STACCATO (Assessment of Stent sTrut Apposition and Coverage in Coronary ArTeries with Optical coherence tomography in patients with STEMI, NSTEMI and stable/unstable angina undergoing everolimus vs. biolimus A9-eluting stent implantation): a randomised controlled trial.

AIMS: To compare tissue coverage in coronary lesions stented with durable fluoropolymer-coated everolimus-eluting stents (EES) vs. biodegradable polymer-coated biolimus A9-eluting stents (BES). METHODS AND RESULTS: Sixty-four patients (64 lesions) with de novo coronary artery lesions were randomised to percutaneous treatment with XIENCE EES (Abbott Vascular, Santa Clara, CA, USA) vs. BioMatrix BES (Biosensors, Morges, Switzerland). The primary endpoint was the percentage of uncovered struts, as assessed with OCT, at nine months. The average percentage of uncovered struts was significantly lower with EES (4.3±4.8% vs. 8.7±7.8% with BES, p=0.019). There was no difference in the average percentage of malapposed struts at baseline (6.8±6.9% vs. 6.9±7.0%, respectively, p=0.974) and at follow-up (0.1±0.3% vs. 0.6±1.3%, p=0.143). Neointimal thickness at nine months was 109±43 µm in EES vs. 64±18 µm in BES (p<0.001), and angiographic LLL was 0.15 mm in EES vs. 0.10 mm in BES (p=0.581). We did not observe differences in the incidence of MACE and ST. CONCLUSIONS: A significantly higher percentage of uncovered struts was detected in the BioMatrix BES compared with the XIENCE EES at nine-month follow-up. Our findings do not support a preferential use of stents with biodegradable polymer-based biolimus elution to reduce the risk for ST.

Automated detection and quantification of clusters of malapposed and uncovered intracoronary stent struts assessed with optical coherence tomography.

To date, accurate quantification and localization of malapposed and uncovered struts needs manual and time consuming analysis of large datasets. To develop an algorithm for automated detection and quantification of clusters of malapposed and uncovered struts in optical coherence tomography (OCT) pullbacks, including comprehensive information about their three-dimensional spatial distribution. 64 lesions in 64 patients treated with drug-eluting stent underwent assessment with OCT immediately after implantation and at 9-month follow-up (55 patients). An automated algorithm was used to detect and quantify stent strut malapposition at baseline and coverage at follow-up on an individual strut level. We subsequently applied an algorithm for the automated clustering of malapposed and uncovered struts and for the quantification of clusters' properties. In the 64 baseline examinations, a total of 24,013 struts were analyzed, of which 1,519 (6 %) were malapposed. Most malapposed struts (78 %) occurred in clusters and more than half of patients had malapposition clusters. The mean number of struts per cluster was 19.7 ± 11.8 with a mean malapposition distance of 213 ± 66 µm. In the 55 follow-up pullbacks, a total of 20,484 struts were analyzed, of which 1,320 (6 %) were uncovered. Again, most uncovered struts (85 %) occurred in clusters. The mean number of struts per cluster was 21.1 ± 14.7. We developed an automated algorithm for studying clustering of malapposed or uncovered struts. This algorithm might facilitate future investigations of the prognostic impact of clusters of malapposed or uncovered struts.

Giant left atrial appendage: a rare anomaly.

A giant left atrial appendage is a rare congenital anomaly that has been reported on only a few occasions. We report two symptomatic patients with atrial fibrillation combined with a cerebellar infarct in one and dyspnea in the other. Both patients were treated surgically with resection of the giant left atrial appendage and radiofrequency pulmonary vein isolation. Recognition of this uncommon pathology can lead to timely surgical intervention.

Subacute papillary muscle rupture following percutaneous mitral valvuloplasty.

INTRODUCTION: Mitral valve stenosis is becoming increasingly rare in industrialized countries thanks to the almost complete extinction of rheumatic valve disease. Nevertheless, every cardiologist will encounter a few cases, notably in elderly with degenerated calcified mitral valves or in younger immigrants coming from parts of the world with endemic rheumatic valve disease. Patients usually present with progressive dyspnoea due to increased left atrial and pulmonary artery pressures and a decline in cardiac output secondary to preload reduction. Introduced by Inoue in 1984, percutaneous balloon mitral valvuloplasty constitutes an elegant treatment modality in patients with appropriate valvular anatomy, with excellent immediate results and long-term outcome.The original Inoue technique, based on the surgically closed commissurotomy, employs the eponymous balloon to crack the mitral commissures to separate the mitral leaflets along their natural plane thereby enlarging the mitral valve area. Similar but slightly different techniques have emerged throughout the years and have extensively been used in the clinic. One of them is the so-called double balloon valvuloplasty, first described in Saoudi Arabia by Al-Zaibag, during which two balloons are positioned side-by-side across the stenotic valve and inflated simultaneously. Mitral regurgitation is relatively common after balloon dilatation, but is mostly mild and caused by excessive commissural tearing or slight prolapse of the anterior leaflet. We present a rare case of severe mitral regurgitation following double balloon mitral valvuloplasty due to papillary muscle rupture.

First-in-man experience with a new embolic deflection device in transcatheter aortic valve interventions.

AIMS: To report our first-in-man experience with a new cerebral embolic deflection device (SMT Embolic Deflection Device) during transcatheter aortic valve implantation (TAVI). A significant number of strokes and brain infarcts are caused by embolisation of atherosclerotic material, clots and other debris during various phases of invasive cardiac procedures, especially TAVI. The application of a temporary filter in the aortic arch averting dislodged emboli from entering the cerebral circulation might prevent this. METHODS AND RESULTS: In 15 patients (mean age 79 years) with severe aortic stenosis undergoing percutaneous transfemoral or transapical aortic valve implantation, the SMT Embolic Deflection Device was advanced utilising the contralateral femoral artery access using a 9 Fr delivery sheath. Once deployed in the aortic arch, a porous membrane shields the supraaortic-cerebral trunks by deflecting emboli away from the cerebral circulation. Embolic material is not contained or removed by the device. A 6 Fr pigtail catheter can be used through the same sheath throughout the whole procedure. Brain diffusion weighted (DW)-MRI was obtained in 10 patients before and at 4 days after (± 2 days) the procedure and retrospectively compared to 20 patients previously undergoing TAVI without a protection device. Successful placement of the embolic protection device was achieved in all patients. Additional procedural time due to the use of the device was 7 min (± 2 min). There were no procedural complications. No patient developed new neurological symptoms or clinical findings of stroke except one patient who suffered from a transient ischaemic attack (TIA) two days after the procedure. DW-MRI showed 3.2 new cerebral lesions per patient, compared to 7.2 new lesions per patient in the group without SMT filter. CONCLUSIONS: In this first-in-man experience, the feasibility of a new embolic deflection device is demonstrated. Larger randomised, prospective studies are required to confirm these findings and prove safety and efficacy by reducing the incidence of cerebral embolism and stroke after TAVI.

In vivo assessment of bifurcation optimal viewing angles and bifurcation angles by three-dimensional (3D) quantitative coronary angiography.

Evaluation and stenting of coronary bifurcation lesions may benefit from optimal angiographic views. The anatomy-defined bifurcation optimal viewing angle (ABOVA) is characterized by having an orthogonal view of the bifurcation, such that overlap and foreshortening at the ostium are minimized. However, due to the mechanical constraints of the X-ray systems, certain deep angles cannot be reached by the C-arm. Therefore, second best or, so-called obtainable bifurcation optimal viewing angle (OBOVA) has to be used as an alternative. This study assessed the distributions of ABOVA and OBOVA using 3D quantitative coronary angiography in a typical patient population. In addition, the bifurcation angles in four main coronary bifurcations were assessed and compared. Patients with obstructive coronary bifurcation disease were included in this multicenter registry. A novel and validated 3D QCA software package was applied to reconstruct the bifurcations and to calculate the bifurcation angles in 3D. A list of optimal viewing angle candidates including ABOVA was also automatically proposed by the software. In a next step, the operator selected the best viewing angle as OBOVA, while applying a novel overlap prediction approach to assure no overlap between the target bifurcation and other major coronary arteries. A total of 194 bifurcations from 181 patients were assessed. The ABOVA could not be reached in 56.7% of the cases; being 40 (81.6%), 40 (78.4%), 9 (17.6%), and 21 (48.8%) cases for LM/LAD/LCx, LAD/Diagonal, LCx/OM, and PDA/PLA, respectively. Both ABOVA and OBOVA distributed sparsely with large ranges of variance: LM/LAD/LCx, 5 ± 33 RAO, 47 ± 35 Caudal versus 4 ± 39 LAO, 35 ± 16 Caudal; LAD/Diagonal, 4 ± 38 RAO, 50 ± 14 Cranial versus 14 ± 28 LAO, 33 ± 5 Cranial; LCx/OM, 21 ± 32 LAO, 27 ± 17 Caudal versus 18 ± 31 LAO, 25 ± 13 Caudal; PDA/PLA, 34 ± 21 LAO, 36 ± 21 Cranial versus 28 ± 25 LAO, 29 ± 15 Cranial. LM/LAD/LCx had the smallest proximal bifurcation angle (128° ± 24°) and the largest distal bifurcation angle (80° ± 21°), as compared with LAD/Diagonal (151° ± 13º and 48° ± 16º), LCx/OM (146° ± 18º and 57° ± 16°), and PDA/PLA (145° ± 19° and 59° ± 17°). In conclusion, large variabilities in optimal viewing angles existed for all main coronary bifurcations. The anatomy-defined bifurcation optimal viewing angle could not be reached in vivo in roughly half of the cases due to the mechanical constraints of the current X-ray systems. Obtainable bifurcation optimal viewing angle should be provided as an alternative or second best. The bifurcation angles in the left main bifurcation demonstrated the largest variabilities.

Optical coherence tomography (OCT) in PCI for in-stent restenosis (ISR): rationale and design of the SEDUCE (Safety and Efficacy of a Drug elUting balloon in Coronary artery rEstenosis) study.

BACKGROUND: The optimal treatment of bare metal stent restenosis is still not defined. The most employed contemporary option is the implantation of a drug-eluting stent (DES). However, this procedure implies the addition of a second metal layer in the vessel wall, which is linked to delayed healing. Furthermore, there may be a increased risk of malapposition of both struts of the bare metal and the newly implanted drug-eluting stent. These phenomena may give rise to an increased risk of stent thrombosis in this patient population. Recently, drug-eluting balloons (DEB) have been proposed as a new treatment strategy for bare metal stent restenosis. The initial results of this technique look promising. OBJECTIVES: To compare healing processes after treatment of bare metal stent (BMS) in-stent restenosis (ISR) with balloon dilatation using DEB versus implantation of DES. STUDY DESIGN: This is a prospective, multicentre (University Hospitals Leuven and ZOL Hospital Genk, Belgium) randomised clinical trial with clinical, angiographic and OCT follow-up at nine months. Patients with bare metal stent restenosis and an indication for repeat PCI are randomised to treatment with a paclitaxel-eluting balloon (SeQuent Please, B-Braun, Melsungen, Germany) versus a Xience V/ Xience Prime everolimus-eluting stent (Abbott Vascular, Santa Clara, CA, USA). The primary objective of this study is to evaluate the vascular healing response of the vessel wall after balloon angioplasty with a paclitaxel-eluting balloon versus implantation of a drug-eluting stent in patients with in-stent restenosis in a coronary artery. The primary endpoint of the study is stent strut coverage and stent strut apposition at nine months, as assessed with OCT. CONCLUSIONS: Currently no prospectively collected data on vessel wall healing after treatment of in-stent restenosis, whether with DES or with DEB, are available. Therefore, the SEDUCE trial will yield pivotal insights on this important topic and guide further optimisation of the interventional treatment for this condition.

Anomalous right coronary artery causing inferior myocardial infarction, diagnosed on the occasion of a life-insurance medical exam.

We present a case of an anomalous right coronary artery (RCA) originating from the opposite aortic sinus causing a transmural inferior myocardial infarction in a former competitive cyclist, followed by a brief discussion of the epidemiology, presentation, diagnosis and treatment of this coronary anomaly.

Sinus node dysfunction after surgical repair of an atrial septal defect (secundum-type): worth the wait.

Sinus node dysfunction after surgical repair of an atrial septal defect is a rather uncommon complication. We report a case of protracted post-operative sinus node dysfunction which was managed successfully by oral theophyllines and 'watchful' waiting. This strategy could avoid placement of a permanent pacemaker in this patient group of younger age.