Intentional coronary revascularization versus conservative therapy in patients after peripheral artery revascularization due to critical limb ischemia: the INCORPORATE trial.

OBJECTIVES: INCORPORATE trial was designed to evaluate whether default coronary-angiography (CA) and ischemia-targeted revascularization is superior compared to a conservative approach for patients with treated critical limb ischemia (CLI). Registered at clinicaltrials.gov (NCT03712644) on October 19, 2018. BACKGROUND: Severe peripheral artery disease is associated with increased cardiovascular risk and poor outcomes. METHODS: INCORPORATE was an open-label, prospective 1:1 randomized multicentric trial that recruited patients who had undergone successful CLI treatment. Patients were randomized to either a conservative or invasive approach regarding potential coronary artery disease (CAD). The conservative group received optimal medical therapy alone, while the invasive group had routine CA and fractional flow reserve-guided revascularization. The primary endpoint was myocardial infarction (MI) and 12-month mortality. RESULTS: Due to COVID-19 pandemic burdens, recruitment was halted prematurely. One hundred eighty-five patients were enrolled. Baseline cardiac symptoms were scarce with 92% being asymptomatic. Eighty-nine patients were randomized to the invasive approach of whom 73 underwent CA. Thirty-four percent had functional single-vessel disease, 26% had functional multi-vessel disease, and 90% achieved complete revascularization. Conservative and invasive groups had similar incidences of death and MI at 1 year (11% vs 10%; hazard ratio 1.21 [0.49-2.98]). Major adverse cardiac and cerebrovascular events (MACCE) trended for hazard in the Conservative group (20 vs 10%; hazard ratio 1.94 [0.90-4.19]). In the per-protocol analysis, the primary endpoint remained insignificantly different (11% vs 7%; hazard ratio 2.01 [0.72-5.57]), but the conservative approach had a higher MACCE risk (20% vs 7%; hazard ratio 2.88 [1.24-6.68]). CONCLUSION: This trial found no significant difference in the primary endpoint but observed a trend of higher MACCE in the conservative arm.

Randomized comparison of 9-month stent strut coverage of biolimus and everolimus drug-eluting stents assessed by optical coherence tomography in patients with ST-segment elevation myocardial infarction. Long-term (5-years) clinical follow-up (ROBUST trial).

BACKGROUND: The aim of the study was to compare healing (assessed by optical coherence tomography [OCT]) of biolimus A9 (BES) and everolimus drug-eluting stents (EES) at 9-month follow-up in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI). Nine-month clinical and angiographic data were also compared in both groups as well as clinical data at 5 years of follow-up. METHODS: A total of 201 patients with STEMI were enrolled in the study and randomized either to pPCI with BES or EES implantation. All patients were scheduled for 9 months of angiographic and OCT follow-up. RESULTS: The rate of major adverse cardiovascular events (MACE) was comparable at 9 months in both groups (5% in BES vs. 6% in the EES group; p = 0.87). Angiographic data were also comparable between both groups. The main finding at 9-month OCT analysis was the greatly reduced extent of mean neointimal area at the cost of a higher proportion of uncovered struts in the BES group (1.3 mm² vs. 0.9 mm²; p = 0.0001 and 15.9% vs. 7.0%; p = 0.0001, respectively). At 5 years of clinical follow-up the rate of MACE was comparable between both groups (16.8% vs. 14.0%, p = 0.74). CONCLUSIONS: The study demonstrates a very low rate of MACE and good 9-month stent strut coverage of second-generation BES and EES in patients with STEMI. BES showed greatly reduced extent of mean neointimal hyperplasia area at the cost of a higher proportion of uncovered struts when compared to EES. The rate of MACE was low and comparable in both groups at 5 years.

Contrast-induced acute kidney injury and its contemporary prevention.

The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies.

Spontaneous coronary artery dissection, two case reports of men.

Spontaneous coronary dissection (SCAD) is one of the less common causes of acute coronary syndrome. It mainly affects younger patients without typical risk factors for ischemic heart disease. SCAD usually arises suddenly in otherwise healthy individuals with a previously full quality of life, and given the potential urgency of the condition, it is an important nosological unit in the differential diagnosis of chest pain. With the improving availability of comprehensive diagnostic methods we could see an increase in number of reported cases, and thus the potential for early intervention or active prevention of complications including malignant arrhythmias and cardiac arrest. It is therefore necessary to think about SCAD during examination of patients that are not yet at a cardiovascular risk. The vast majority of published case reports relate to cases described in women. Our article describes two case reports in men.

The role of central autonomic nervous system dysfunction in Takotsubo syndrome: a systematic review.

INTRODUCTION: Takotsubo syndrome (TTS), also known as stress cardiomyopathy or "broken heart" syndrome, is a mysterious condition that often mimics an acute myocardial infarction. Both are characterized by left ventricular systolic dysfunction. However, this dysfunction is reversible in the majority of TTS patients. PURPOSE: Recent studies surprisingly demonstrated that TTS, initially perceived as a benign condition, has a long-term prognosis akin to myocardial infarction. Therefore, the health consequences and societal impact of TTS are not trivial. The pathophysiological mechanisms of TTS are not yet completely understood. In the last decade, attention has been increasingly focused on the putative role of the central nervous system in the pathogenesis of TTS. CONCLUSION: In this review, we aim to summarize the state of the art in the field of the brain-heart axis, regional structural and functional brain abnormalities, and connectivity aberrancies in TTS.

Primary percutaneous coronary intervention is appropriate in transient ST-elevation myocardial infarction.

INTRODUCTION: Reperfusion therapy by primary percutaneous coronary intervention (PPCI) is generally indicated in patients suffering from acute myocardial infarction (MI) with ST-segment elevation (STEMI). Prior to hospital admission, full ST-segment resolution (fSTR) may occur. Optimal management of such patients with transient STEMI (TSTEMI) is potentially challenging. Our aim was to evaluate the hypothesis that in TSTEMI patients, patency of infarct related artery (IRA) is achieved before PPCI, and to compare the outcome of TSTEMI and STEMI patients during a prolonged follow-up. MATERIAL AND METHODS: Three hundred consecutive adult STEMI patients were referred to catheterization laboratory. In all patients, standard 12 lead ECGs were obtained both at the time of the first medical contact, and on catheterization laboratory admission. RESULTS: TSTEMI occurred in 20 patients (6.7%). Despite fSTR (isoelectric ST segment), occluded IRA was found in 5 of these patients (25%). Pre-PPCI TIMI flow grade 2 was found in 6 TSTEMI patients (30%). Troponin T value at 24 h after symptom onset was lower in the TSTEMI group (1.8±2.5 mg/L vs. 3.6±3.5 mg/L, P=0.008). These patients also had a lower value of brain natriuretic peptide (156.3±119.5 ng/L vs. 438.5±429.0 ng/L, P<0.001) and higher left ventricular ejection fraction (59.9±6.3% vs. 51.6±10.2%, P<0.001). All patients were followed for a median of 5.6 years during which the overall survival did not differ between the TSTEMI and STEMI groups. CONCLUSION: Primary PCI is strongly recommended in TSTEMI patients because of a relatively high incidence of occluded infarct related arteries. The rate of patients with TSTEMI is relatively low.

First zero contrast PCI guided by intracoronary ultrasound in the Czech Republic.

Contrast induced nephropathy is associated with worse clinical outcome in patients undergoing coronary intervention. The most profound risk factor is advanced chronic renal insufficiency. Due to the increasing number of coronary interventions on severally ill patients, there is a need of modern therapeutic approach that could reduce the volume of contrast media to minimum or even zero. Herein, the authors present a case report of a 68-year-old patient with chronic kidney disease, who required elective coronary intervention (PCI) due to a significant lesion of the left anterior descending coronary artery. During this intervention, maximum emphasis was given on reduction of contrast media. To the best of our knowledge, this was the first similar intervention performed in the Czech Republic. Minimum contrast PCI guided by the intracoronary ultrasound, i.e. the IVUS-guided zero-contrast PCI may serve as a potential alternative to standard, angiography-guided PCI.

Myocardial infarction or broken heart syndrome?

Takotsubo or broken heart syndrome represents a rare type of cardiomyopathy, often imitating acute myocardial infarction. It is a sudden transient cardiac syndrome that typically involves left ventricular apical akinesis with preserved motility of basal heart segments. In contrast to acute myocardial infarction, the pathology is fully reversible in the majority of patients. In the present casereport, we discuss 78yearsold female referred to our department for typical symptomatology of acute myocardial infarction. Coronary angiography revealed significant stenosis on the left anterior descending coronary artery, but ventriculography disclosed apical dysfunction and clinical course of the disease result in the diagnosis of Takotsubo cardiomyopathy. Until recently, normal or nonobstructive coronary angiography represented one of the mean diagnostic features of Takotsubo cardiomyopathy. In 2018, new diagnostic criteria were introduced, importantly modifying our approach to the Takotsubo diagnostics with omitting a coronary lesion as an exclusion criterium of the Takotsubo cardiomyopathy.

OCT guidance during stent implantation in primary PCI: A randomized multicenter study with nine months of optical coherence tomography follow-up.

AIMS: To assess the possible merits of optical coherence tomography (OCT) guidance in primary percutaneous coronary intervention (pPCI). METHODS AND RESULTS: 201 patients with ST-elevation myocardial infarction (STEMI) were enrolled in this study. Patients were randomized either to pPCI alone (angio-guided group, n=96) or to pPCI with OCT guidance (OCT-guided group, n=105) and also either to biolimus A9 or to everolimus-eluting stent implantation. All patients were scheduled for nine months of follow-up angiography and OCT study. OCT guidance led to post-pPCI optimization in 29% of cases (59% malapposition and 41% dissections). No complications were found related to the OCT study. OCT analysis at nine months showed significantly less in-segment area of stenosis (6% [-11, 19] versus 18% [3, 33]; p=0.0002) in favor of the OCT-guided group. The rate major adverse cardiovascular events were comparable at nine months in both groups (3% in the OCT group versus 2% in the angio-guided group; p=0.87). CONCLUSIONS: This study demonstrates the safety of OCT guidance during pPCI. The use of OCT optimized stent deployment in 1/3 of patients in this clinical scenario and significantly reduced in-segment area of stenosis at nine months of follow-up. Whether such improvements in OCT endpoints will have a positive impact on late clinical outcomes, they demand both a larger and longer-term follow-up study.

Radial artery neointimal hyperplasia after transradial PCI-Serial optical coherence tomography volumetric study.

AIMS: Transradial catheterization (TRC) is a dominant access site for coronary catheterization and percutaneous coronary interventions (PCI) in many centers. Previous studies reported higher intimal thickness of the radial artery (RA) wall in patients with a previous history of TRC. In this investigation the aim was to assess the intimal changes of RA using the optical coherence tomography (OCT) intravascular imaging in a serial manner. METHODS AND RESULTS: 100 patients with the diagnosis of non-ST-elevation myocardial infarction (nSTEMI) treated by PCI were enrolled (6 patients were excluded from this analysis because of occluded RA at follow-up [2 patients] and insufficient quality of OCT images [4 patients]). An 54mm long OCT run of the RA was performed immediately after the index PCI and repeated 9 months later. Volumetric analyses of the intimal layer and lumen changes were conducted. Median intimal volume at baseline versus 9 months was 33.9mm3 (19.0; 69.4) versus 39.0mm3 (21.7; 72.6) (p<0.001); and median arterial lumen volume was 356.3mm3 (227.8; 645.3) versus 304.7mm3 (186.1; 582.7) (p<0.001). There was no significant difference in the effect of any clinical factor on the RA volume changes. CONCLUSIONS: OCT volumetric analyses at baseline and 9 months showed a significant increase in the radial artery intimal layer volume and a decrease in lumen volume after transradial PCI. No significant factors affecting this process were identified.

Association of the right ventricle impairment with electrocardiographic localization and related artery in patients with ST-elevation myocardial infarction.

INTRODUCTION: The right ventricular myocardial infarction (RVMI) has traditionally been mainly related to inferior wall ST elevation myocardial infarction (STEMI). This study assessed the RVMI electrocardiographic (ECG-RVMI) signs in relationship to ECG-based STEMI localization and to the infarct related artery in patients treated with primary percutaneous coronary intervention (pPCI). METHODS: Three hundred consecutive adult patients (107 females) were referred to catheterization laboratory with the acute STEMI diagnosis. In all patients, both the standard 12-lead ECGs and the right-sided precordial leads (V1R-V6R) were recorded. ECG-RVMI was diagnosed by ST segment elevation above 100µV in V4R. RESULTS: ECG signs of RVMI were found in 35 and 31 (23.8% for both) patients with inferior and anterior wall STEMI, respectively. In 32 ECG-RVMI patients, the right coronary artery (RCA) was occluded while in 34 patients, the occlusions were in the left anterior descending (LAD) or the left circumflex artery. No statistically significant differences were found in ECG-RVMI patients when comparing clinical variables between those with anterior and inferior wall STEMI. CONCLUSIONS: ECG signs of RVMI during acute STEMI are not uncommon. RCA was the infarction-related artery in only one half of these patients. Anterior wall STEMI and the LAD were associated with a significant proportion of ECG-RVMI cases.

Short sheath benefit in radial artery injury after PCI - optical coherence tomography serial study.

BACKGROUND AND AIMS: Transradial catheterization is the predominant access site for coronary catheterization and percutaneous coronary interventions (PCI). Previous studies have reported a high incidence of radial artery (RA) injury. The aim of this investigation was to evaluate the incidence of RA injury using last generation optical coherence tomography (OCT) intravascular imaging in a serial manner. METHODS: 100 patients with a diagnosis of non-ST-elevation myocardial infarction (nSTEMI) treated by PCI were enrolled. OCT of RA was performed immediately after the index PCI. OCT was repeated 9 months later. RESULTS: There were 11 patients with RA injuries (11.0%) at baseline, including 3 patients with RA medial dissection and 8 patients with intimal tears. In the follow-up OCT data, the number of RA injuries was 10 (10.0%), including 7 patients with RA medial dissection and 3 patients with intimal tear. All injuries were clinically asymptomatic and there was no finding of vessel perforation. There was no significant difference between the baseline and follow-up procedure in terms of number of injuries. CONCLUSION: The study showed no significant difference between baseline and follow-up RA injury incidence. There was a higher risk of radial injury for repeated catheterization in women. The conclusion is that radial catheterization is a very safe procedure in terms of radial artery damage. This is evidenced by considerably fewer injuries compared to published studies. The use of the short radial sheath (7 cm in this study) is protective and reduces the incidence of radial injury.

Depression and Anxiety after Acute Myocardial Infarction Treated by Primary PCI.

AIMS: The main objective of the study was to find out prevalence of depression and anxiety symptoms in the population of patients with AMI with ST-segment elevation (STEMI), treated with primary PCI (pPCI). Secondary target indicators included the incidence of sleep disorders and loss of interest in sex. METHODS AND RESULTS: The project enrolled 79 consecutive patients with the first AMI, aged <80 years (median 61 years, 21.5% of women) with a follow-up period of 12 months. Symptoms of depression or anxiety were measured using the Beck Depression Inventory II tests (BDI-II, cut-off value ≥14) and Self-Rating Anxiety Scale (SAS, cut-off ≥ 45) within 24 hours of pPCI, before the discharge, and in 3, 6 and 12 months). Results with the value p<0.05 were considered as statistically significant. The BDI-II positivity was highest within 24 hours after pPCI (21.5%) with a significant decline prior to the discharge (9.2%), but with a gradual increase in 3, 6 and 12 months (10.4%; 15.4%; 13.8% respectively). The incidence of anxiety showed a relatively similar trend: 8.9% after pPCI, and 4.5%, 10.8% and 6.2% in further follow-up. CONCLUSIONS: Patients with STEMI treated by primary PCI have relatively low overall prevalence of symptoms of depression and anxiety. A significant decrease in mental stress was observed before discharge from the hospital, but in a period of one year after pPCI, prevalence of both symptoms was gradually increasing, which should be given medical attention.

[Near-infrared spectroscopy (NIRS), new intracoronary imaging technique of unstable coronary plaque]. / Near-infrared spectroscopy (NIRS), nová technika intrakoronárního zobrazení nestabilního koronárního plátu.

Acute coronary syndrome may develop in the background of hemodynamically non-significant coronary artery disease. It may be caused by the presence of "vulnerable plaque", which is characterized by the lipid rich core and thin fibrous cap content. NIRS - near infrared spectroscopy - is a morphological imaging method allowing determining atherosclerotic plaque cholesterol burden. Information about the chemical composition may contribute to "high risk" plaque early identification and subsequent optimal interventional strategy. The first experience with the clinical implementation of this novel method is demonstrated in a case report. Key words: acute coronary syndrome - chemogram - intravascular imaging - NIRS - vulnerable plaque.

An unusual reason for severe bradycardia leading to cardiac arrest during general anaesthesia: a case report.

BACKGROUND: Takotsubo cardiomyopathy also known as transient balooning syndrome is an increasingly reported phenomenon characterized by acute reversible apical or midventricular dysfunction. This stress- induced cardiomyopathy mimics myocardial infarction, but without significant coronary artery disease, and rarely presents in perioperative period. METHODS AND RESULTS: We report a case of postmenopausal woman scheduled to undergo elective cholecystectomy, with no history of coronary artery disease. She presented perioperatively with Takotsubo cardiomyopathy by unique manifestation-asystoly. This uncommon cause of cardiac arrest during anaesthesia was possibly induced by preoperative emotional stress. There was full recovery thanks to intensive management. In Takotsubo cardiomyopathy related cardiogenic shock we used the calcium sensitiser levosimendan successfully. CONCLUSION: Takotsubo cardiomyopathy has an excellent long-term prognosis and nearly all patients have full recovery of left ventricular function. We emphasize the importance of heavy premedication by stress compromised patients and the need of sufficiently deep anaesthesia and analgesia during surgeries.

Acute myocardial infarction complicated by shock: outcome analysis based on initial electrocardiogram.

OBJECTIVES: To assess the relation between initial ECG findings, presence of risk factors, coronary angiography findings, and clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS). DESIGN: Data from a total of 5572 acute myocardial infarction patients admitted to the four tertiary hospitals during a period of 3 years were analyzed. CS on admission was present in 358 patients (6.4%). They were divided into four groups based on the admission ECG: ST-segment elevation (STEMI), ST-segment depression (STDMI), bundle branch block (BBBMI), and other ECG acute myocardial infarction. RESULTS: CS developed most frequently among BBBMI patients (in 12.1% of all BBBMIs, p < 0.001 vs. STEMI), followed by STEMI (6.7%), STDMI (4.4%), and other ECG acute myocardial infarction (2.3%). The risk of CS development was similar in patients with left bundle branch block (LBBB) (13.3%) and right bundle branch block (RBBB) (11.2%). The one-year mortality was highest among RBBBMI patients (66.7%, p < 0.001), followed by LBBBMI (48.6%), other ECG (47.1%), STEMI (41.7%), and STDMI patients (38.1%). CONCLUSIONS: RBBB on admission ECG is associated with the highest risk of CS development, frequent left main coronary artery affection, and unsuccessful revascularization. It is also an independent predictor of one-year mortality.

Right ventricular myocardial infarction: From pathophysiology to prognosis.

Right ventricle myocardial infarctions (RVMIs) accompany inferior wall ischemia in up to one-half of cases. The clinical sequelae of RVMIs vary from no hemodynamic compromise to severe hypotension and cardiogenic shock. Diagnosis is based on physical examination, electrocardiography, echocardiography and coronary angiography. Because the standard 12-lead electrocardiogram is insufficient for the assessment of RV involvement, right-sided precordial leads should always be included. Adequate fluid administration in combination with positive inotropic agents and early coronary reperfusion are crucial components of treatment, while diuretics and nitrates should be avoided. Intra-aortic balloon counterpulsation and right ventricle assist devices may be used with success in RVMIs associated with medically refractory heart failure. Right ventricular involvement appears to be an independent prognostic factor that dramatically increases in-hospital mortality, due, in part, to a significantly higher risk of hemodynamically compromising arrhythmias. Thus, using right-sided precordial leads and early RVMI identification to trigger an appropriately aggressive treatment protocol may improve patients' prognosis.

Volumetric quantification of fibrous caps using intravascular optical coherence tomography.

The rupture of thin-cap fibroatheroma accounts for most acute coronary events. Optical Coherence Tomography (OCT) allows quantification of fibrous cap (FC) thickness in vivo. Conventional manual analysis, by visually determining the thinnest part of the FC is subject to inter-observer variability and does not capture the 3-D morphology of the FC. We propose and validate a computer-aided method that allows volumetric analysis of FC. The radial FC boundary is semi-automatically segmented using a dynamic programming algorithm. The thickness at every point of the FC boundary, along with 3-D morphology of the FC, can be quantified. The method was validated against three experienced OCT image analysts in 14 lipid-rich lesions. The proposed method may advance our understanding of the mechanisms behind plaque rupture and improve disease management.

Age-related treatment strategy and long-term outcome in acute myocardial infarction patients in the PCI era.

BACKGROUND: Older age, as a factor we cannot affect, is consistently one of the main negative prognostic values in patients with acute myocardial infarction. One of the most powerful factors that improves outcomes in patients with acute coronary syndromes is the revascularization preferably performed by percutaneous coronary intervention. No data is currently available for the role of age in large groups of consecutive patients with PCI as the nearly sole method of revascularization in AMI patients. The aim of this study was to analyze age-related differences in treatment strategies, results of PCI procedures and both in-hospital and long-term outcomes of consecutive patients with acute myocardial infarction. METHODS: Retrospective multicenter analysis of 3814 consecutive acute myocardial infarction patients divided into two groups according to age (1800 patients ≤ 65 years and 2014 patients > 65 years). Significantly more older patients had a history of diabetes mellitus and previous myocardial infarctions. RESULTS: The older population had a significantly lower rate of coronary angiographies (1726; 95.9% vs. 1860; 92.4%, p < 0.0001), PCI (1541; 85.6% vs. 1505; 74.7%, p < 0.001), achievement of optimal final TIMI flow 3 (1434; 79.7% vs. 1343; 66.7%, p < 0.001) and higher rate of unsuccessful reperfusion with final TIMI flow 0-1 (46; 2.6% vs. 78; 3.9%, p = 0.022). A total of 217 patients (5.7%) died during hospitalization, significantly more often in the older population (46; 2.6% vs. 171; 8.5%, p < 0.001). The long-term mortality (data for 2847 patients from 2 centers) was higher in the older population as well (5 years survival: 86.1% vs. 59.8%). Though not significantly different and in contrast with PCI, the presence of diabetes mellitus, previous MI, final TIMI flow and LAD, as the infarct-related artery, had relatively lower impact on the older patients. Severe heart failure on admission (Killip III-IV) was associated with the worst prognosis in the whole group of patients, though its significance was higher in the youngers (HR 6.04 vs. 3.14, p = 0.051 for Killip III and 12.24 vs. 5.65, p = 0.030 for Killip IV). We clearly demonstrated age as a strong discriminator for the whole population of AMI patients. CONCLUSIONS: In a consecutive AMI population, the older group (>65 years) was associated with a less pronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomy by coronary angiography and proceed to PCI if suitable regardless of age is crucial in all patients, though the primary success rate of PCI in the older age is lower. Age, when viewed as a risk factor, was a dominant discriminating factor in all patients.