A Redo Percutaneous Emergency Intervention of Left Ventricular Assist Device Graft Occlusion.

In patients with advanced heart failure (HF), left ventricular assist devices (LVADs) have demonstrated to be effective in improving the quality of life and reducing further hospitalizations. Although uncommon, LVAD outflow graft obstruction (OGO) is a potentially life-threatening complication and percutaneous treatment has been proposed as a standard intervention strategy in such cases. We report the case of a 69 year old man admitted due to LVAD failure causing unstable HF. Past medical history included percutaneous intervention on the outflow graft with stent implantation one year before. The patient was under chronic treatment with vitamin K antagonists (VKA). Emergent percutaneous angiography was performed, showing recurrent OGO due to thrombosis located at a kinking site, distally to the previously treated segment. Using distal anchoring technique, a balloon-expandable 10 × 79 mm endoprosthesis (GORE® Viabahn® VBX) was effectively positioned and post-dilated. Final angiography confirmed the patency of the stent implanted one-year before. Despite the procedure succeeding in restoring LVAD function, the patient died due to septic shock ten days after. Our case suggests that recurrent OGO can be effectively treated with percutaneous redo and that long-term stent patency can be achieved with a standard antithrombotic treatment, despite further thrombotic events in other segments of the graft are still possible (especially at the kinking site). Moreover, other noncardiac conditions as infective complications, can dramatically impact the clinical course and lead to unfavorable outcomes.

A Case of Successful Use of the "Anchoring Technique" for Percutaneous Treatment of Left Ventricular Assist Device Graft Occlusion.

Left ventricular assist device (LVAD) obstruction can be a dramatic and life-threatening complication in patients with advanced heart failure (HF). Despite surgical redo is often required in these patients, it is associated with a high risk of periprocedural negative outcome. We report the case of a 68-year-old male with a thrombotic stenosis of the LVAD proximal outflow-graft. Following Heart Team debate, a percutaneous intervention was planned during veno-arterial Extra Corporeal Membrane Oxygenation (ECMO) assistance. To achieve the needed catheter support, we used the "distal balloon anchoring technique" through the outflow-graft and managed to implant a covered stent, rapidly restoring the flow through the LVAD. The patient was discharged without further complications. Our case shows that, in selected cases, percutaneous treatment of LVAD obstructions can be feasible, especially using advanced techniques derived from the experiences in coronary interventions and under ECMO assistance. More cases and prospective studies are mostly needed to explore long-term patency of the LVADs and clinical outcomes in these high-risk patients.

A Comparison Between Gore Cardioform and Amplatzer Septal Occluder for Percutaneous Closure of Patent Foramen Ovale Associated With Atrial Septal Aneurysm: Clinical and Echocardiographic Outcomes.

OBJECTIVES: To evaluate the short- and long-term clinical and echocardiographic outcomes of the percutaneous closure of the patent foramen ovale (PFO) with an atrial septal aneurysm (ASA) using 2 different devices. METHODS: We enrolled 100 patients with PFO and ASA. Fifty consecutive patients had transcatheter closure of the PFO with the Gore Cardioform septal occluder (GSO) (Gore Medical) and a second group of 50 consecutive patients with the Amplatzer PFO occluder (APO) (Abbott). A clinical and transthoracic echocardiographic follow-up was performed at 1, 3, 6, and 12 months after the implant procedure. The primary endpoint was the incidence of moderate-to-severe residual right-to-left shunting (rRLS) at the 6-month follow-up. The procedural results and the recurrence of embolic events at 1 year were also investigated. RESULTS: The procedure was successful in all patients. The immediate postprocedural moderate-to-severe rRLS incidence was similar between the 2 groups (GSO 14% vs APO 12%; P=NS) as well as the incidence of moderate-to-severe rRLS at the 6-month follow-up (GSO 4% vs APO 4%; P=non-significant). In only 1 patient of the GSO group, there was a persistent moderate rRLS at the 1-year follow-up. The 6-month and 1-year complete occlusion rate for all subjects was 93% and 96%, respectively. No devices embolized and no death or recurrent embolic events were observed during hospitalization through the 1-year follow-up. CONCLUSIONS: GSO and APO devices appear to be safe and effective devices for the percutaneous closure of a PFO with ASA, showing similar results for the presence of rRLS at the 6-month follow-up, complete occlusion rate, and clinical embolic recurrences.

Extracorporeal membrane oxygenation-assisted emergency percutaneous treatment of left ventricular assist device graft occlusion.

End-stage heart failure is more often treated with Implantable left ventricular assist device (LVAD), even if the prolonged use may increase the risk of complications. In this case, a 51-year-old male patient presented to our emergency department showing acute heart failure signs and symptoms and a dramatic reduction of LVAD flow. Laboratory tests ruled out significant haemolysis, usually associated with pump thrombosis. The echocardiogram and the computed tomography were not able to clarify the correct diagnosis. We immediately placed a veno-arterial extracorporeal membrane oxygenation, followed by a selective retrograde angiography of the pump. The images showed stenosis of the LVAD-outflow graft, suggesting a twist. Through a hand-made J-tip guidewire, we performed multiple dilatations of the occlusion using peripheral balloons. Finally, we implanted an aortic coarctation covered-stent, re-establishing an adequate cardiac output to the patient. Our case indicates that catheter-based approach in extracorporeal membrane oxygenation assistance provides an important therapeutic alternative to treat outflow graft stenosis, especially in the case of acutely unstable patient.

Single-Staged Compared With Multi-Staged PCI in Multivessel NSTEMI Patients: The SMILE Trial.

BACKGROUND: A lack of clarity exists about the role of complete coronary revascularization in patients presenting with non-ST-segment elevation myocardial infarction. OBJECTIVES: The aim of our study was to compare long-term outcomes in terms of major adverse cardiovascular and cerebrovascular events of 2 different complete coronary revascularization strategies in patients with non-ST-segment elevation myocardial infarction and multivessel coronary artery disease: 1-stage percutaneous coronary intervention (1S-PCI) during the index procedure versus multistage percutaneous coronary intervention (MS-PCI) complete coronary revascularization during the index hospitalization. METHODS: In the SMILE (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction Patients: One Stage Versus Multistaged Percutaneous Coronary Intervention) trial, 584 patients were randomly assigned in a 1:1 manner to 1S-PCI or MS-PCI. The primary study endpoint was the incidence of major adverse cardiovascular and cerebrovascular events, which were defined as cardiac death, death, reinfarction, rehospitalization for unstable angina, repeat coronary revascularization (target vessel revascularization), and stroke at 1 year. RESULTS: The occurrence of the primary endpoint was significantly lower in the 1-stage group (1S-PCI: n = 36 [13.63%] vs. MS-PCI: n = 61 [23.19%]; hazard ratio [HR]: 0.549 [95% confidence interval (CI): 0.363 to 0.828]; p = 0.004). The 1-year rate of target vessel revascularization was significantly higher in the MS-PCI group (1S-PCI: n = 22 [8.33%] vs. MS-PCI: n = 40 [15.20%]; HR: 0.522 [95% CI: 0.310 to 0.878]; p = 0.01; p log-rank = 0.013). When the analyses were limited to cardiac death (1S-PCI: n = 9 [3.41%] vs. MS-PCI: n = 14 [5.32%]; HR: 0.624 [95% CI: 0.270 to 1.441]; p = 0.27) and myocardial infarction (1S-PCI: n = 7 [2.65%] vs. MS-PCI: n = 10 [3.80%]; HR: 0.678 [95% CI: 0.156 to 2.657]; p = 0.46), no significant differences were observed between groups. CONCLUSIONS: In multivessel non-ST-segment elevation myocardial infarction patients, complete 1-stage coronary revascularization is superior to multistage PCI in terms of major adverse cardiovascular and cerebrovascular events. (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction [NSTEMI] PATIENTS: One Stage Versus Multistaged Percutaneous Coronary Intervention [PCI] [SMILE]: NCT01478984).

CoreValve repositioning complicated by entrapment of snare in the valve delivery anchor.

We report on the treatment of a patient, with severe peri-prosthetic regurgitation, following CoreValve implantation too low into the left ventricle outflow tract, adjusted by 'snaring' prosthesis. This bail-out manoeuvre allows the appropriate positioning of the prosthesis but was complicated by the entrapment of the goose-neck loop in the valve delivery anchor and was solved successfully with a second different device.

Multiple and Contemporary Coronary Thrombosis inspite of Low Platelet Function Response.

We are reporting a clinical case of a 78-year-old male who had oppressive chest pain at rest, which regressed with the intake of sublingual nitrates. Coronary angiography showed a chronic total occlusion (CTO) of the left anterior descending (LAD) artery, a normal circumflex, a hypoplasic right coronary artery and a Cardiac Magnetic Resonance showing vital tissue in anterior wall. During the procedure of CTO-PCI on LAD, patient developed multiple and contemporary coronary thrombosis in spite of low platelet reactivity, which was assessed by using Multiplate. A manual thrombectomy was performed with a good final result only after drug eluting stents (DES) implantation.

Thrombus aspiration in acute myocardial infarction: Rationale and indication.

Reperfusion of myocardial tissue is the main goal of primary percutaneous coronary intervention (PPCI) with stent implantation in the treatment of acute ST-segment elevation myocardial infarction (STEMI). Although PPCI has contributed to a dramatic reduction in cardiovascular mortality over three decades, normal myocardial perfusion is not restored in approximately one-third of these patients. Several mechanisms may contribute to myocardial reperfusion failure, in particular distal embolization of the thrombus and plaque fragments. In fact, this is a possible complication during PPCI, resulting in microvascular obstruction and no-reflow phenomenon. The presence of a visible thrombus at the time of PPCI in patients with STEMI is associated with poor procedural and clinical outcomes. Aspiration thrombectomy during PPCI has been proposed to prevent embolization in order to improve these outcomes. In fact, the most recent guidelines suggest the routine use of manual aspiration thrombectomy during PPCI (class IIa) to reduce the risk of distal embolization. Even though numerous international studies have been reported, there are conflicting results on the clinical impact of aspiration thrombectomy during PPCI. In particular, data on long-term clinical outcomes are still inconsistent. In this review, we have carefully analyzed literature data on thrombectomy during PPCI, taking into account the most recent studies and meta-analyses.

Five years on dual-antiplatelet therapy. DES thrombosis after clopidogrel withdrawal.

Drug-eluting stents (DES) have a moderately higher incidence of stent thrombosis compared to bare metal stents (BMS) and very late DES thrombosis has been frequently described. We report a case of a 66 year-old male who experienced very late stent thrombosis at 5 years after paclitaxel-eluting stent (PES) implantation and 3 days after clopidogrel withdrawal. Intravascular ultrasound (IVUS) performed during the index procedure showed that the previously implanted PES was undersized. Since the patient could not take clopidogrel, we treated him with only a noncompliant balloon (3.0 × 15 mm) with optimal expansion as confirmed by IVUS. This case report describes a patient who continued clopidogrel treatment for 5 years and was probably protected from a procedural failure. During the current hospitalization, the patient was found to be a responder to clopidogrel after a platelet function assessment with Multiplate (Dynabyte Informationssysteme GmbH, Munich, Germany).

Pharmacodynamic effect of switching therapy in patients with high on-treatment platelet reactivity and genotype variation with high clopidogrel Dose versus prasugrel: the RESET GENE trial.

BACKGROUND: High on-treatment platelet reactivity (HTPR) is associated with adverse outcomes. We aim to compare the novel thienopyridine prasugrel versus double-dose clopidogrel in patients with HTPR and explore the interaction between CYP2C19 genotype and both drugs. METHODS AND RESULTS: Consecutive stable patients undergoing percutaneous coronary intervention were screened with the Multiplate Analyzer P2Y12 assay, defining HTPR as area under the curve >450. Those with HTPR were randomized to prasugrel (10 mg/day) or high-dose clopidogrel (150 mg/day) for 2 weeks and then crossed-over to, respectively, clopidogrel and prasugrel, repeating the P2Y12 assay at the end of each cycle. Clinical follow-up (until 3 months) and CYP2C19 genotyping was performed in all patients. The primary end point was platelet reactivity after 14 days of prasugrel versus high-dose clopidogrel. Thirty-two patients were randomized to prasugrel and then high-dose clopidogrel or to high-dose clopidogrel followed by prasugrel. Prasugrel was associated with a significantly lower platelet reactivity than high-dose clopidogrel was (325.8 versus 478.5 area under the curve, P=0.028). No patient treated with prasugrel exhibited HTPR, whereas 9 (28.1%) receiving high-dose clopidogrel still had prevalence of HTPR (P=0.001). Similar findings were obtained changing cutoffs or considering platelet reactivity as a continuous variable. Genotyping showed the same efficacy between high-dose clopidogrel and prasugrel in the 18 (56.3%) CYP2C19*2 noncarriers (HTPR in 12.5% versus 0, P=0.274), whereas it was significantly worse in the 14 (43.7%) carriers (HTPR in 43.7% versus 0, P=0.003). CONCLUSIONS: HTPR is successfully abolished by therapy with prasugrel irrespective of CYP2C19 genotype. Conversely, high-dose clopidogrel can address HTPR only in CYP2C19*2 noncarriers. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01465828.