Diagnostic performance of quantitative flow ratio in non-ST elevation acute coronary syndromes in comparison to non-hyperemic pressure ratios: a prospective study.

Quantitative flow ratio (QFR) is a new angiography-based coronary physiology tool aimed to evaluate functional relevance of intermediate coronary lesions. Aim of the study is to assess diagnostic performance of QFR in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in comparison to currently used non-hyperaemic pressure ratios (NHPRs). In this prospective, single-centre study, coronary physiology of intermediate coronary stenoses of non-culprit vessels in patients presenting with NSTE-ACS was evaluated using NHPRs (iFR, DFR or RFR). Subsequently, QFR was computed offline by a QFR analyst blinded to the NHPR results. Diagnostic performance of QFR was assessed in comparison to NHPRs as reference standard. A total of 60 vessels with intermediate coronary stenoses was investigated. The NHPRs were used as follows: RFR 38%, DFR 47% and iFR 15% of the cases. The NHPR result was positive, showing significant lesion, in 19 cases. A significant correlation was found between NHPR and QFR (r = 0.84, p < 0.001). Classification agreement of the two methods (95%) and diagnostic performance of QFR in comparison to NHPR (AUC: 0.962 [0.914-1.00]) were both high. Sensitivity, specificity, positive and negative predictive value of QFR in comparison to NHPR were 84.2%, 100%, 100% and 93.2% respectively. QFR has high diagnostic performance in detecting functionally significant lesions of non-culprit arteries in patients with NSTE-ACS and multivessel disease. Due to its high negative predictive value, it can be used to safely avoid unnecessary invasive physiological assessment of these lesions.

"Missing" acute coronary syndrome hospitalizations during the COVID-19 era in Greece: Medical care avoidance combined with a true reduction in incidence?

BACKGROUND: Reports from countries severely hit by the COVID-19 pandemic suggest a decline in acute coronary syndrome (ACS)-related hospitalizations. The generalizability of this observation on ACS admissions and possible related causes in countries with low COVID-19 incidence are not known. HYPOTHESIS: ACS admissions were reduced in a country spared by COVID-19. METHODS: We conducted a nationwide study on the incidence rates of ACS-related admissions during a 6-week period of the COVID-19 outbreak and the corresponding control period in 2019 in Greece, a country with strict social measures, low COVID-19 incidence, and no excess in mortality. RESULTS: ACS admissions in the COVID-19 (n = 771) compared with the control (n = 1077) period were reduced overall (incidence rate ratio [IRR]: 0.72, P < .001) and for each ACS type (ST-segment elevation myocardial infarction [STEMI]: IRR: 0.76, P = .001; non-STEMI: IRR: 0.74, P < .001; and unstable angina [UA]: IRR: 0.63, P = .002). The decrease in STEMI admissions was stable throughout the COVID-19 period (temporal correlation; R2 = 0.11, P = .53), whereas there was a gradual decline in non-STEMI/UA admissions (R2 = 0.75, P = .026) following the progressively stricter social measures. During the COVID-19 period, patients admitted with ACS presented more frequently with left ventricular systolic impairment (22.2 vs 15.5% control period; P < .001). CONCLUSIONS: We observed a reduction in ACS hospitalizations during the COVID-19 outbreak in a country with strict social measures, low community transmission, and no excess in mortality. Medical care avoidance behavior is an important factor for these observations, while a true reduction of the ACS incidence due to self-isolation/quarantining may have also played a role.

Calcium Handling and Arrhythmogenesis.

Intracellular calcium homeostasis plays a fundamental role in the electric and mechanical function of the heart by modulating action potential pattern and duration, by linking cell membrane depolarization to myocardial contraction and by regulating cardiac automaticity. Abnormalities of intracellular calcium regulation disrupt the electrophysiological properties of the heart and create an arrhythmogenic milieu, which promotes atrial and ventricular arrhythmogenesis and impairs cardiac automaticity and atrioventricular conduction. In this brief review, we summarize the basic genetic, molecular and electrophysiological mechanisms linking inherited or acquired intracellular Ca(2+) dysregulation to arrhythmogenesis.

Clinical and echocardiographic correlates of serum copper and zinc in acute and chronic heart failure.

AIM: Emerging evidence suggests a pathophysiological role of micronutrient dyshomeostasis in heart failure, including promotion of adverse remodeling and clinical deterioration. We sought to evaluate serum copper (Cu) and zinc (Zn) levels in acute (AHF) and chronic (CHF) heart failure. METHODS: We studied 125 patients, 71 % male, aged 69 ± 11 years, 37 % with preserved left ventricular ejection fraction (LVEF ≥40 %) (HFPEF), including 81 with AHF and 44 with CHF; 21 healthy volunteers served as controls. Serum Cu and Zn levels were determined using air-acetylene flame atomic absorption spectrophotometry. RESULTS: Serum Cu levels were significantly higher in AHF (p = 0.006) and CHF (p = 0.002) patients compared to controls after adjusting for age, gender and comorbidities, whereas they did not differ between AHF and CHF (p = 0.840). Additionally, serum Cu in patients with LVEF <40 % was significantly higher compared to both controls (p < 0.001) and HFPEF patients (p = 0.003). Serum Zn was significantly lower in AHF (p < 0.001) and CHF (p = 0.039) compared to control after adjusting for the above-mentioned variables. Moreover, serum Zn was significantly lower in AHF than in CHF (p = 0.015). In multiple linear regression, LVEF (p = 0.033) and E/e ratio (p = 0.006) were independent predictors of serum Cu in total heart failure population, while NYHA class (p < 0.001) and E/e ratio (p = 0.007) were independent predictors of serum Zn. CONCLUSION: Serum Cu was increased both in AHF and CHF and correlated with LV systolic and diastolic function. Serum Zn, in contrast, was decreased both in AHF and CHF and independently predicted by clinical status and LV diastolic function.

Association of virtual histology characteristics of the culprit plaque with post-fibrinolysis flow restoration in ST-elevation myocardial infarction.

OBJECTIVES: We sought to test the hypothesis that virtual histology characteristics of the culprit lesion in patients with ST-elevation myocardial infarction are associated with blood flow restoration after thrombolysis. METHODS: Consecutive patients referred for coronary angiography after successful thrombolysis were included in this correlational cross-sectional study. Evaluation with intravascular ultrasound (IVUS) and virtual histology of the culprit arterial segment was performed in all cases. RESULTS: Forty-eight patients (60.5 ± 10.7 years) were included. TIMI flow grade 3 was found in 24 (50%). Diabetes was strongly associated with lower TIMI flow 3 rate (26.7% vs 60.6%; p = 0.029) and there was a significant difference in the time to thrombolysis (2.0 ± 0.8 hours in those with TIMI flow 3 vs 3.0 ± 0.7 hours in TIMI flow grades 1-2; p < 0.001). Patients with TIMI flow grades 3 and 1-2 had similar absolute total plaque volume (152.8 ± 59.3mm(3) vs 147.5 ± 92.3mm(3); p = 0.817) and absolute necrotic core (NC) volume (31.2 ± 13.9 mm(3) vs 33.6 ± 23.2mm(3); p = 0.671). However, there were significant differences in the relative NC content, both in proportion to the whole plaque volume (26.3% vs 29.9%; p = 0.016) and as an area fraction at the largest NC site (31.5% vs 40.3%; p < 0.001). CONCLUSION: The NC content of atherosclerotic plaques is meaningful for flow restoration after the occurrence of a coronary event. This finding highlights the importance of plaque composition, as studied with virtual histology, not only for the sequence of processes leading to an acute plaque-related event, but also for thrombus formation and lysis, following the occurrence of such an event.

Moderate procedural sedation and opioid analgesia during transradial coronary interventions to prevent spasm: a prospective randomized study.

OBJECTIVES: The aim of this study was to test the hypothesis that moderate procedural sedation can reduce the incidence of radial artery spasm. BACKGROUND: Transradial access for left heart catheterization and percutaneous coronary intervention is increasingly used for emergent and elective procedures, in lieu of the femoral approach. However, increased rates of access site crossover have been reported, with radial artery spasm being a major contributor to this effect. METHODS: Patients undergoing elective transradial percutaneous coronary intervention were prospectively randomized to receive fentanyl and midazolam during the procedure or no treatment (control subjects). The primary endpoint was angiographically confirmed radial artery spasm. Patient discomfort was quantified with a visual analogue scale. RESULTS: Two thousand thirteen patients (age 64.5 ± 8.4 years) were randomized. Spasm occurred in 2.6% of the treatment group versus 8.3% of control subjects (p < 0.001; odds ratio [OR]: 0.29). The number needed to treat to avoid 1 case of spasm was 18 (95% confidence interval [CI]: 12.9 to 26.6). The access site crossover rate was 34% lower in the treatment group: 9.9% versus 15.0% (OR: 0.62; 95% CI: 0.48 to 0.82). Patient discomfort visual analogue scale score was 18.8 ± 12.5 in the treatment group versus 27.4 ± 17.4 in control subjects (p < 0.001). No significant differences were observed in the 30-day rate of death or repeat hospital stay for any cause: 4.6% versus 4.5% (OR: 1.02; 95% CI: 0.67 to 1.56). CONCLUSIONS: Routine administration of relatively low doses of an opioid/benzodiazepine combination during transradial interventional procedures is associated with a substantial reduction in the rate of spasm, the need for access site crossover, and the procedure-related level of patient discomfort.

Congestión pulmonar en la insuficiencia cardiaca aguda: de la hemodinámica a la lesión pulmonar y la disfunción de la barrera alveolocapilar / Pulmonary congestion in acute heart failure: from hemodynamics to lung injury and barrier dysfunction

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Transradial access as first choice for primary percutaneous coronary interventions: experience from a tertiary hospital in Athens.

INTRODUCTION: The transfemoral approach (TFA) has been the mainstay for arterial access during percutaneous coronary intervention (PCI) in the setting of acute ST-segment elevation myocardial infarction (STEMI). However, the transradial approach (TRA) has been shown to be an equally effective and possibly safer way of performing primary PCI (pPCI). METHODS: The study population included 98 serially recruited patients who underwent pPCI in our institution. All patients were clinically followed during their hospital stay (6.4 ± 3.1 days). RESULTS: In the 98 patients included in the study, 65 procedures (66.3%) were completed via TRA, whereas the remaining 33 procedures (33.7%) used TFA. Door-to-balloon time was similar (57 ± 19 min vs. 54 ± 15 min, p=ns). Patients in the TRA group were mobilized sooner (28 ± 9 hours vs. 36 ± 13 hours, p<0.05). Hospital stay was significantly shorter in the TRA group (6.0 ± 3.2 days vs. 7.1 ± 2.8 days, p<0.05). TRA and TFA did not differ significantly as to the incidence of death, non-fatal myocardial infarction or subacute stent thrombosis, but major access-related vascular complications were significantly more frequent in the TFA group (2% vs. 15%, p<0.01). Cerebrovascular events did not differ between TRA and TFA. CONCLUSIONS: Compared to TFA, TRA seems to be associated with a lower incidence of bleeding complications, as well as earlier mobilization and discharge from hospital. It is conceivable that TRA could become the first choice in the treatment of STEMI patients in the near future, while TFA is kept as an alternative.

Successful surgical repair of mitral valve prolapse endocarditis: a case report and review of the current literature.

We present the case of a 42-year-old man with mitral valve prolapse (MVP) and infective endocarditis. He was referred to our hospital by his family physician for the evaluation of a cardiac murmur. A detailed medical history revealed that he had been feeling fatigue with occasional episodes of slight fever during the last two months. Echocardiography revealed MVP with a sizeable vegetation and severe mitral insufficiency. Serial blood cultures were positive for Streptococcus viridans, highly penicillin susceptible. He was put on appropriate antimicrobial therapy, but both the vegetation and the concomitant mitral insufficiency persisted after otherwise successful medical therapy. Thus, the patient underwent surgical vegetectomy with mitral valve repair. He had an uneventful postoperative course and remains free of disease at the 12-month follow up. Our case report reinforces the value of early diagnosis in the presence of a high clinical suspicion of MVP endocarditis. An extended clinical workup, including serial detailed echocardiography studies, is mandatory in such a patient. Medical treatment of infective endocarditis in the setting of MVP is often successful. However, cardiac surgical intervention plays an important role in the treatment of intracardiac complications. Mitral valve repair in the context of a healed and stable infective endocarditis is the treatment of choice.

Successful retrieval of a coronary stent dislodged in the brachial artery by means of improvised snare and guiding catheter.

This is a case report regarding the retrieval, by means of an improvised snare and guiding catheter, of a stent dislodged in the brachial artery during a transradial coronary intervention. A full-length guiding catheter could not be used to approach the lost stent, which was a mere 30 to 35 cm away from the sheath insertion site at the radial artery, and a commercial snare was not available at the time. Thus, we had to improvise a shortened guiding catheter and a snare, which was formed by folding an angioplasty Whisper guide wire (Abbott Laboratories, Abbott Park, IL) and was used successfully to snare the stent and retrieve it.

Comparison of muscle functional electrical stimulation to conventional bicycle exercise on endothelium and functional status indices in patients with heart failure.

The aim of this prospective, open-label, cohort study was to compare the effect of muscle functional electrical stimulation (FES) on endothelial function to that of conventional bicycle training. Eligible patients were those with New York Heart Association class II or III heart failure symptoms and ejection fractions ≤ 0.35. Two physical conditioning programs were delivered: FES of the muscles of the lower limbs and bicycle training, each lasting for 6 weeks, with a 6-week washout period between them. Brachial artery flow-mediated dilation (FMD) and other parameters were assessed before and after FES and the bicycle training program. FES resulted in a significant improvement in FMD, which increased from 5.9 ± 0.5% to 7.7 ± 0.5% (95% confidence interval for the difference 1.5% to 2.3%, p < 0.001). Bicycle training also resulted in a substantial improvement of endothelial function. FMD increased from 6.2 ± 0.4% to 9.2 ± 0.4% (95% confidence interval for the difference 2.5% to 3.5%, p < 0.001). FES was associated with a 41% relative increase in FMD, compared to 57% with bicycle exercise (95% confidence interval for the difference between the relative changes 1.2% to 30.5%, p = 0.034). This resulted in attaining a significantly higher FMD value after bicycle training compared to FES (9.2 ± 0.4% vs 7.7 ± 0.5%, p < 0.001). In conclusion, the effect of muscle FES in patients with heart failure on endothelial function, although not equivalent to that of conventional exercise, is substantial. Muscle FES protocols may prove very useful in the treatment of patients with heart failure who cannot or will not adhere to conventional exercise programs.

Clinical outcome and angiographic results with novel polysulfone polymer coating paclitaxel eluting stent in real-world clinical practice: a clinical centre registry.

BACKGROUND: The Intek-Apollo stent (Switzerland) employs a polysulfone polymer coating which has demonstrated low interaction with blood and high thrombo-resistance. The aim of this study was to assess the clinical and angiographic outcomes after Intek-Apollo stent utilisation in a real-world setting. MATERIAL/METHODS: A total of 130 patients (77.7% males) were enrolled with 174 lesions in native coronary arteries (92.4%), saphenous vein grafts (7.5%) and in-stent restenosis (6.3%). Indications for stenting were stable coronary artery disease (CAD) 52.3%, acute coronary syndrome (ACS) 37.7% and STEMI 10%. Clinical follow-up and coronary angiography (after symptoms occurrence or positive stress test) was performed at 6 and 12 months.The primary end points were target lesion revascularization (TLR) and target vessel revascularization (TVR), while secondary end points were major adverse cardiac events (MACE) during the follow-up period. RESULTS: The mean age of patients included was 61.62±11.13 years. Complex lesions treatment (ostial, bifurcation) reached 13.7%. Mean stenosis diameter was 83.52±10.5%. Reference vessel diameter was 2.85±0.39 mm with a mean lesion length of 14.66±4.5mm. Average stent size was 2.93±0.39mm × 16.6±4.73 mm. At 15±3 months, primary events included TLR (4.6%), TVR (4.6%) and MACE (2.3%). There was 1one myocardial infarction and no cardiac death). No incidence of early or late stent thrombosis was demonstrated. CONCLUSIONS: Intek-Apollo stent implantation is safe and efficient in a real world population. The unique properties of polysulfone polymer coating can effectively protect from late stent thrombosis and lead to reduced rates of TLR, TVR and MACE.

Sensitivity and specificity of sodium channel blocking test in the diagnosis of Brugada syndrome.

The ECG features of Brugada syndrome are dynamic and frequently concealed. Sodium channels blockers are widely used to unmask the Brugada electrocardiographic (ECG) pattern. The sensitivity and specificity of I(Na) channel blocking test varies significantly. A negative I(Na) blocking test does not exclude the presence of a SCN5A mutation, which is responsible for the phenotype of Brugada syndrome. Herein, we describe the case of a 65-years-old asymptomatic male who underwent a I(Na) channel blocking test, seven years ago due to a type 2 ECG pattern (saddleback configuration) which failed to induce the diagnostic type 1 ECG pattern. Diagnostic considerations at a molecular level and their clinical relevance are being discussed.

Potential-guided versus anatomic-guided approach for slow pathway ablation of the common type atrioventricular nodal reentry tachycardia: a randomized study.

OBJECTIVE: The present study aimed to compare the effectiveness and safety of the potential- and the anatomic-guided approach for slow pathway ablation in patients with recurrent episodes of symptomatic common type atrioventricular (AV) nodal reentrant tachycardia. METHODS: Two hundred and twenty-eight patients were randomly assigned to undergo either a potential- (n=114, 47% men, mean age 52.85 +/- 14.04 years) or an anatomic-guided approach (n=114, 50% men, mean age 52.45 +/- 14.46 years) for radiofrequency ablation of the slow pathway.The mean duration of the follow-up period was 26.7 +/- 7.9 and 24.8 +/- 7.6 months in the potential- and anatomic- guided approach, respectively (P > 0.05). RESULTS: The success rate for slow pathway ablation was 100% in both ablative methods.The mean duration of atrial electrograms at the successful ablation sites of the potential- and the anatomic-guided approaches was 69 +/- 14 msec and 57 +/- 10 msec, respectively (P = 0.001).There were no significant differences between the potential- and the anatomic-guided approach regarding the duration of the procedure (121.13 +/- 56.83 vs. 109.93 +/- 57.12 min, P = 0.139), the duration of fluoroscopic exposure (6.12 +/- 3.32 vs. 6.64 +/- 3.33 min, P = 0.239) or the mean number of radiofrequency applications delivered (3.96 +/- 2.77 vs. 4.33 +/- 2.73, P = 0.311). Residual dual AV nodal pathway following successful ablation was observed in 9.6% of patients who underwent the potential-guided approach and in 23.7% of patients who underwent the anatomic method (P = 0.004). During followup, arrhythmia recurrence was observed in four patients (1.8%), two in each group (P > 0.05). CONCLUSIONS: The efficacy and safety of the slow pathway ablation is very high using either the potential- or the anatomic-guided approach.

Wide QRS complex supraventricular tachycardia with negative precordial concordance.

The authors describe the case of a 49-year-old man who experienced an episode of palpitations and dizziness. The results of 24-hour Holter monitoring demonstrated an episode of wide QRS complex regular tachycardia. During the electrophysiological study, a wide QRS complex tachycardia with negative precordial concordance was induced. A diagnosis of orthodromic atrioventricular re-entrant tachycardia involving a left lateral accessory pathway with left bundle branch aberration was made. This case represents a rare exception to the rule that negative precordial QRS concordance is diagnostic of ventricular tachycardia.