Exercise electrocardiogram for risk-based screening of severe residual coronary lesion in children after coronary surgery.

BACKGROUND: Residual severe coronary artery (CA) lesion (SCL) in children after cardiac surgery involving the CA is a major concern. AIM: To evaluate the value of exercise electrocardiogram (eECG) for risk-based screening of SCL. METHODS: We analysed 135 maximal eECG from 115 children (mean age 13.6±3.7 years) who underwent concomitant CA imaging. SCL was defined as a stenosis exceeding 50%. RESULTS: Underlying congenital heart diseases were transposition of the great arteries (TGA) (n = 116), CA pathway anomaly (n = 13) and left CA from the pulmonary artery (n = 6). Eleven SCLs were identified in 10 patients, of which 3 had a known untreated non-severe lesion and 4 had no lesions on previous imaging. In multivariable analysis, risks markers for SCL were effort chest pain (OR: 4.72, 95% CI: 1.23-18.17; P=0.024), intramural pathway (OR: 4.37, 95% CI: 1.14-16.81; P=0.032). Yacoubs C-type CA was added as a risk marker for patients with TGA (P=0.0009). All patients with SCL had a positive eECG (sensitivity: 100%, 95% CI: 72-100). Specificity was 81% (95% CI: 73-87). In the low-risk group (0 risk markers), 3/95 patients had SCL (3%), and the post-test probability of SCL with positive eECG (PPr+) was 15% (95% CI: 8-21). In the high-risk group (≥1 risk marker) comprising 8/40 SCLs (20%), PPr+ was 53% (95% CI: 35-67). CONCLUSIONS: Most SCL tended to develop gradually, years after surgery. Provided it is near maximal, a negative eECG appears sufficient to exclude SCL. In the high-risk group, PPr+ exceeded 50%.

[Rotational atherectomy (Rotablator®) : complementary technique in management of undilatable coronary lesions]. / Athérectomie rotationnelle (Rotablator®) : technique complémentaire dans la prise en charge des lésions coronaires indilatables.

In 40 years of existence, interventional cardiology has witnessed the introduction of numerous tools and techniques that have contributed to the important application's broadening of percutaneous techniques, particulary in anatomical situations previously unfavourable, and which were, at that time, subject to surgical revascularization. Among these hostiles situations, one of the principal consists in failure to adequately dilate the lesions and/or to the inability to deliver and implant a stent appropriately, situations frequently associated with a high rate of procedural complications and poor long-term clinical outcomes. Thanks to the development of complementary dedicated techniques such atherectomy device, the treatment of most fibrotic and heavily calcified lesions has become feasible and safe. The present article describes the rotational atherectomy procedure, its indications and its clinical results.

En 40 ans d'existence, la cardiologie interventionnelle a vu émerger l'introduction d'un nombre important d'outils et de techniques qui ont contribué à l'élargissement de l'application des interventions percutanées dans des situations anatomiques initialement non favorables et qui constituaient, à ce moment-là, des indications de revascularisation chirurgicale. Parmi ces situations hostiles, une des principales est représentée par la difficulté de dilater, de manière adéquate, les lésions coronaires et/ou par l'impossibilité d'implanter, de manière appropriée, un stent au site traité. Ces deux situations sont associées à des hauts taux de complications procédurales et à une évolution clinique à long terme défavorable. Grâce au développement de techniques complémentaires, telle que l'athérectomie rotationnelle, le traitement de la plupart des lésions fibreuses ou très calcifiées est devenu actuellement possible et ce, en toute sécurité. Le présent article décrit la technique d'athérectomie rotationnelle, ses indications et ses résultats cliniques.

Resultados a mediano plazo del implante de stents imbricados en pacientes con infarto con supradesnivel del ST: el rol de los stents medicados / Midterm results of overlapping stents implantation in patients with ST elevation myocardial infarction

Resumen: Introducción: El implante de dos stents imbricados (SIMB) es una práctica frecuente en el laboratorio de hemodinamia. Sin embargo, evidencia reciente sugiere que en pacientes con infarto con supradesnivel del segmento ST (IAMc/SDST) esta técnica puede asociarse a mejores resultados cuando se utilizan exclusivamente stents medicados. Objetivo: Evaluar en una cohorte de pacientes chilenos las causas, características clínicas y sobrevida a 2 años de los pacientes con IAMc/SDST que son tratados con SIMB, en función del tipo de dispositivo y combinación utilizada; metálico/metálico (BMS/BMS), metálico/medicado (BMS/DES), medicado/medicado (DES/DES). Método: Se realizó un estudio prospectivo, caso incidente, entre enero del año 2012 y mayo del año 2016 en nuestro laboratorio de hemodinamia. Se recolectó la información clínica, angiográfica y sobrevida a 2 años de los pacientes ingresados por IAMc/SDST que fueron tratados con SIMB. Para el análisis estadístico se utilizó chicuadrado, regresión logística y análisis multivariado en programa SPSS, considerando significativa una p<0,05. Resultados: De 2403 pacientes evaluados, el 13% (n=312) recibió tratamiento con SIMB. La edad pro-medio fue de 68 ± 6,6 años y el 71% correspondió a hombres. La presencia de DMII fue de 37%, HTA 65%, tabaquismo 41%, dislipidemia 29% y cardiopatía coronaria previa 18%. Se observó que la fracción de eyección promedio fue de 45 ± 3,5%, medida por método de Simpson. Las causas para imbricar stents fueron la disección post implante de stent en 72%, desplazamiento de placa en 22,5% y extensión de placa más allá de la longitud del stent en un 5,5%. El 38% fue tratado con 2 stents BMS, el 26% con stents BMS/DES y el 36% con DES/DES. El diámetro y largo promedio de SIMB fue de 2,8 ± 2,6 mm y 41,3 ± 6,4 mm, respectivamente. Se observó una mortalidad a 2 años de 11% en el grupo BMS/BMS, 8% BMS/DES y 6% DES/DES (p<0,01) y la necesidad de revascularización fue 8%, 5,2% y 2% respectivamente (p=0,02). El usar la combinación BMS/ BMS se asoció a una mayor mortalidad a 2 años en análisis de regresión logística univariado (OR 5,2, IC 95% 2,0-17,9, p<0,01) y multivariado (ajustado por variables clínicas, número de vasos enfermos y presentación clínica) [OR 5,5, IC 95% 1,9-21,0, p<0,01]). Excluyendo a los pacientes con mortalidad temprana, como marcador de severidad de presentación clínica, la mortalidad a 2 años en el grupo BMS/BMS tuvo un OR de 5.9, 95% CI 2.1- 19.5 (p < 0.01). No se observó diferencia en la mortalidad de pacientes tratados con 2 SIMB DES/DES y los tratados con 1 stent DES. Conclusión: El implantar stents imbricados en pacientes con IAMc/SDST es una práctica común en el laboratorio de hemodinamia. Nuestros resultados sugieren que los resultados a mediano plazo son significativamente mejores cuando al menos uno de los stents utilizados es medicado, lo cual es concordante con reportes recientes.

Abstracts: Background: Coronary angioplasty using two overlapping (OL) stents is a frequent practice at the cath laboratory, however the impact this strategy has on patient prognosis and the preferred stent type are largely unknown. Aim: To evaluate 2-year outcomes of STEMI patients who underwent treatment with OL stents and assess the impact of different types of stents combinations:(BMS/BMS), (BMS/DES), or (DES/DES). Methods: Patients presenting with STEMI undergoing primary angioplasty with 2 OL stents between January 2012 to May 2016 were included. Baseline and procedural information was collected, clinically-driven new revascularizations were recorded, and 2-year survival status was confirmed from the national database registry. OL stents technique was defined as a segment with a double layer of stents of at least 1 mm and less than 5 mm long. Statistical analyses were performed with SPSS v21.0 (IBM, Armonk, NY, USA), at with p<=0.05 being considered significant. Results: Of 2403 STEMI patients treated within this period, in 312 (13%) the OL was used. Mean age was 68 ± 6.6 years. 71% males. Type 2 diabetesmellitus was present in 37%, arterial hypertension in 65%, smoking in 41%, dyslipidemia in 29% and previously treated coronary heart disease (either CABG or PCI) in 18% of patients. Mean left ventricular ejection fraction (LVEF) as assessed by 2D Simpson method was 48±3.5%. Indications for overlapping stents were plaque extension in 72%, edge dissection after stent implantation in 22.5%, and plaque displacement in 5.5%. One, 2 or 3 vessels disease was present in 23%, 34% and 43%, respectively. Thirty-eight percent of patients were treated with 2 BMS stents, 26% with BMS/DES stents and 36% with two DES stents. The mean stent diameter and length were 2.8 ± 2.6 mm and 41.3 ± 6.4 mm, respectively, with no difference between the 3 groups. Post procedure target vessel revascularization was 8% for BMS/BMS, 5.2% for BMS/DES and 2% for DES/DES groups (p=0.02). Two-year cardiovascular mortality was 11% for the BMS/BMS group, 8% for the BMS/DES group and 6% for the DES/DES (p <0.01). BMS/BMS combination was associated with a greater cardiovascular 2-year mortality in both univariate (OR 5.2, 95% CI 2.0-17.9, p <0.01) and multivariate analyses ([OR 5.5, 95% CI 1.9-21.0, p <0.01]). After excluding early mortality cases during the first week (due to their overall severity at presentation), 2-year cardiovascular mortality in the BMS/BMS group had an adjusted OR of 5.9, 95% CI 2.1-19.5 (p< 0.01). There were no differences between the treatment with 2 OL DES stents and the treatment with BMS/DES. Conclusion: Overlapping stent technique is a common practice in our cath lab, mainly driven by an initial unfavorable result with the first stent. The reported findings suggest that midterm results are better when at least on of the imbricated stents is These results are in agreement with recent reports on the subject.

Self-expanding STENTYS stents in daily routine use.

BACKGROUND: In the era of modern interventional cardiology, implantation of a balloon expandable stent is the finishing touch of almost every coronary angioplasty. However, sometimes we face a clinical situation in which the decision regarding the stent diameter is complicated, especially in the ectatic part of arteries, in situations when the artery lumen is obscured with the thrombus, or when the reference diameter of the proximal and distal part of the lesion vary greatly. That is why the idea of a self-apposing stent similar to the one used in peripheral vascular interventions was adopted into cardiology. AIM: The aim of this study was to present a single-centre registry of STENTYS® stent implantation in 40 selected patients with acute coronary syndromes (ACS) or with stable angina (coronary artery disease [CAD]) treated with this self-expandable stent. METHODS AND RESULTS: The device was successfully implanted in all patients. During in-hospital observation and 30-day follow-up there were two cases of death, but none of the patients had acute stent thrombosis or ACS ST elevation myocardial infarction. In one case ACS type 4b was diagnosed. In all patients the stent was delivered in the target lesion. In two cases the procedure was performed in patients with multivessel CAD extending into the left main stem in a state of cardiogenic shock. These patients died immediately after the procedure. There were two procedure complications: in one case dissection after post dilatation occurred distally to the stent, and in one patient the calcified proximal part of the left anterior descending artery was dissected with system passage. Thirty-eight patients survived the 12-month follow-up period, and three (7.8%) patients underwent repeated target-lesion revascularisation. CONCLUSIONS: In the presented single-centre registry the STENTYS® stent was used with a high delivery and procedural success rate. Satisfactory clinical long-term outcome both in stable patients and ACS patients with a repeated revascularisation ratio of 7.8% was observed. The stent design allowed successful treatment of bifurcation lesions.

Association between mobilization of circulating endothelial progenitor cells and time or degree of injury from angioplasty in patients with exertional angina: A prospective study.

The aim of the present study was to investigate the effect of coronary artery angioplasty on the recruitment of circulating endothelial progenitor cells (EPCs) in patients with angina pectoris. A total of 66 patients treated by coronary stenting were enrolled in the PCI group and 17 patients that underwent angiography alone were enrolled in the control group. The EPC count in the blood was measured by flow cytometry prior to and at 1, 3, 5, 7 and 24 h following angioplasty in the percutaneous coronary intervention (PCI) group, and at three time-points following angiography in the control group. Differences between the two groups included the characteristics of the coronary artery lesions, the incidence of diabetes and family history of coronary heart disease. The mean surface area of the stent deployed was 335.59±234.99 mm2. No significant change in EPC count was measured in the control group. In the PCI group, a moderate and delayed increase in the number of cluster of differentiation (CD)34+/kinase domain receptor (KDR)+ EPCs occurred at 24 h post-balloon inflation compared with the baseline level. The CD133-/CD34+/KDR+ subpopulations showed undulating changes at 3, 7 and 24 h post-PCI (P=0.016, P=0.01 and P=0.032, respectively). An arch shape was displayed in CD133+/KDR+ cells; initially, a reduction occurred at 3 h and was maintained constantly until 7 h (P=0.003, P=0.013 and P=0.033 at 3, 5 and 7 h, respectively), after which a slight increase to the baseline level occurred at 24 h (P=0.084). The CD133+/CD34+ cells increased in stepwise manner until 24 h. The CD34+/KDR+ EPC change magnitude correlated significantly with a global damage index by partial correlation analysis (P<0.001). The results suggested that a time-dependent mobilization of EPCs may be initiated by PCI; the change magnitude of the CD34+/KDR+ cells was associated particularly with endothelial injury degree from the PCI procedure.

Effect of oral sirolimus therapy on inflammatory biomarkers following coronary stenting

We studied the effect of oral sirolimus, administered to prevent and treat in-stent restenosis (ISR), on the variation of serum levels of inflammatory markers following coronary stenting with bare metal stents. The mean age of the patients was 56 ± 13 years, 65 percent were males and all had clinically manifested ischemia. Serum levels of high sensitivity C-reactive protein (hs-CRP) concentration were determined by chemiluminescence and serum levels of all other biomarkers by ELISA. One group of patients at high risk for ISR received a loading oral dose of 15 mg sirolimus and 5 mg daily thereafter for 28 days after stenting (SIR-G). A control group (CONT-G) was submitted to stenting without sirolimus therapy. The increase in hs-CRP concentration was highest at 24 h after stenting in both groups. A significant difference between SIR-G and CONT-G was observed at 4 weeks (-1.50 ± 5.0 vs -0.19 ± 0.4, P = 0.008) and lost significance 1 month after sirolimus discontinuation (-1.73 ± 4.3 vs -0.01 ± 0.7, P = 0.0975). A continuous fall in MMP-9 concentration was observed in SIR-G, with the greatest reduction at 4 weeks (-352.9 ± 455 vs +395.2 ± 377, P = 0.0004), while a positive variation was noted 4 weeks after sirolimus discontinuation (227 ± 708 vs 406.2 ± 472.1, P = 0.0958). SIR-G exhibited a higher increase in P-selectin after sirolimus discontinuation at week 8 (46.1 ± 67.9 vs 5.8 ± 23.7, P = 0.0025). These findings suggest that the anti-restenotic actions of systemic sirolimus include anti-proliferative effects and modulation of the inflammatory response with inhibition of adhesion molecule expression.

Effect of polydanshinolate on myocardial reperfusion after percutaneous coronary interventions in patients with acute myocardial infarction / 中国综合临床

Objective To compare the effect of percutaneons coronary interventions (PCI) combined with polydanshinolate on myocardial reperfusion with PCI combined with regular medicine in patients with acute myocardi-al infrarction ,and whether polydanshinolate would decrease no-reflow,improve the myocardial micro-circulation and the ventricular remodeling and clinical end-point events at the sixth month. Methods Random,parallel control and prospective clinical design was used in the current study. Sixty eligible patients for PCI, who were diagnosed as first-time acute myocardial infrarction with ST stage increasing,were recruited in the study with informed consent. All par-ticipants were divided into two groups randomly. Group A was treated with PCI combined with polydanshinolate, group B was treated with PCI combined with regular medicine. The participants were followed up for six months. The resolution of the sum of ST segment elevation (sum STR) ,corrected TIMI frame count (CTFC) and myocardial con-trast echocardiography (MCE) were used to assess myocardial perfusion. Bleeding events, heart function and major adverse cardiac events (MACE) were observed during hospitalization and follow-up visit. Results No significant difference was observed between two groups on the clinical condition and the results of emergency CAG and PCI. Compared to group B,the incidence of TIMI grade 3 was significantly higher in group A (90.0% vs 63.3% ,χ~2 = 4.565, P=0.0326). Sum STR one hour after PCI in group A was siguificanfly higher than that in group B (80.0% vs 50.0%, χ~2=4.689, P=0.0304). CTFC after PCI also differed significantly between the two groups (24.1±8.3 vs 33.4±15.9 respectively,P=0.0062). Localized myocardial blood flow 48 hours after PCI showed no significant difference between the two groups (P>0.05), whereas both increased at the 7th day after PCI (5.85±1.26 vs 2.09±1.85,t=9.2008,P<0.0001 ;3.95±1.35 vs 1.95±1.29,t=5.8666,P<0.0001) ,and there were signifi-cant difference between the two groups (P<0.05). No significant difference of LVEF, LVEDV, LVESV were found between the two groups during the hospitalization and follow-up visit after 6 months (P>0.05). The incidences of cardiovascular events and severe heart failure during hospitalization and follow-up visit in group A were significantly lower than that in group B (P<0.05 ). Conclusions Polydanshinolate addition to PCI could reduce no reflow phe-nomenan in patients of acute myocardial infrarction, improve myocardial reperfusion, and furthermore, decrease cardi-ovascular events and ameliorate prognosis.