Prevalence and clinical impact of high platelet reactivity in patients with chronic kidney disease treated with percutaneous coronary intervention: An updated systematic review and meta-analysis.

BACKGROUND: High platelet reactivity (HPR) on clopidogrel and chronic kidney disease (CKD) are recognized as potent risk factors for adverse outcomes in patients suffering coronary artery disease (CAD) and undergoing percutaneous coronary intervention (PCI). However, conclusive evidence regarding their reciprocal interaction and the consequent impact on clinical events is still lacking. OBJECTIVES: We performed a metaanalysis with the aim to evaluate the prevalence of HPR in patients with and without CKD and the incidence of major adverse cardiovascular events (MACE) according to the renal and platelet function status in current literature (co-primary endpoints). Secondary endpoints were myocardial infarction (MI), all-cause death, and definite/probable stent thrombosis (ST). METHODS: We searched on PubMed, EMBASE, and Cochrane Library studies investigating CKD and HPR on clopidogrel in patients suffering CAD who underwent PCI and their related outcomes. Overall, 13 studies including 22.464 patients were selected. Odds ratios (ORs) and 95% confidence intervals (CI) were calculated using a random-effects model with the Mantel-Haenszel method. RESULTS: Patients with CKD presented significantly higher odds of HPR compared with those without CKD (OR 1.51 [95% CI: 1.29, 1.76]). In patients without CKD, HPR was associated with increased odds of MACE (OR 1.31 [95% CI: 1.01, 1.72]), MI (OR 1.48 [95% CI: 1.17, 1.86]) and definite/probable ST (OR 2.45 [95% CI: 1.08, 5.60]). In patients with CKD, HPR was associated with higher odds of both MACE (OR 1.61 [95% CI: 1.14, 2.27]) and MI (OR 1.69 [95% CI: 1.11, 2.59]), compared to those without HPR. CONCLUSIONS: Our analysis shows that HPR on clopidogrel is more frequent in patients with CKD treated with PCI. Patients with HPR are exposed to a high risk of MACE after PCI, regardless of the renal function status.

Intracardiac echocardiography with ultrasound probe placed in the upper left pulmonary vein to guide left atrial appendage closure: First description.

Intracardiac echocardiography (ICE) has become an effective alternative to trans-esophageal echocardiography (TEE) as a guidance during interventional procedures for structural heart diseases, allowing to proceed under conscious sedation. To guide percutaneous left atrial appendage (LAA) closure, the ICE probe is usually placed in the right atrium, in the pulmonary artery or in the left atrium (LA); however, the views from the right atrium or the pulmonary artery are often suboptimal, debarring a complete visualization of the LAA and the surrounding structures, whereas the LA location requires trans-septal puncture, may provoke LA wall mechanical stimulation and is often associated with unstable position of the ICE probe. In our case, after a second trans-septal puncture, the ICE probe was placed in the upper left pulmonary vein; this was safely performed and provided an optimal imaging of the LAA, comparable to that obtained by TEE, thus warranting an adequate guide during all procedural steps.

Carotid Doppler sonography: additional tool to assess hemodynamic improvement after transcatheter aortic valve implantation.

PURPOSE: The aim of our study was to assess the arterial cerebral blood flow variations in patients with aortic valve stenosis, immediately after the transcatheter aortic valve implantation (TAVI). METHODS: The study population includes 62 consecutive patients who underwent TAVI for aortic valve stenosis (95%) and sugical bioprosthesis degeneration (5%). Carotid Doppler examination was performed recording blood flow, systolic peak velocity, time average mean velocity and mean acceleration time at baseline, after balloon aortic valvuloplasty, and within 10 min after the device release. RESULTS: A significant improvement of blood flow was recorded at the end of the procedure (from 315.05 ±â€Š141.72 to 538.67 ±â€Š277.46 ml/min; P < 0.00001). The systolic peak velocity and the time average mean velocity increased from 52.27 ±â€Š14.29 to 78.89 ±â€Š20.48 cm/s (P < 0.00001) and from 12.24 ±â€Š4.74 to 21.21 ±â€Š9 cm/s (P < 0.00001), respectively. Consensually, the mean acceleration time decreased from 0.22 ±â€Š0.02 to 0.03 ±â€Š0.02 s (P < 0.00001) after the procedure. CONCLUSION: Monitoring of Doppler measurements may be a useful and noninvasive method to assess acutely the improvement of hemodynamic flow after TAVI, specifically for the cerebral district.

Intradevice misalignment predicts residual leak in patients undergoing left atrial appendage closure.

AIMS: Postdeployment mutual orientation between the disk and the lobe in patients undergoing left atrial appendage closure with Amplatzer cardiac plug/Amulet device might impact on the risk of residual leak during follow-up. Thus, we evaluated in an exploratory, pilot study whether the degree of intradevice misalignment, measured by cardiac computed tomography (CT), discriminates the occurrence of peridevice leak in those patients. METHODS: All patients (N = 15) undergoing percutaneous left atrial appendage closure with those specific devices between April 2013 and January 2015 were prospectively included. All patients received follow-up evaluation by cardiac CT at 6 months after the intervention to calculate the angle of misalignment within the device and to detect presence of residual peridevice leak. RESULTS: The angle of misalignment between the disk and the lobe of the device significantly discriminated between patients with and without peridevice leak (area under the curve 0.96, 95% confidence interval 0.88-1.0; P = 0.003), with an angle more than 20° being associated with nine-fold higher risk of residual leak. This angle of intradevice misalignment calculated by cardiac CT was significantly correlated with that measured by two-dimensional transesophageal echocardiography or X-rays in the cath lab after the device deployment (r = 0.943 and r = 0.938, respectively). CONCLUSION: A marked intradevice misalignment after Amplatzer cardiac plug/Amulet device implantation significantly predicts the occurrence of postprocedural leak in patients with atrial fibrillation; if confirmed by larger studies, these findings may impact on practice patterns.

Percutaneous aortic leak closure in a small and frail annulus after double heart valve replacement.

: Paravalvular leak (PVL) is an uncommon but serious complication associated with the implantation of prosthetic valves. Following aortic valve replacement, up to 5% of patients affected by PVL develop clinical symptoms of heart failure, hemolysis or both. Percutaneous treatment of PVL has emerged instead of conventional surgery, as a well tolerated and less invasive procedure but remains a challenge. We present the case of a young woman with mechanical aortic and mitral prostheses, who presented surgical aortic PVL caused by a serious frailty of native annulus, became symptomatic after 5 months and was successfully percutaneously treated with an Amplatzer Duct Occluder device.

Immediate and 12-Month Outcomes of Ischemic Versus Nonischemic Functional Mitral Regurgitation in Patients Treated With MitraClip (from the 2011 to 2012 Pilot Sentinel Registry of Percutaneous Edge-To-Edge Mitral Valve Repair of the European Society of Cardiology).

In literature, there are limited data comparing ischemic mitral regurgitation (I-MR) versus nonischemic MR regarding outcomes after percutaneous "edge-to-edge" repair. We aimed to describe the early and 12-month results after MitraClip device implantation regarding the 2 etiologies. From January 2011 to December 2012, the Transcatheter Valve Treatment Sentinel Pilot Registry included 452 patients with MR who underwent MitraClip procedure in 25 centers across Europe. The prevalent etiology was I-MR (235 patients, 52.0%). I-MR group had a significantly higher proportion of men (74.9 vs 59.9%, p <0.001) and surgical risk (logistic EuroSCORE 24.8 ± 18.2 vs 18.8 ± 16.3, p <0.001). Acute procedural success was high (96%) and similar between groups (p = 0.48). Patients with I-MR required a higher, albeit not significant, number of clips to reduce MR (p = 0.08). Inhospital mortality was low (2.0%) without significant differences between etiologies. The estimated 1-year mortality and rehospitalization rates were 15.0% and 25.8%, respectively, without significant differences between groups. Paired echocardiographic data showed a persistent improvement of MR at 1 year in both etiologies. Despite a significant overall reverse atrial remodeling after clip, there were no significant changes in left ventricular volumes. In conclusion, this large independent cohort showed that percutaneous "edge-to-edge" therapy was associated with early- and long-term improvement of MR severity and functional condition both in patients with I-MR and nonischemic MR. There were no significant differences between the 2 etiologies regarding survival and freedom from rehospitalization due to heart failure at the 1-year follow-up.

Transcatheter treatment of chronic mitral regurgitation with the MitraClip system: an Italian consensus statement.

New percutaneous technologies are rapidly emerging for the treatment of structural heart disease including mitral valve disease. Preliminary data suggest a potential clinical benefit of percutaneous treatment of mitral regurgitation by the MitraClip procedure in selected patients. Until final data are available from randomized, controlled, multicenter clinical trials, there is an urgent need for a consensus among all the operators involved in the treatment of patients with mitral regurgitation, including clinical cardiologists, heart failure specialists, surgeons, interventional cardiologists, and imaging experts. In the absence of evidence-based guidelines, the heart-team approach is the most reliable method of making proper decisions. This study is the result of multidisciplinary consensus activity, and has the aim of helping physicians in the difficult task of making decisions for the treatment of patients with mitral regurgitation. It is the result of a joint effort of the major Italian Cardiology and Cardiac Surgery Societies, working together to find a proper balance between the points of view of the clinical cardiologist, the interventional cardiologist, and the cardiac surgeon.

Cardiovascular magnetic resonance for the assessment of patients undergoing transcatheter aortic valve implantation: a pilot study.

BACKGROUND: Before trans-catheter aortic valve implantation (TAVI), assessment of cardiac function and accurate measurement of the aortic root are key to determine the correct size and type of the prosthesis. The aim of this study was to compare cardiovascular magnetic resonance (CMR) and trans-thoracic echocardiography (TTE) for the assessment of aortic valve measurements and left ventricular function in high-risk elderly patients submitted to TAVI. METHODS: Consecutive patients with severe aortic stenosis and contraindications for surgical aortic valve replacement were screened from April 2009 to January 2011 and imaged with TTE and CMR. RESULTS: Patients who underwent both TTE and CMR (n = 49) had a mean age of 80.8 ± 4.8 years and a mean logistic EuroSCORE of 14.9 ± 9.3%. There was a good correlation between TTE and CMR in terms of annulus size (R2 = 0.48, p < 0.001), left ventricular outflow tract (LVOT) diameter (R2 = 0.62, p < 0.001) and left ventricular ejection fraction (LVEF) (R2 = 0.47, p < 0.001) and a moderate correlation in terms of aortic valve area (AVA) (R2 = 0.24, p < 0.001). CMR generally tended to report larger values than TTE for all measurements. The Bland-Altman test indicated that the 95% limits of agreement between TTE and CMR ranged from -5.6 mm to + 1.0 mm for annulus size, from -0.45 mm to + 0.25 mm for LVOT, from -0.45 mm2 to + 0.25 mm2 for AVA and from -29.2% to 13.2% for LVEF. CONCLUSIONS: In elderly patients candidates to TAVI, CMR represents a viable complement to transthoracic echocardiography.

Clinical pharmacotherapy and drug development for pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a rare, but serious condition which, if untreated, is associated with a poor survival. Currently, even if several trials have led to the approval of many drugs for PAH, there is no established cure for this disease. However, approved drugs for PAH have contributed to significantly improve symptoms, exercise capacity, quality of life and survival of these patients. The aim of this review is to overview the standard treatment of PAH and to give some insights about new treatments that are currently under investigation along with the discussion of recent patents.

Long-term outcomes of bifurcation lesions after implantation of drug-eluting stents with the "mini-crush technique".

OBJECTIVES: To evaluate clinical and angiographic long-term outcome of "the mini-crush" technique for treating bifurcation lesions. BACKGROUND: Despite proven efficacy of drug-eluting stent (DES) within most lesions subsets, bifurcation lesions continue to exhibit high restenosis rate using current DES stenting technique. METHODS: We report a new stenting technique which was employed in 45 consecutive patients (52 lesions) between April 2004 and July 2005 to treat true bifurcation lesions using DES in both branches. RESULTS: Using this technique procedural success was obtained in 100% of cases, without complications and with excellent angiographic result in 96.1% and 98.1% of main vessel and side branch. Preprocedure reference vessel diameter and minimal lumen diameter (MLD) were 2.68 +/- 0.48 and 0.90 +/- 0.55 mm for the main branch, respectively and 2.28 +/- 0.34 and 1.14 +/- 0.47 mm for the side branch, respectively. Postprocedure MLD was 2.56 +/- 0.39 mm for the main branch and 2.16 +/- 0.29 mm for the side branch. There were no in-hospital major adverse cardiac events (MACE). At 72 days after procedure there was one case of side branch stent thrombosis (2.2%), which resulted in non Q-wave MI. Angiographic follow up was obtained in 100% of patients at 7.5 +/- 1.3 months. Target lesion revascularization (TLR) was 12.2%; no death and Q-wave MI were observed; reference vessel diameter and MLD for the main branch were 2.79 +/- 0.51 and 1.99 +/- 0.65 mm respectively and for the side branch 2.28 +/- 0.40 and 1.63 +/- 0.48 mm respectively. Restenosis rate in the main branch was 12.2% while in the side branch was 2.0%. CONCLUSIONS: In-hospital outcome indicates that the mini-crush technique for bifurcation lesions with DES can be easily performed. It provides very low total MACE rate and restenosis at 8-month follow-up. These results confirmed the advantage of this specific technique to give complete coverage of the ostium of the side branch using two stents technique.