Pre-discharge 18F-Flourodeoxyglucose uptake pattern following transcatheter aortic-valve replacement and adverse prognostic features in aortic stenosis.

18F-Flourodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) has been shown to be of utility in transcatheter aortic valve replacement (TAVR) patients with suspected prosthetic valve endocarditis. In the present study, we sought to analyze the relationship between 18F-FDG-PET/CT performed before discharge in TAVR patients and adverse prognostic features of aortic stenosis. We analyzed the association between 18F-FDG-PET/CT uptake pattern and degree of left ventricular mass index, aortic root dilatation, and aortic leaflet calcification extent. This is the first study to demonstrate that pre-discharge 18F-FDG-PET/CT in patients undergoing TAVR shows a significant negative correlation between 18F-FDG uptake pattern and adverse prognostic features.

Native aortic leaflets and permanent pacemaker implantation risk following balloon-expandable transcatheter aortic valve implantation.

OBJECTIVE: Permanent pacemaker implantation (PPI) risk is higher following transcatheter aortic valve implantation (TAVI) than surgical valve replacement. Native aortic leaflets are retained in patients undergoing TAVI, unlike in surgical valve replacement. Whether the retained leaflets influence PPI risk because of their proximity to the conduction system is unknown. The study sought to determine the association between infra-annular extension of native right coronary cusp/noncoronary cusp (RCC/NCC) post balloon-expandable TAVI and PPI risk. METHODS: We performed a retrospective analysis of 190 patients undergoing balloon-expandable TAVI at a single center. Manifestation of infra-annular extension of RCC/NCC was considered to be present when part of leaflet extended below aortic-annular plane on post-implantation aortic-root angiography. RESULTS: Infra-annular extension of RCC/NCC was observed in 33 patients (17.37%). PPI incidence post-TAVI was higher in patients with infra-annular extension of RCC/NCC than in those without (36.36% versus 8.92%, relative-risk: 4.08, p˂0.0001). On logistic-regression analysis, preexisting right bundle-branch block (RBBB) (odds-ratio: 12.73, 95% confidence-interval: 2.16-74.93, p = 0.005), and infra-annular extension of RCC/NCC (odds-ratio: 5.63, 95% confidence-interval: 2.17-14.58, p < 0.0001) were independently associated with PPI risk. Preexisting RBBB (φ = +0.25, p = 0.001) and infra-annular extension of RCC/NCC (φ = +0.30, p < 0.0001) showed a positive-correlation with PPI risk. Infra-annular extension of RCC/NCC was a significant predictor of PPI risk on receiver-operating-characteristic curve analysis (area under-the-curve 0.67; 95% confidence-interval: 0.54-0.79, p = 0.006). CONCLUSION: The retained native aortic leaflets play a significant role in PPI risk following balloon-expandable TAVI. Infra-annular extension of RCC/NCC is a novel predictor, and is associated with a four-fold higher risk of PPI.

Coronary artery bypass graft in an isolated single coronary ostium with triple vessel disease.

Single coronary artery (SCA) is a rare congenital anomaly whereby only one coronary artery arises from single coronary artery ostium of the aortic trunk and supplies the whole heart. The incidence of this anomaly is 0.0024-0.066% in patients undergoing coronary angiography. It is usually an isolated anomaly and majority of patients are picked up incidentally. Lipton classification is widely used to classify this anomaly. Most cases are detected by computerized tomography and/or coronary angiography and are treated medically. Here, we present a rare case of type RII-B in which the patient underwent coronary artery bypass graft for severe triple vessel disease presenting as acute myocardial infarction.

Mechanical circulatory support with Impella in percutaneous coronary intervention: current status.

In patients with, or at risk of, hemodynamic instability during percutaneous coronary intervention, maintaining perfusion of vital organs is crucial. The intra-aortic balloon pump and Impella are the two most commonly used percutaneous mechanical circulatory support devices. Intra-aortic balloon pump has been in widespread use for over three decades. Mechanical circulatory support with Impella is being used increasingly often in patients with acute myocardial infarction complicated by cardiogenic shock, and in those undergoing high-risk percutaneous coronary intervention. Besides improving cardiac output and coronary perfusion, Impella has potential myocardial protective effects. Three key measures that determine the clinical utility of a device are clinical outcome, device-related complications, and cost impact. In this review, the current data on use of Impella in patients with acute myocardial infarction complicated by cardiogenic shock, in left ventricular unloading in acute myocardial infarction, and in those undergoing high-risk percutaneous coronary intervention is analyzed.

Endogenous fibrinolysis inhibitors in acute coronary syndrome.

Patients with acute coronary syndrome have a high residual risk of ischemic events despite current treatment methods, both invasive and antithrombotic strategies. The strategy of very early revascularization although has been suggested to improve patient outcome, remains associated with a high residual risk of adverse events. Stenting of nonflow-limiting vulnerable plaques in addition to stenting of hemodynamically significant lesions in patients with acute coronary syndrome, has not shown a beneficial effect on major adverse cardiovascular events in early studies. Current antithrombotic therapy in acute coronary syndrome is focused mainly on antiplatelet agents, and to a lesser extent on oral anticoagulants. Besides thrombotic atherosclerotic plaque rupture and activated platelets, impaired fibrinolysis has gained attention as a strong independent risk factor for cardiovascular mortality and adverse outcome in patients with acute coronary syndrome. Various endogenous fibrinolysis inhibitors that act at different levels of the hemostatic process have been associated with the impaired fibrinolysis. This review presents available data for association of impaired fibrinolysis with major adverse cardiovascular outcome in acute coronary syndrome, and the potential role of endogenous fibrinolysis inhibitors in acute coronary syndrome. In addition, experimental evidence for modulation of impaired fibrinolytic state with profibrinolytic agents that target endogenous fibrinolysis inhibitors is summarized.

Local delivery of 17beta-estradiol improves reendothelialization and decreases inflammation after coronary stenting in a porcine model.

In the current study, we investigated the effect of local intravascular delivery of 17beta-estradiol (17beta-E) on subsequent in-stent neointimal hyperplasia. Twenty-seven stents were implanted in coronary arteries of juvenile swine. Coronary arteries were randomized to local treatment with 17beta-E or no drug therapy (control-vehicle treated). Twenty-eight days post-treatment, angiographic images revealed an improved minimal lumen diameter (2.2 +/- 0.2 vs. 1.3 +/- 0.2 mm, P < 0.005) and a reduction of late lumen loss (1.7 +/- 0.2 vs. 2.3 +/- 0.1 mm, P < 0.01) in 17beta-E-treated vessels compared to control-vehicle treated. Histological analyses showed a reduction of stenosis (51.49 +/- 6.75 vs. 70.86 +/- 6.24%, P < 0.05), mean neointimal thickness (0.51 +/- 0.07 vs. 0.83 +/- 0.14 mm, P < 0.05) and inflammation score (1.29 +/- 0.28 vs. 2.85 +/- 0.40, P < 0.05) in 17beta-E-treated arteries compared to control-vehicle treated arteries. Immunohistochemistry analyses revealed a reduction of proliferating smooth muscle cells and increased in-stent reendothelialization in 17beta-E-treated arteries. Finally, we observed a correlation between neointimal hyperplasia and inflammation score, which in turn, was inversely related to reendothelialization. Locally delivered, 17beta-E is inhibiting the inflammatory response and smooth muscle cells proliferation and improving vascular reendothelialization which together are contributing to reduce in-stent restenosis in a porcine coronary injury model. Together, these data demonstrate the potential clinical application of 17beta-estradiol to improve vascular healing and prevent in-stent restenosis.

17beta-estradiol and restenosis: a novel vaso-protective role for estrogen?

Restenosis is the major limitation of percutaneous transluminal coronary angioplasty. Several therapies to prevent restenosis, pharmacological and non-pharmacological, have shown favorable results in experiments, and a few in clinical trials. Evidence is accumulating that 17beta-estradiol, the predominant circulating form of estrogen in premenopausal women, inhibits neointimal formation following arterial injury. Evidence demonstrating the ability of estrogen to suppress neointimal formation and underlying mechanisms are reviewed.