Appraising failure of surgical and percutaneous revascularization: long term outcomes from an observational registry.

AIM: Many randomized trials have compared coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in terms of efficacy, but data comparing outcomes of patients in which these two techniques have failed are lacking. METHODS: We included patients undergoing PCI at our center between July 2002 and December 2004. Subjects were distinguished in 2 groups: those with at least one occluded or stenotic saphenous vein graft (CABG failure), and those with at least one stent with angiographically documented restenosis (PCI failure). The primary endpoint was the long-term rate of major adverse clinical events. RESULTS: Two hundred and thirthy four patients were included, with a medium follow up of 61±13 months; 134 were assigned to the CABG failure group, and 104 to the PCI failure group, sharing high rates of baseline risk factors. At long term rates of death were higher in post CABG group (22.1% vs. 9.9%; P=0.015, RR 2.24 C.I. 95% 1.14-4.40) while death rates in patients with diagnosis of diabetes mellitus (24.0% vs. 23.5%; P=0.969, RR 1.020 C.I. 95% 0.38-2.74) were not different CONCLUSION: PCI can be safely offered to both these kinds of patients: as recently demonstrated post CABG outcomes seem to be more favorable in patients with diabetes mellitus.

Incidence and very long- term outcomes of stent thrombosis after bare-metal or drug-eluting stent implantation: a retrospective analysis.

AIM: Stent thrombosis is a major safety issue after percutaneous coronary intervention (PCI) with stent implantation and it is associated with major early and mid-term complications. However, its long-term impact has been incompletely described. We thus aimed to appraise incidence, predictors and very long-term outlook of stent thrombosis after bare metal stent (BMS) or drug-eluting stent (DES) implantation. METHODS: We identified all patients undergoing PCI with BMS or DES at our center between July 2002 and June 2004. For the purpose of this study, we employed a composite definition of stent thrombosis including any Academic Research Consortium stent thromboses (definite, probable, or possible). We adjudicated the following clinical events: death, myocardial infarction (stent thrombosis related), repeated revascularization, and the composite of these events (i.e., major adverse cardiac events, MACE). RESULTS: A total of 1112 patients were included, 854 (76.8%) treated with BMS and 258 (23.2%) treated with DES. At a median follow-up of 61.2 (11.03) months the incidence of stent thrombosis was 20 (1.8%), with 14 (1.3%) definite, 4 (0.4%) probable, and 2 (0.1%) possible according to the American Research Consortium statement. Patients developing stent thrombosis were more likely to have more complex angiographic features at baseline (including angiographically evident thrombus, 4 [20%] vs. 73 [6.6%], P=0.02) and a saphenous vein graft as target vessel (2 [10%] vs. 28 [2.5%], P=0.04). Conversely, being treated with a BMS or a DES did not confer any significant decrease or increase in the risk of stent thrombosis, as 7 [35%] of those with stent thrombosis had received at least a DES vs. 251 [22.9%] of those without stent thrombosis, P=0.28). Early clinical outcomes (at 30 days) distinguishing those with stent thrombosis versus those without were as follows: death in four (20%) vs. 2 (0.2%, P<0.001), myocardial infarction in 1 (5%) vs. 7 (0.6%, P=0.02), revascularization in 5 (25%) vs. 43 (3.9%, P<0.001), and MACE in 8 (40%) vs. 53 (4.8%, P<0.001). After more than 60 months of clinical follow-up, outcomes were as follows: death in 7 (35%) vs. 147 (13.5%, P=0.057), myocardial infarction in 6 (30%) vs. 40 (3.6%, P<0.001), revascularization in 15 (75%) vs. 317 (29%, P<0.001), and MACE in 19 (95%) vs. 453 (41.5%, P<0.001). CONCLUSION: This long-term registry shows that stent thrombosis remains a major safety issue after PCI with stent implantation, with a significant prognostic impact. However, in the present work the risk of stent thrombosis was similar with either DES or BMS, suggesting thus that DES are not associated with any increase in long-term thrombotic risk in comparison to BMS.

Very long-term outcome of peripheral arterial disease in patients undergoing percutaneous coronary revascularization: a retrospective analysis.

AIM: Peripheral arterial disease (PAD) in patients undergoing percutaneous coronary intervention (PCI) with stent implantation is a well known risk factor leading to an increased rates of stroke, cardiovascular death and myocardial infarction. Anyway there are few data on very-long term outcome (more than 1 year follow up) of PAD after stent implantation. We thus aimed to evaluate the influence of PAD on very long-term outcome of our PCI-population. METHODS: We retrospectively identified all patients undergoing PCI with stent implantation at our center between July 2002 and June 2004, and thus eligible for at least 4 years of follow-up. For the purpose of this study, we considered a diagnosis of PAD based on clinical evaluation and/or angiographic documentation. We adjudicated the following clinical events: death, myocardial infarction, repeat revascularization, and their composite (i.e. major adverse cardiac events, MACE). RESULTS; A total of 1008 patients were included, 109 with PAD and 899 Without PAD. Those with had more often diabetes (35% vs. 25%, P=0.002), hypertension (83% vs. 68%, P=0.001) and unfavorable basal clinical condition at the start of this study: past-Percutaneous Coronary Intervention (PCI) (30% vs. 22%, P=0.005), past-Coronary Artery Bypass Graft (CABG) (24% vs. 14%, P=0.001), ejection fraction (EF) <35% (14% vs. 7%, P=0.02) and chronic renal failure (CRF) (15% vs. 6%, P=0.002). In addiction patient with PAD were more likely to have chronic total occlusion (CTO) (36% vs. 25%, p=0.02) and unprotected left main (16% vs. 8%,P=0.01). Clinical outcome at the time of follow-up (4,42 ± 1,66 years) was as follow: Revascularization (53% vs. 37%, P=0.002), Cardiac death (21% vs. 13%, P=0.04), MACE (69% vs. 49%, p<.001). Independent predictors of MACE according to our survival analysis were: PAD (HR 1.31; 95% CI 1.01-1.69), Age >75 (HR 1.23; 95% CI 1-1.51), Chronic heart failure (HR1.72; 95% CI 1.19-2.5), Unprotected left main (HR 1.48; 95% CI 1.12-1.96). CONCLUSION: This long-term registry shows that PAD remains an important clinical condition that negatively influences the outcome of patients undergoing PCI with stent implantation in a very long-term follow-up period.

Short and long term outcome of percutaneous coronary intervention with drug eluting stent and bare metal stent in patients with chronic kidney disease.

AIM: Coronary artery disease represents the most important cause of mortality and morbidity in chronic kidney disease (CKD). Despite continuous improvements in percutaneous coronary intervention (PCI), CKD is still associated with more adverse events after PCI. We performed a retrospective study to compare bare metal stents (BMS) versus drug eluting stents (DES) in CKD. METHODS: We included consecutively all patients undergoing PCI at our Centre from July 2002 to December 2005 with CKD, defined as creatinine clearance <60 mL/min. Patients who received only DES were compared to those who received only BMS. The primary end-point was the long-term rate of major adverse cardiac events (MACE, i.e. the composite of death, myocardial infarction and repeat revascularization). RESULTS: We included a total of 219 patients with CKD out of a total of 2354 patients, with 164 receiving BMS and 55 DES. After a mean follow up of 48 months, the MACE rate was significantly higher in BMS group (71% versus 38%, P<0.001). A similarly increased risk with BMS was found for death (45% versus 17%, P<0.001), whereas the rates for repeat coronary revascularization, myocardial infarction and stent thrombosis were not significantly different. Multivariable analysis showed that BMS vs.. DES implantation was not statistically significant associated with MACE, death, myocardial infarction, rePTCA or stent thrombosis. CONCLUSION: Compared with BMS, use of DES in patients with CKD is safe and effective in reducing adverse outcomes. However, differences found between groups in clinical end-point could be ascribed to selection bias and confounding factors.

Percutaneous drug-eluting stent implantation in diabetic patients: short and long term outcomes from an observational study.

AIM: The introduction of drug-eluting stents (DES) has markedly improved mid-term results of percutaneous coronary intervention (PCI) in diabetics. However, it is unclear whether the risk-benefit balance of DES in diabetics is maintained also at long-term and in insulin-requiring patients. We thus aimed to appraise long-term outcomes of diabetic patients treated with PCI with DES, stratifying according to insulin therapy. METHODS: We retrospectively collected baseline, procedural and outcome data from all patients undergoing PCI with DES from July 2002 to June 2004 at our center. We distinguished three groups: insulin-requiring diabetics, non-insulin-requiring diabetics and patients without diabetes. The primary end-point was the long-term rate of major adverse cardiac events (MACE, i.e. the composite of death, myocardial infarction, or target vessel revascularization). We also considered stent thrombosis according to the Academic Research Consortium Definition. RESULTS: We included a total of 1266 patients, with 3% of insulin-requiring diabetes, 22% with non-insulin-requiring diabetes, and 75% without diabetes. There were significant differences across groups in prevalence of male gender (respectively, 32.4%, 74.6% and 81%, P<0.001), and DES usage (54.1%, 34%, and 30.4%, P=0.007). Thirty-day MACE occurred with similar frequency in the three groups (8.1%, 7.3% and 6.3%, P=0.78), with death in 3%, 2%, and 1.4% (P=0.71) and myocardial infarction in 5.4%, 1.8% and 0.8% (P=0.02). After a median follow-up period of 58 months, MACE occurred in 59.5% of patients with insulin-requiring diabetes, in 50.6% of non-insulin-requiring diabetics and in 38.9% of non-diabetics (P<0.001). Death occurred in 24.3%, 17.5% and 8.5%, (P<0.001), myocardial infarction in 10.8%, 6.6%, and 5.1% (P=0.25), repeat revascularization in 46%, 31.6%, and 30% (P=0.11), and definite stent thrombosis in 0%, 1.1%, and 1.3% (P=0.78). CONCLUSION: Our study confirms the high risk profile of diabetic patients, especially when ischemic disease it is known. In this setting, diabetic and comorbidities fix the price not only in term of need of further revascularization, but mainly in survival decrease. It can be concluded that not only revascularization but also ­ and especially ­ comorbidities treatment plays a determinant role reducing follow-up events. Further research on additional pharmacologic treatments or hybrid revascularization strategies may mitigate the burden of morbidity and mortality.

Short and long-term outcomes of percutaneous revascularization in patients with prior coronary artery bypass graft.

AIM: Patients with prior coronary artery bypass grafting (CABG) represent a sizable portion of those undergoing percutaneous coronary intervention (PCI): in many instances, it is unclear whether performing PCI on the bypass graft or in the native coronary vessels can offer the best risk-benefit balance. METHODS: We included patients with prior CABG undergoing PCI at our center between July 2002 and June 2004 and we distinguished them in three groups. Those in whom PCI was performed on stenotic saphenous vein graft (SVG group), those in whom PCI was performed on native vessels despite the presence of potentially treatable SVG disease (optional native group), and those in whom PCI had to be performed mandatorily in the native vessels because of chronic SVG occlusions or disease in non-bypassed segments (mandatory native group). The primary end-point was long-term rate of major adverse clinical events (MACE, i.e. death, myocardial infarction, or target vessel revascularization). RESULTS: We identified 109 patients: 28 were in the SVG group, 25 in the optional native group, and 56 in the mandatory native group. Early major adverse cardiac events (MACE) occurred with similar frequency in the three groups (respectively, 9.1%, 0% and 5.7%, P=0.35). After more than three years of follow-up, MACE occurred in 39.3% vs. 28 and 39.4% (P=0.59), death occurred in 27.2 vs. 24.0% vs. 13.5% (P=0.30), and TVR in 27.3% vs. 8.0% vs. 28.8% (P=0.14). CONCLUSION: In selected patients, PCI of native coronary vessels despite the presence of apparently treatable SVG lesions can be envisioned.

Impact of multivessel coronary disease on long-term outcome after percutaneous recanalization of coronary chronic total occlusions.

AIM: Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is common even with concomitant multivessel disease. We aimed to investigate the impact of multivessel disease on long-term outcome after PCI for CTO. METHODS: We collected baseline, procedural and follow-up data on patients undergoing successful PCI with stenting for CTO. We divided our population into three groups: patients with 1 vessel disease (1VD), those with 2-vessel disease (2VD) and subjects with 3-vessel disease (3VD). The primary end-point was the occurrence of major adverse cardiac events (MACE), i.e. death, myocardial infarction or target vessel revascularization. RESULTS: A total of 111 patients were included: 24 (21%) in group 1VD, 28 (25%) in group 2VD, and 59 (53%) in group 3VD. Clinical follow-up was available in 109 (98%) of them after a median of 27 months (range 6-68), yielding MACE rates of 1 (4%) in group 1VD, 5 (18%) in group 2VD, and 17 (29%) in group 3VD, respectively (P=0.03). No statistically significant difference was found comparing the 3 groups for the individual rates of death, myocardial infarction or target vessel revascularization (all P>0.05). No case of definite or probable stent thrombosis was adjudicated, despite use of DES in 99 (89%) patients. CONCLUSION: Patients with diffuse coronary disease undergoing PCI for a CTO fare a significantly worse prognosis. Nonetheless, despite liberal use of DES, stent thrombosis is rare in this setting, without differences according to the initial severity of disease, thus supporting the long-term safety of DES, even if used in this "off-label" context.

Clopidogrel treatment in a patient with ticlopidine-induced hepatitis following percutaneous coronary stenting.

Thienopyridines are commonly prescribed antiplatelets drugs, extremely useful for the acute and chronic management of patients with cerebrovascular and cardiovascular diseases. The occurrence of their side effects is fortunately uncommon, although unpredictable. We thereby describe a case of prescription of clopidogrel in a patient with ticlopidine-induced hepatitis confirmed by liver biopsy that had undergone multiple percutaneous coronary stenting procedures necessitating subsequent compulsory antiplatelets treatment. The description of this exceptional clinical case is of relevant knowledge to orientate a physician treating a patient with absolute need of antiplatelets and history of previous drug-induced reactions.

Repeat adverse events long after percutaneous coronary revascularization in diabetics.

AIM: Diabetics with coronary artery disease face a high risk of adverse events following coronary revascularization. However, recurrence rates of after the first revascularization have never been appraised. The aim of this study was to evaluate recurrent events in diabetics undergoing percutaneous coronary intervention (PCI) in the current era. METHODS: Authors collected baseline and outcome data of consecutive type-2 diabetics treated with PCI (July 2002-December 2005) . End-points of interest were the long-term rates of major adverse cardiac events (MACE: cardiac death, myocardial infarction [MI], percutaneous target vessel revascularization [TVR-PCI], or coronary artery bypass grafting [CABG]), non-TVR PCI, and stent thrombosis. RESULTS: A total of 429 diabetics were included, 191 (44%) insulin-dependent, with drug-eluting stents implanted in 232 (54%). After a median of 38 months, events were as follows: MACE in 167 (38.9%) subjects, cardiac death in 38 (8.8%), MI in 42 (9.8%), TVR-PCI in 130 (30.3%), CABG in 11 (2.6%), non-TVR-PCI in 52 (12.1%), and definite stent thrombosis in 9 (2.1%). Among the 129 patients undergoing TVR-PCI as first event, as many as 28 (21.7%) underwent a second TVR-PCI, 7 (5.4%) underwent a third TVR-PCI, and a further 2 (1.5%) underwent a fourth TVR-PCI, whereas CABG was performed in 2 (1.5%) and non-TVR-PCI in 4 (3.1%). CONCLUSIONS: This work, originally reporting on the risk of recurrent repeat revascularization events among diabetics treated with PCI, showed that adverse events occur frequently in these patients, but can be managed in most cases safely and successfully by means of repeat PCI only.

Analysis of recurrent revascularization events following percutaneous coronary intervention of diabetic patients.

AIM: Greater incidence of recurrent events following percutaneous coronary intervention (PCI) has been described among patients with diabetes mellitus (DM). A clear actual picture of these events can hitherto be considered as lacking. Aim of this study was to describe frequency and peculiarity of recurrent cardiovascular events following PCI in a group of high risk DM patients and to compare the impact of repeat PCI and/or surgical revascularizations on the need of further coronary interventions in a long-term follow-up. METHODS: 254 consecutive DM patients undergoing PCI for known coronary artery disease (CAD) were followed by outpatient visits for 39+/-9 months. The registered endpoints were target vessel PCI (TVR PCI), target vessel surgical revascularizations (TVR CABG), non target vessel percutaneous revascularization interventions (NON TVR PCI), and no repeat revascularizations. RESULTS: 74 (35%) of the DM patients undergoing an index PCI required further revascularization and 10 (17%) patients needed more than one repeat TVR procedure. Second TVR revascularisation procedures occurred similarly following first PCI (15%) or surgical revascularisation (17%) driven by coronary lesions located in epicardial vessels treated during the index PCI. Patients undergoing TVR surgical revascularisation disclosed a higher probability of incurring in a second PCI driven by coronary lesions located in epicardial vessels not previously treated (P=0.003) compared to those approached by PCI. CONCLUSIONS: The present study reports on a seemingly superior coronary protection of PCI compared to surgical revascularization in preventing disease progression upon the native coronary arteries. These results need confirmation in larger population samples.

Percutaneous aortic valve replacement in two cases at high surgical risk: procedural details and implications for patient selection.

The morbidity and mortality burden of heart valve disease is increasing in the developing world, especially among the elderly. Whereas surgery remains the standard of care in fit patients with degenerative aortic stenosis, percutaneous aortic valve replacement could become an effective alternative to surgery in selected higher risk patients. The authors report on two women with aortic stenosis, both at high surgical risk (an 81-year-old female with coronary artery and cerebro-vascular disease, and a 70-year-old female with end-stage cirrhosis), in whom percutaneous valve replacement was effectively performed by means of transfemoral access and retrograde CoreValve Re-valving System implantation. Two major post-procedural complications occurred, both effectively managed, in the second patient: a third degree atrio-ventricular block (requiring permanent pace-maker implantation) and bleeding from the right femoral artery access (requiring implantation of two covered stents and blood transfusion). Despite the increased baseline risk, both patients were discharged asymptomatic, the first twelve days and the other three weeks after admission. In the authors' experience percutaneous aortic valve replacement can be performed with reasonable safety in patient with severe aortic stenosis at high surgical risk.

Impact of drug-eluting stent selection on long-term clinical outcomes in patients treated for unprotected left main coronary artery disease: the sirolimus vs paclitaxel drug-eluting stent for left main registry (SP-DELFT).

AIM: To compare the long-term relative efficacy and safety of SES and PES in patients undergoing percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease and to evaluate the role of lesion location and stenting technique in determining outcomes. METHODS AND RESULTS: From April 2002 to April 2004, 288 consecutive patients who underwent elective PCI with DES implantation for de novo lesions on ULMCA have been retrospectively selected and analyzed in seven European and US tertiary care centers. All patients had a minimum follow-up of 3 years. SES was used in 152 patients while 136 received PES. Isolated ostial-shaft disease was present in 27% of patients. Distal LM disease (73%) was treated with single and double stent approach in 29.5% and 43.4% of patients respectively. After 3 years, rates of survival free from any of the events investigated, were independent from lesion location and stenting approach and did not differ significantly between SES and PES groups. Freedom from MACE (SES vs. PES) was 76.3% vs. 83.1% in the ostial/shaft group, 80.3% vs. 72.8% in the distal-single stent group and 67.1% vs. 66.2% in the distal-double stent group. Definite stent thrombosis occurred only in 1(0.3%) patient at 439 days. CONCLUSIONS: In elective patients who underwent PCI for de novo lesions in the ostium, shaft or distal ULMCA, long-term clinical outcomes with SES and PES use were similar independently of lesion location and stenting technique.

Safety of coronary collateral stenting in a patient with acute coronary syndrome.

A protective role of the presence of collateral arteries, generating smaller infarcts, improved ventricular function, fewer future cardiovascular events, and improved survival following a myocardial ischemia has been described in numerous reports. However little is known about atherosclerotic disease of the collateral vessels, and the possibility to treat critical stenosis of these vessels has never been described. Therefore this report describes a unique case of percutaneous coronary intervention on a well developed yet atherosclerotic coronary collateral vessel triggering an acute coronary syndrome with hemodynamic instability. In the present case balloon angioplasty and stenting of the collateral vessel was safe and effective. Nonetheless, further studies are warranted.

Clinical and pharmacological management of a high risk diabetic population undergoing percutaneous coronary interventions.

AIM: An optimal clinical management and monitoring of patients with diabetes mellitus (DM) and coronary artery disease (CAD) has proved to reduce the incidence of cardiovascular events. The main aim of this report is to verify the adherence to the latest guidelines recommendations in a considerable group of DM patients undergoing a percutaneous coronary intervention, stratifying the population by the degree of the DM management. METHODS: The patients recruited were those consecutive, unselected patients with type 2 DM undergoing a balloon angioplasty followed by a stent implantation, between July 2002 and December 2004. Follow-up was completed in 220 patients at 39+/-8.7 months. The follow-up interview concerned sociodemographic details, medical history, pharmaceutical treatment, major adverse cardiac and cerebrovascular events and clinical variables regarding the quality of DM management and monitoring. RESULTS: Thirty-six percent of these high short and long-term risk patients received insulin treatment at index hospitalization despite a poor glucometabolic control (59% presented HbA1c >7%, mean 8+/-1.26%). The clinical management of the 204 (80%) survivors over time proved overall unsatisfactory: HbA1c, arterial blood pressure and body mass index uncommonly achieved the recommended targets (41%, 36% and 22% of the patients respectively). The DM monitoring revealed satisfactory, with the exception of the diabetic foot monitoring (performed in 38% of the patients). Concerning guideline adherence 26% of the patients proved to adhere strictly, while 38% and 36% were mildly and severely distant from these requirements. CONCLUSION: Quality of DM management absolutely necessitates to be improved to attempt reducing the high cardiovascular event rates.

Iatrogenic coronary-to-right ventricle fistula: benign outcome irrespective of patency?

Coronary perforation is an uncommon, but potentially lethal complication of percutaneous coronary interventions. Most perforations have proved to lead to intramyocardial or intrapericardial extravasation. However, perforation may also lead to direct coronary-to-right ventricle fistula, more commonly occurring in complex lesions and/or the use of atheroablative devices. To prevent this complication careful manipulation of the guidewire across the obstruction is mandatory, together with avoidance of oversized balloons and high-pressure inflations. The factors that determine the hemodynamic significance of the fistulas include size of the communication, resistance of the recipient chamber, and potential for development of myocardial ischemia. Accordingly a broad range of signs and symptoms may be referred. Despite iatrogenic fistulas are usually benign and asymptomatic, spontaneous closures are very rare. In most cases fistulas need to be treated by percutaneous or surgical closure, being the conservative management a debated option. In isolated cases serious complications have been described resulting from volume overload and distal myocardial flow impairment. We hereby describe two cases of coronary-to-right ventricle fistula occurred during percutaneous coronary intervention, highlighting full angiographic iconography and the issues involved in the management and follow-up of this iatrogenic complication.

Percutaneous coronary intervention with everolimus-eluting stents (Xience V): systematic review and direct-indirect comparison meta-analyses with paclitaxel-eluting stents (Taxus) and sirolimus-eluting stents (Cypher).

First-generation drug-eluting stents (DES) have brought major improvements in results of percutaneous coronary intervention (PCI). However, there is currently debate on the safety of these first-generation DES, given the potential for late stent thrombosis, especially after discontinuation of dual antiplatelet therapy. Second-generation DES, such as zotarolimus- (Endeavor) and everolimus-eluting stents (Xience V), have recently become available in the USA and/or Europe. Indeed, the Xience V stent holds the promise of superior anti-restenotic efficacy as well as long-term safety, yet there is uncertainty on its risk-benefit balance. Authors conducted a systematic review of basic science and clinical evidence on the Xience V, by thoroughly searching PubMed and online databases (updated September 2007). They also compared the clinical results of Xience V vs paclitaxel-eluting stents (Taxus) and sirolimus-eluting stents (Cypher) by means of direct and indirect comparison meta-analysis. A total of three clinical studies has been retrieved focusing on Xience V, however both most recent and important trials were still unpublished. The first trial compared Xience V vs bare-metal stents, whereas the other two randomized trials compared Xience V vs Taxus. Direct meta-analysis of Xience V vs Taxus showed that Xience V was significantly superior to Taxus in preventing binary angiographic restenosis and target lesion revascularization (P<0.05 for both). Indirect comparison between Xience V and Cypher, exploiting a recent 16-trial large meta-analysis, showed that Xience V was at least as effective as Cypher in preventing target lesion revascularization (P=0.12). Everolimus-eluting stents (Xience V) appear as a major breakthrough in coronary interventions, and superior efficacy has already been demonstrated in comparison to paclitaxel-eluting stents (Taxus). Data available to date also suggest that Xience V is at least as effective as sirolimus-eluting stents (Cypher). Whether long-term results and direct comparison to Cypher will also be favorable remains to be established by future clinical trials.

Percutaneous unprotected left main angioplasty with drug-eluting stents in a nonagenarian: feasible and safe despite recurrent restenosis.

The management of severe coronary artery disease in the very elderly is challenging and the most appropriate revascularization strategy highly debated. To date, coronary artery bypass surgery has been the treatment of choice for significant stenosis of unprotected left main (ULM) coronary. Whether this holds true also in very old patients is unknown. The Authors hereby report the case of a 91-year-old diabetic man who underwent coronary angiography in June 2005 for subacute unstable angina. Angiography disclosed a critical stenoses in the distal unprotected left main, left anterior descending, and distal left circumflex, which were treated with a paclitaxel-eluting stent and a bare-metal stent (BMS), respectively. Four months later, recurrent angina lead to a second angiography which showed critical restenosis in the left anterior descending and significant ostial stenosis in the left circumflex. Another paclitaxel-eluting stent was implanted in the left anterior descending, followed by kissing balloon in the left main, achieving a good angiographic result. Six months later angina recurred again: at angiography diffuse restenosis in the left main, left anterior descending and left circumflex was documented. A crushing technique was thus employed to deliver 2 sirolimus-eluting stents, achieving a satisfactory final result. Since then, and to date for more than 17 months since the last procedure, this nonagenarian has remained free from anginal chest. This case highlights the potentials and drawbacks of percutaneous coronary intervention for unprotected left main disease, suggesting nonetheless, that this revascularization strategy can be safely repeated even in elderly patients.

Telecardiogram: still of matter in the modern cardiac imaging era?

The modern cardiovascular imaging era has seen the introduction in clinical practice of highly innovative and performing diagnostic features. The negative side of this outstanding evolution risks to be an under-assessment of well-established classical diagnostic techniques. Thereby, to support the actual relevance of a properly executed chest X-ray, this article describes two paradigmatic cases of exceptional cardiac abnormalities, in which X-rays played a key diagnostic role.