Combination of Double Chimney Technique and Prosthesis Post-Dilation After Valve-in-Valve Implantation.

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is an effective treatment for aortic bioprosthetic valve degeneration. ViV-TAVI could lead to coronary occlusion. We describe the case of a patient treated with double chimney technique to protect coronary ostia followed by post-dilation for high residual transvalvular gradient using "three-kissing balloon" approach. (Level of Difficulty: Advanced.).

The Activated Clotting Time Paradox: Relationship Between Activated Clotting Time and Occlusion of the Radial Artery When Used as Vascular Access for Percutaneous Coronary Procedures.

BACKGROUND: Radial artery occlusion (RAO) is a thrombotic complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Sheath-vessel diameter ratio, postprocedure compression time, occlusive hemostasis, and insufficient anticoagulation are all predictors of RAO. However, excessive anticoagulation can lead to longer time to achieve complete hemostasis and less patent hemostasis rate. This study was designed to assess the relationship among residual anticoagulation at the end of a percutaneous coronary procedure and the risk of RAO. METHODS: Eight hundred thirty-seven patients undergoing transradial catheterization were enrolled. Activated clotting time (ACT) was measured before sheath removal. Patients were divided into 3 groups according to ACT values (ACT <150 s, ACT between 150 and 249 s, ACT >250 s), patent hemostasis with reverse Barbeau test was attempted in all patients, and compression device removed as soon as possible. Within 24 hours, patency of radial artery was checked by Doppler using reverse Barbeau technique. RESULTS: Incidence of RAO was higher for the extreme ACT values. Patent hemostasis were less frequently obtained and time to hemostasis significantly longer for increasing ACT values (P=0.004 for trend and <0.0001 for trend, respectively). At logistic regression analysis, ACT values <150 s were an independent predictor of RAO (odds ratio, 3.53; 95% IC, 1.677-7.43; P=0.001) while adjusted probability for RAO confirmed U-shaped relationship with ACT values. CONCLUSIONS: The level of anticoagulation is strongly related to incidence of RAO and should be measured objectively by ACT. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02762344.

[Endovascular treatment of symptomatic carotid artery dissection]. / Trattamento endovascolare della dissezione carotidea sintomatica.

Internal carotid artery dissection is one of the possible causes of stroke in young adults. The effectiveness of medical therapy alone is often limited and endovascular strategy should be considered, particularly in the presence of persisting neurological symptoms. Currently, there is no general consensus on the most appropriate therapeutic strategy to follow in symptomatic carotid artery dissection. We here report a case of symptomatic carotid artery dissection treated with an endovascular approach, and we review the recent literature regarding this therapeutic strategy. Materials and methods for performing endovascular treatment are also described, along with the possible steps to follow. Data in the literature and our clinical experience suggest that stenting is promising in patients with internal carotid artery dissection and should be considered as a valid therapeutic strategy in case of failure of medical therapy in highly experienced centers.

Drug-coated balloon: Long-term outcome from a real world three-center experience.

OBJECTIVES: In-stent restenosis (ISR) and diffuse small vessel disease still represent challenging subsets for percutaneous coronary interventions, also in the new-generation DES era. We aim at reporting on the long-term clinical outcome of drug-coated balloons (DCB) in all-comers population. METHODS: Consecutive patients treated with DCB between January 2011 and December 2014 were retrospectively studied in three centers of northern Italy. The measured end-points were cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and major adverse cardiac events (MACE) defined as combination of cardiac death, MI, and TLR. RESULTS: We included 143 patients. Of the 167 lesions treated, 41 (24.5%) were de novo lesions in small coronary vessels (<2.5 mm) and 126 (75.4%) were ISR. Among ISR lesions, 78.5% were DES-ISR, 32.5% were focal, 15.8% multifocal, 30.1% diffuse, 18.2% proliferative, and 3.1% were total occlusions. Procedural success was achieved in 94.6% of cases. Overall survival free from MACEs was 91.6% at 12 months, and 75.3% at 48 months, with a total of 3 cardiac deaths, 8 MI, and 27 TLR. No thrombotic event occurred in the treated segments. There were no differences in MACESs between the ISR and de novo lesions groups. At multivariate analysis, acute coronary syndromes, previous MI, previous surgical revascularization, peripheral arterial disease and diabetes were independent predictors of MACEs at long-term follow-up. CONCLUSIONS: DCB proved a valid revascularization strategy in an all-comers population of patients with ISR and de novo lesions in small vessels, with an acceptable rate of cardiac events up to 48 months follow-up.

Stent-assisted coil embolization for the treatment of aneurysm involving a coronary bifurcation.

Coronary artery aneurysm (CAA) is an uncommon disease with high risks of complications including rupture and ischemia from embolic events or thrombosis, especially if associated with critical stenosis of the coronary artery. No consensus document or guidelines has been established regarding the optimal therapy for concomitant CAAs and acute coronary syndrome (ACS). Percutaneous catheter-based treatments using only membrane-covered stents have been described; however, only few reports of drug-eluting stent (DES) and coil embolization for CAAs during ACS have been published to date. Therefore, we report a case of coronary artery disease with aneurysm and critical stenosis successfully treated with DES and coil embolization. © 2016 Wiley Periodicals, Inc.

Tpeak-to-Tend/QT is an independent predictor of early ventricular arrhythmias and arrhythmic death in anterior ST elevation myocardial infarction patients.

BACKGROUND: The aim of our study was to analyse the markers of transmural dispersion of ventricular repolarization, especially Tpeak-to-Tend and Tpeak-to-Tend /QT ratio, in patients with anterior ST elevation myocardial infarction on admission and to evaluate their association with in-hospital life-threatening arrhythmias and mortality. METHODS AND RESULTS: A total of 223 consecutive patients with anterior wall ST elevation myocardial infarction admitted to our Division of Cardiology between January 2010 and December 2012 were prospectively evaluated. A standard electrocardiogram was obtained on admission and then analysed. The primary end point was constituted by in-hospital ventricular arrhythmias and arrhythmic death. At univariate analysis heart rate (odds ratio = 1.03; 95% confidence intervals 1.006-1.05; p=0.001), maximal ST elevation (odds ratio =1.25; 95% confidence intervals 1.10-1.43; p=0.0001), QTc Bazett (odds ratio = 1.01; 95% confidence intervals 1.006-1.02; p=0.002), QT dispersion (odds ratio = 1.02; 95% confidence intervals 1.002-1.04; p=0.02) and both Tpeak-to-Tend and Tpeak-to-Tend/QT (odds ratio = 1.02; 95% confidence intervals 1.01-1.03; p<0.0001 and OR = 1.07; 95% confidence intervals 1.03-1.11; p<0.0001 respectively) were significantly associated with ventricular arrhythmias and arrhythmic mortality. Of note, Tpeak-to-Tend /QT remained a predictor of early ventricular arrhythmias and arrhythmic death (odds ratio = 1.04; 95% confidence intervals 1.003 - 1.10; p=0.03) independently from heart rate and maximal ST elevation. Receiver operating characteristic curve analysis showed that Tpeak-to-Tend /QT values <0.31 had a predictive negative value of 92% for the prediction of the composite outcome. CONCLUSIONS: Tpeak-to-Tend /QT was an independent predictor of early ventricular arrhythmias and arrhythmic mortality in patients with anterior ST elevation myocardial infarction. Especially, Tpeak-to-Tend /QT <0.31 may identify a subgroup of ST elevation myocardial infarction patients with low risk of early arrhythmias and arrhythmic death.

iFR-FFR comparison in daily practice: a single-center, prospective, online assessment.

AIMS: To compare the performance of instantaneous wave-free ratio (iFR) with fractional flow reserve (FFR) in a real-life, prospective, single-center, and independent study. METHODS AND RESULTS: Fifty-four patients were included and 89 angiographic intermediate lesions underwent functional evaluation with both iFR and FFR. FFR was used as the gold standard, and the patients having FFR values 0.80 or less only underwent percutaneous coronary intervention. Linear regression demonstrated close agreement between the two techniques (R = 0.83, P < 0.0001). Receiver operator characteristic analysis confirmed the strong correlation, with an area under the curve approximately equal to unity. iFR detected ischemia with a sensitivity and specificity of 100 and 87%, respectively, thus revealing a positive predictive value of 78% and a negative predictive value of 100%. In addition, according to FFR assessment, percutaneous coronary intervention was performed on 39 lesions (43.8%) in 27 patients (50%), whereas positive iFR values were found in 52 lesions (+14.6% compared with FFR). At clinical follow-up (ranging from 6 to 16 months), all patients remained asymptomatic and none of them experienced major adverse cardiovascular events. CONCLUSIONS: In this independent, online, comparison of iFR-FFR values in patients with angiographic intermediate lesions, results are consistent with those derived from previous offline controlled trials, and support the correlation between iFR and FFR in daily clinical practice.

Huge ST elevation and ventricular arrhythmias in vasospastic angina diagnosed by Holter monitoring.

We report a case of a 67year old man with a recent history of sporadic chest pain and palpitations. After a normal, maximal stress test he underwent 24-hours Holter monitoring that showed two short periods of huge ST segment elevation associated with non sustained ventricular tachycardia and chest pain, referable to coronary spasm. Coronary angiogram showed significant atherosclerotic stenosis in the right coronary artery treated by angioplasty and bare metal stent implantation. Holter monitoring is a non-invasive and low-cost examination that can give valuable informations; it should be reserved for selected patients when vasospastic angina is suspected.