glomerular filtration rate (GFR) is not established. METHODS: Eighteen HTs aged 65.7 ± 9.2 years with angiographically diagnosed unilateral RAS (≥ 60%) were randomized to receive PR-STENT (N=9) or to NO-STENT (N=9). BP (mercury sphygmomanometer) and GFR (99mTc-DTPA clearances during renal scintigraphy) were evaluated yearly for three years. Echo-Doppler of renal arteries was performed to verify the anatomic patency and flow velocities of the reperfused artery. Analysis of variance compared BP and GFR values changes from baseline to the follow-up; differences for continuous variables were evaluated between groups with the Tukey's post hoc test after adjustment for age, change of BP between baseline and at the follow-up, GFR and body mass index (BMI). RESULTS: Baseline systolic BP and GFR values were not different between groups. The significantly greater GFR increase observed in PR-STENT than in NO-STENT at univariate analysis at the end of follow-up (62.5 ± 19.2 vs. 42.24 ± 17.6, P<0.02) disappeared after adjustment for confounding factors. However, systolic BP remained significantly lower in PR-STENT than in NO-STENT (140.1 ± 4.6 vs. 170.0 ± 8.3, P<0.0001) also after adjustment for age, GFR and BMI. CONCLUSION: PR-STENT reduces systolic BP without improving GFR. Due to the strong association between high BP and renal damage, this study raises the question on whether PR-STENT should be performed in all HTs with unilateral and incidental RAS.

Safety and long-term results of patent foramen ovale transcatheter closure in patients with thrombophilia.

AIM: Trials on transcatheter closure of patent foramen ovale (PFO) in different settings attempted to exclude patients with thrombophilia for the risk of device thrombosis. Authors sought to retrospectively evaluate safety and results of transcatheter PFO closure in patients with confirmed coagulation abnormalities. METHODS: Between December 2006 and December 2008, 30 out of 98 consecutive patients (mean age 40+/-10.9 years, 23 females) referred to Rovigo General Hospital for transcatheter closure had coagulation abnormalities including mutations of factor V Leiden, factors X, VIII, protein C, S, MHFTR factors, and antiphospholipid and anticardiolipin antibodies, hyperhomocisteinimia. All patients underwent preoperative transesophageal echo and brain magnetic resonance imaging, and intra-cardiac echo-guided transcatheter PFO closure. RESULTS: Success rate was 100%; there was no difference in occlusion and complications rates between patients with and without thrombophilia: in particular no device thrombosis or recurrent cerebral ischemia or stroke were observed during the follow-up. Patients with thrombophilia had a higher incidence of atrial septal aneurysm, migraine with aura and deep venous thrombosis in the previous medical history compared to patients without. CONCLUSIONS: Despite its small sample, this study suggests that patients with coagulation abnormalities should not be excluded from the trial; they have potentially a higher risk of stroke through a PFO compared to other patients, and transcatheter closure is as safe and effective as in general population with almost no additional therapy rather than aspirin.

Early post-procedural migraine attack predicts migraine resolution after patent foramen ovale transcatheter closure.

AIM: In patients with patent foramen ovale-related migraine, the procedure of transcatheter closure itself is likely to cause a migraine attack. Our study is aimed to evaluate the incidence of migraine attacks immediately after closure procedure and their clinical and potential prognostic significance. METHODS: We reviewed our database from January 2005 to April 2007 searching for patients with severe disabling migraine despite anti-headache therapy who were submitted to transcatheter closure of patent foramen ovale (PFO). Medical records of these patients were carefully reviewed in order to record migraine episodes immediately (0 to 6 h) after closure procedure. RESULTS: Twenty-one patients with previous stroke and migraine underwent PFO closure: the procedure was successful in all of the patients with no perioperative and in-hospital complications. Ten patients (47.6%) experienced a migraine attack of mean duration 3.5+/-2.4 h immediately after the closure procedure. Those patients had the same procedure time compared with other patients, but had larger PFO: patients with migraine attack immediately after closure had higher rate of complete abolition of migraine in the follow-up. CONCLUSION: Although more larger studies are needed to evaluate the exact relationships between migraine and PFO, in patients with a tight correlation between migraine and PFO, a prolonged opening of the PFO, as during closure procedure, may cause a migraine attack immediately after the closure. This fact can be considered a positive prognostic factor for migraine abolishment in the follow-up.

Intracardiac echocardiography-guided atrial septal defect transcatheter closure of a very old surgical residual shunt.

Although some studies have suggested excellent long-term outcome, arrhythmias, pulmonary hypertension, and paradoxical cerebral embolism are mentioned as results of residual shunts in the long-term follow-up after surgical atrial septal defect (ASD) closure at a young age. In cases of previous patch closure, transcatheter repair of residual shunts can be problematic due both to clinical decision-making in the presence of elevated pulmonary pressure and to a very old patch. A 70-year-old woman operated for an ASD with synthetic patch closure when she was 35 years old was referred to our center because of recurrent paroxysmal atrial fibrillation, initially decompensated right heart failure with rest and exercise-induced dyspnea as results of a residual shunt and moderate pulmonary hypertension. Complete right heart catheterization confirmed a mean pulmonary pressure of about 55 mm Hg and a Qp:Qs ratio of 1.78. A mechanical intracardiac echocardiography study with a 9F 9 MHz UltraICE catheter (Boston Scientific Corp.) showed a highly echogenous interatrial patch with a very stiff appearance and a very high residual defect of 8.7 and 11.2 mm on the aortic valve plane and on the four-chamber views, respectively. An occlusion test with a compliant AGA medical balloon demonstrated a decrease in mean pulmonary pressure to 36 mm Hg. A 10 mm Amplatzer's ASD occluder was implanted after a first unsuccessful attempt due to patch stiffness. Three-month echocardiography follow-up demonstrated almost normal pulmonary pressure and only slight dilation of the right chambers. At six-month follow-up, the patient no longer experienced dyspnea. This case demonstrates that transcatheter closure of a residual shunt following surgical ASD repair can be successfully accomplished also in elderly patients with a very old patch and decompensated right heart failure: the balloon occlusion test and intracardiac echocardiography appear to be effective in the operative decision-making process.

Vascular remodeling after carotid artery stenting.

Carotid stenting is an alternative to endarterectomy for the treatment of carotid stenosis. To determine the role of vascular remodeling after stent placement, we studied 19 high surgical risk patients undergoing carotid stenting for severe stenosis. Using high-resolution ultrasound, we evaluated the intima-media thickness (IMT), the intima-intima diameter, and the adventitia-adventitia diameter at prespecified sites of the carotid artery tree during 3 years of follow-up. The IMT of internal carotid artery, at the site of maximum stenosis, increased significantly from 0 mm after 24 hours, to 0.41 mm at 3 months, to 0.48 mm at 6 months, and to 0.51 mm at 3 years of follow-up. In the same site, diameters and residual stenosis (range 29-24%) did not change over time. Our study showed that stent is self-expanding against the atherosclerotic plaque within the 3-year follow-up period. Despite neointima formation, the intima-intima diameter does not change without worsening of the residual stenosis.

Patent foramen ovale management: who should do what?

Although definitive evidence of effectiveness of percutaneous patent foramen ovale (PFO) closure is still debated and closure seems to be recommendable only for secondary prevention of stroke, many different specialists may be involved in diagnosis and treatment of the different PFO-related syndromes. When many different professionals are involved in the same patient management, confusion about who does make the diagnosis and who does take decision about medical or interventional therapy would be frequent and correct judgment and actions would be delayed. The authors propose a model of multidisciplinary protocol to manage PFO-related syndrome, in which each specialists has a specific role during the decision-making process that is driven by the cardiologist.

Endovascular treatment of femoro-popliteal obstructive disease.

The systemic nature of vascular atherosclerosis is beginning to involve not only the angiologists and the vascular surgeons, but also the clinical and the invasive cardiologists. Femoral occlusive disease is one of the most challenging field due to the particular anatomical morphology of the femoral arterial wall that is prone to obstructive disease and high restenosis rate after percutaneous revascularization. Acute and chronic arterial diseases are the main clinical scenario involving femoral vessels. Percutaneous techniques include endoluminal recanalization, subintimal recanalization, stent implantation, mechanical and rheolytic thrombectomy, laser angioplasty, and cryoplasty. In this review the authors propose an overview and an update of the most recent advances in techniques and results in the field of endovascular treatment of femoral artery occlusive disease.

Percutaneous revascularization of coexisting severe carotid and coronary artery disease: a case report.

Following the NASCET and ACAS trials, the use of carotid endarterectomy for the treatment of carotid artery stenosis has become widespread. However, in high-risk patients, the perioperative morbidity and mortality have reached 18%. In such populations, a percutaneous approach including coronary angioplasty and stenting of the carotid lesion could be an option worth exploring. In this report we discuss a case that is representative of our experience with the simultaneous treatment of critical carotid and coronary stenosis. A 74-year-old patient with advanced coronary artery disease and severe bilateral carotid pathology was submitted to coronary angioplasty and stenting of the carotid lesions.

Positron emission tomography is a useful tool in differentiating idiopathic from ischemic dilated cardiomyopathy.

We evaluated the utility of positron emission tomography in differentiating patients with idiopathic dilated cardiomyopathy from those with ischemic cardiomyopathy. Twenty consecutive non-diabetic patients with dilatation (end-diastolic volume > or = 120 cc/m2) and reduced systolic function (ejection fraction < or = 40%) of the left ventricle on cineangiography, underwent coronary angiography, F18 fluorodeoxyglucose (F18-FDG) (glucose load technique) and N13-ammonia (N13-NH3) positron emission tomography. A semiquantitative score based on the extension and the severity of the uptake defects was calculated. Endomyocardial biopsy was performed in patients with normal coronary arteries. Ten patients (group A) had normal coronary arteries and histologic features of the endomyocardium fitting with the diagnosis of idiopathic dilated cardiomyopathy. Cineangiography showed critical stenosis of at least one major coronary artery in the other 10 patients (group B). The two groups were similar in age. left ventricular end-diastolic volume and ejection fraction. Both N13-NH3, positron emission tomography and F18-FDG positron emission tomography scores were lower in group A than in group B: 0.1 +/- 0.3 vs. 10.6 +/- 5.1 (P<0.0001) and 2.4 +/- 4.4 vs. 9.9 +/- 4.1 (P<0.0001) respectively. but only N13-NH3 positron emission tomography allowed a complete separation of the two groups (score range 0-1 group A vs. 4-12 group B). The F18-FDG score value showed some overlapping between the two groups (score range 0-12 in the group A vs. 2-17 in the group B). All three idiopathic dilated cardiomyopathy patients with a F18-FDG score value >2 had left bundle branch block on standard ECG. Positron emission tomography imaging with N13-NH3 and F18-FDG provided a complete differentiation between idiopathic dilated cardiomyopathy and ischemic cardiomyopathy patients. However patients with left bundle branch block on ECG could present defects in FDG uptake even if affected by idiopathic dilated cardiomyopathy.

Angiographic presentation of coronary artery spasm in heart transplant recipients.

We describe the angiographic characteristics of coronary artery spasm observed in 12 out of 247 (4.9%) patients who underwent 808 coronary angiographies after heart transplantation. Coronary artery spasm was diagnosed when localized and reversible narrowing of the coronary lumen was identified. After coronary artery spasm identification all patients were followed-up clinically for a mean period of 5.1 years. Coronary artery spasm was documented 1-3 years after heart transplant. Coronary artery spasm affected 1 main coronary artery in 10 patients and 2 in 2 patients; in 3 patients 1 or more secondary branches were also affected. The right coronary artery was affected by coronary artery spasm in 8 patients and the anterior descending coronary artery in 6 patients. In 6 patients coronary artery spasm was mechanically induced by the catheter tip. The degree of luminal narrowing due to coronary artery spasm ranged from mild to almost complete occlusion. Coronary artery spasm appeared as a single tubular smooth and concentric stenosis in 8 patients, was discrete in 2 patients and multiple on the same vessel in 2 patients. In 1 patient coronary artery spasm was erroneously interpreted as an organic lesion and percutaneous transluminal coronary angioplasty was planned. During follow-up 3 patients out of 4 who had shown multiple coronary artery spasm died and 2 patients developed critical organic stenosis. In conclusion coronary artery spasm after heart transplant is less rare than commonly believed. Although it usually has a peculiar appearance, it can be misinterpreted as an organic lesion. Multiple coronary artery spasm appears to carry a poor prognosis.

Analytical expression of effective afterload in aortic and mitral regurgitation.

Effective arterial elastance (Ea) is the coupling parameter between the left ventricle and peripheral circulation in normal subjects. If left ventricular end systolic pressure (Pes), contractility (Es) and Ea are known, left ventricular end diastolic volume (LVEDV) and ejection fraction of the ventricle are completely determined. The aim of this study was to give an analytical expression for Ea in patients with mitral and aortic regurgitation, and predict both LVEDV and the effect of vasodilator therapy on LVEDV. Twenty-three subjects with atypical chest pain, 15 patients with mitral insufficiency and 11 with aortic insufficiency underwent diagnostic cardiac catheterization, coronary angiography, and left ventricular cineangiography, which was analyzed quantitatively. Ea was 2.05 +/- 0.63 in normal subjects, while it was 1.28 +/- 0.71 and 1.57 +/- 0.87 in patients with mitral and aortic insufficiency, respectively. All these groups differed with ANOVA test (p = 0.0031). We tested the ability of the analytical expressions for Ea in normal subjects, and patients with mitral insufficiency or aortic insufficiency to predict measured Ea and LVEDV. Ea and LVEDV were predicted rather accurately in every case (p < 0.0001). We used published data to test the effect of resistance modulation on LVEDV. Predicted and measured LVEDV were linearly correlated both in aortic (p < 0.0001) and mitral insufficiency (p = 0.027). Moreover, in some cases a left ventricular enlargement after vasodilator therapy could be anticipated because of an unbalanced decrease in resistance and heart rate. Ea seems to be the coupling parameter between the left ventricle and the peripheral circulation not only in normal subjects, but also in patients with mitral or aortic regurgitation; its measurement before administering vasodilating drugs may be useful in order to predict the effects on LVEDV, and achieve an optimal ventriculoarterial coupling.

[Coronary angioplasty in acute myocardial infarction]. / Angioplastica coronarica primaria nell'infarto miocardico acuto.

Primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) allows to obtain a higher reperfusion rate in the culprit vessel than thrombolytic therapy, reducing the incidence of death, non fatal reinfarction and recurrent ischemia. The aim of this study was to test the in-hospital and mid-term results of an early invasive strategy with PTCA in patients with AMI. Thirty-four patients with AMI underwent coronary angiography within 3 hours from the onset of symptoms. Twenty-four patients had anterior AMI and 3 were in cardiogenic shock. Three patients, 1 without significant lesions and 2 with multivessel diffuse coronary disease, were left out of the procedure, and 31 patients underwent PTCA. Twenty-six lesions were total occlusions with TIMI flow 0.A TIMI flow 1 was present in the other 5 vessels. Stent deployment was decided for 16 lesions (52%). Primary success (TIMI flow 3 with mean residual stenosis of 15 +/- 20%) was obtained in 30 patients (97%). In 1 patient recanalization of the anterior descending coronary artery was not possible due to tortuosity of the abdominal and thoracic aorta. At pre-discharge angiography a good result was confirmed in 24/25 patients. After 6 months only 1 patient (3%) underwent a new PTCA for recurrent angina. In conclusion, primary PTCA for AMI within 3 hours of symptom onset allows good in-hospital and mid-term results with a low rate of complications.