Trends and outcomes of optical coherence tomography use: 877 patients single-center experience.

BACKGROUND: Optical-coherence-tomography (OCT) is an emerging invasive coronary imaging with still undefined clinical value. Recent data have underlined daily impact of such technique in several clinical settings such as acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI) guidance. We aimed at assessing the trends and outcomes of OCT use in a high-volume percutaneous coronary interventions (PCI)-center. METHODS: Over 6 years, 1025 coronary artery segments in 877 patients underwent OCT evaluation. Clinical and procedural characteristics were prospectively collected. Clinical setting for OCT was: "Diagnostic OCT" (OCT for lesion evaluation after coronary angiography without further PCI); "PCI-guidance OCT" (OCT as a guidance for complex PCI, both by intention or after diagnostic OCT). Primary study end-point was the occurrence of target-vessel-failure (TVF) during the follow-up. RESULTS: Overall, OCT was successful in 99.1% of attempted lesions. Only one complication (coronary dissection requiring urgent PCI) occurred during OCT. After a follow-up of 695 ±â€¯562 days, TVF occurred in 8.2% of cases. Despite similar baseline characteristics, TVF-free survival curves were different in the two populations (5.4% after diagnostic OCT and 9.9% after PCI-guidance OCT). Minimal-lumen-area (MLA) of target lesion was independently associated with TVF (HR 0.7, 95% CI 0.6-0.8). This was mainly driven by a significant impact of MLA in patients not revascularized (HR 0.6, 95% CI 0.4-0.9). TVF did not change according to the study period despite the selection of patients with increasing complexity. CONCLUSIONS: OCT has a good safety profile across a broad spectrum of patients encountered in daily practice. The easy-to-assess MLA parameter may help stratify prognosis of patients undergoing OCT. These data call for further evaluations of OCT clinical impact. SUMMARY: OCT is a light-based imaging tool which had subvert the quite ordinary world of coronary imaging and the present study evaluates OCT use in a high-volume center. Our results suggest that application of OCT in "real world" patients presenting higher risk has a good safety profile. Several factors could predict a worse long-term outcome in patients undergoing OCT evaluation, mostly related to more complex clinical conditions. These findings could encourage even low-to intermediate volume centers to improve their OCT use in daily practice.

Data on optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions.

The data presented in this article are related to the research article entitled "Optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions: early clinical experience" [1]. In this article we reports details about our clinical experience with frequency domain-optical coherence tomography (FD-OCT) guidance for the management of patients with left main (LM) bifurcation lesions of intermediate angiographic severity. LM patients were assessed by FD-OCT and, on the bases of the findings, managed by myocardial revascularization or conservative treatment (revascularization deferral). The observed outcomes support the feasibility of FD-OCT guidance for LM bifurcated lesions and call for further clinical evaluations in appropriately designed prospective studies.

Optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions: Early clinical experience.

BACKGROUND: Left main (LM) atherosclerotic lesions affect clinical outcomes. Frequency domain-optical coherence tomography (FD-OCT) allows detailed characterization of non-ostial coronary atherosclerotic lesions. The clinical impact of FD-OCT assessment of LM bifurcation disease on the revascularization decision is unknown. METHODS: Patients who underwent FD-OCT assessment to guide management of angiographically intermediate distal LM stenosis were retrospectively selected. The FD-OCT LM criteria for percutaneous or surgical revascularization were: Clinical follow-up was obtained to evaluate the occurrence of target vessel failure (TVF) defined as cardiac death and/or acute myocardial infarction (AMI) not related to other vessel and/or target vessel revascularization. RESULTS: Out of 131 patients underwent FD-OCT assessment of LM, 122 patients (93%) entered the study. Based on FD-OCT features, 58 (48%) patients were conservatively managed, while the remaining 64 (52%) were revascularized by stenting (n=48) or surgery (n=16). After a mean follow-up of 18months, TVF-free survival was not different between patients undergoing conservative management vs. revascularization (HR 0.40, CI 95% 0.10-1.61, P=0.20). Of note, two patients only in the conservative management group had TVF (elective LM stenting, no death or myocardial infarction). CONCLUSIONS: This preliminary experience suggests that a FD-OCT based management for patients with angiographically-intermediate LM bifurcation stenosis may help identify patients in whom revascularization could be deferred. Such observation calls for further evaluations by appropriately designed trials.

Trends and Outcomes of Radial Approach in Left-Main Bifurcation Percutaneous Coronary Intervention in the Drug-Eluting Stent Era: A Two-Center Registry.

OBJECTIVE: To analyze the immediate and long-term outcomes of transradial (TR) percutaneous coronary intervention (PCI) to unprotected left main stem (ULMS) bifurcation and to assess the main aspects affecting access-site choice in this specific PCI setting. BACKGROUND: TR-PCI to the ULMS is feasible, but data specifically comparing TR and transfemoral (TF) approaches in ULMS-bifurcation PCI are limited. METHODS: We set up a two-center (Rome, Italy and Oxford, United Kingdom) retrospective registry aimed at comparing the immediate and 1-year outcomes of consecutive patients who underwent ULMS-bifurcation PCI with drug-eluting stent implantation from 2005 to 2013 using the TF or TR approach. Clinical endpoints were: total mortality; major adverse cardiac and cerebrovascular event (MACCE) rate; and net adverse clinical event (NACE) rate. RESULTS: A total of 467 patients undergoing ULMS-bifurcation PCI were enrolled (221 TF and 244 TR). TR approach was increasingly adopted over time for both simple and complex procedures. No significant differences were observed between the TR and TF groups in terms of 1-year mortality (10.7% vs 9.8%; P=.79) and MACCE (18.2% vs 15.2%; P=.44). TR patients, as compared with TF, had significantly fewer access-site complications (2.0% vs 6.3% in TF; P=.02), resulting in a significant reduction of NACE rate (6.9% vs 15.7;%; P=.01). CONCLUSION: In patients undergoing ULMS-bifurcation PCI, the selection of TR instead of TF approach is associated with similar early and long-term ischemic complications and with a significant reduction of access-site complications, resulting in lower NACE rate.

Frequency domain optical coherence tomography to assess non-ostial left main coronary artery.

AIMS: The aim of this study was to assess the feasibility of unprotected non-ostial left main (LM) imaging by frequency domain optical coherence tomography (FD-OCT). METHODS AND RESULTS: We conducted a retrospective analysis of OCT studies performed to image lesions located in the non-ostial LM. OCT studies were analysed off-line to detect the number of artefact frames in the different LM/bifurcation segments. OCT cross-sectional images were used to assess area measures. OCT longitudinal reconstructions were used to obtain the LM length. Standard quantitative coronary angiography (QCA) was used as the reference methodology. A total of 54 patients with non-ostial LM disease entered the study. The mean number of LM artefact frames was 8±10, corresponding to 19% of the total number of LM frames analysed. The percentages of artefact frames differed significantly according to the segment analysed: 43.3% proximal LM, 11.4% mid LM and 2.1% distal LM, 2.0% ostial left anterior descending artery and 0% ostial left circumflex artery (p<0.0001). All LM OCT measurements were significantly correlated with QCA measurements. CONCLUSIONS: The results of the present study show that FD-OCT assessment of non-ostial LM disease is feasible and may provide high-quality imaging. OCT assessment of distal LM is more efficient than that of the proximal LM segment.

How to recognize endomyocardial fibrosis?

Endomyocardial fibrosis is a disease of unknown cause, characterized by the development of restrictive cardiomyopathy. Although it is endemic in Africa, some cases have been described in Asia, South America and Europe, where a substantial unfamiliarity with this disease still exists. Moreover, differential diagnosis of endomyocardial fibrosis with other cardiomyopathies can be difficult, especially in asymptomatic patients and in initial stage of the disease. After initial echocardiographic analysis, the gold standard imaging technique is the cardiac magnetic resonance. Adjunctive diagnostic tools as endomyocardial biopsy can be considered in ambiguous cases and can help in patient management.

Percutaneous management of vascular access in transfemoral transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) using stent-based bioprostheses has recently emerged as a promising alternative to surgical valve replacement in selected patients. The main route for TAVI is retrograde access from the femoral artery using large sheaths (16-24 F). Vascular access complications are a clinically relevant issue in TAVI procedures since they are reported to occur in up to one fourth of patients and are strongly associated with adverse outcomes. In the present paper, we review the different types of vascular access site complications associated with transfemoral TAVI. Moreover, we discuss the possible optimal management strategies with particular attention to the relevance of early diagnosis and prompt treatment using endovascular techniques.

Association between inflammatory biomarkers and in-stent restenosis tissue features: an Optical Coherence Tomography Study.

AIMS: Inflammatory reaction after stent implantation is associated with in-stent restenosis (ISR). We assessed the association of optical coherence tomography (OCT) features of neointima with systemic levels of high-sensitivity C-reactive protein (hs-CRP) and eosinophil cationic protein (ECP) measured at the time of ISR detection. METHODS AND RESULTS: Patients presenting with symptomatic angiographically documented ISR (diameter stenosis ≥ 50% by visual estimation) were included. Quantitative OCT analysis included the measurement of minimal lumen diameter, minimal luminal area, stent and neointimal area, stent and restenosis length, restenotic tissue burden, and symmetry ratio. Qualitative OCT analysis included the assessment of ISR plaque type, neointimal tissue structure, lumen shape, presence of microvessels and calcific nodules. At the time of ISR detection hs-CRP and ECP levels were measured, and statistical analysis was performed using as cut-off 3 mg/L and 4.5 µg/L, respectively. Our population included 40 patients, 24 bare metal stents and 16 drug-eluting stents. Patients with high hs-CRP levels had a higher restenostic tissue symmetry ratio (0.56 ± 0.17 vs. 0.42 ± 0.13, P = 0.01) when compared with patients with low hs-CRP levels. Patients with high ECP levels had a higher neointimal burden (70 ± 14 vs. 64 ± 11, P = 0.05) in comparison with patients with low ECP levels. CONCLUSIONS: Inflammatory biomarkers assessed at the time of ISR detection are associated with different aspects of neointimal tissue. While hs-CRP seems to have a role in neointimal tissue shape, ECP is related to a neointimal burden.

Endothelial progenitor cells, microvascular obstruction, and left ventricular remodeling in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Endothelial progenitor cells (EPCs) are released from the bone marrow during cardiac ischemic events, potentially influencing vascular and myocardial repair. We assessed the clinical and angiographic correlates of EPC mobilization at the time of primary percutaneous coronary intervention in 78 patients with ST elevation myocardial infarction and the impact of both baseline and follow-up EPC levels on left ventricular (LV) remodeling. Blood samples were drawn from the aorta and the culprit coronary artery for cytofluorimetric EPC detection (CD34+CD45dimKDR+ cells, in percentage of cytofluorimetric counts). Area at risk was assessed by Bypass Angioplasty Revascularization Investigation myocardial jeopardy index, thrombotic burden as thrombus score and microvascular obstruction (MVO) as a combination of ST segment resolution and myocardial blush grade. Echocardiographic evaluation of LV remodeling was performed at 1-year follow-up in 54 patients, whereas peripheral EPC levels were reassessed in 40 patients. EPC levels during primary percutaneous coronary intervention were significantly higher in intracoronary than in aortic blood (0.043% vs 0.0006%, p <0.001). Both intracoronary and aortic EPC were related to area at risk extent, to intracoronary thrombus score (p <0.001), and inversely to MVO (p = 0.001). Peripheral EPC levels at 1-year follow-up were lower in patients with LV remodeling than in those without (0.001% [0.001 to 0.002] vs 0.003% [0.002 to 0.010]; p = 0.01) and independently predicted absence of remodeling at multivariate analysis. In conclusion, a rapid intracoronary EPC recruitment takes place in the early phases of ST elevation myocardial infarction, possibly reflecting an attempted reparative response. The extent of this mobilization seems to be correlated to the area at risk and to the amount of MVO. Persistently low levels of EPC are associated to LV remodeling.

Multiple coronary plaque ruptures in a patient with a recent ST-elevation acute myocardial infarction causing recurrent coronary instability.

Multiple plaque instability has been reported in about one-third of patients with ST elevation acute myocardial infarction (STEMI) and could be responsible for early recurrent instability after STEMI. Optical coherence tomography (OCT) is a high-resolution imaging technique that may help in detection and characterization of unstable coronary plaques. We present a case of multiple coronary instability in a patient with anterior STEMI where OCT has tailored an optimal diagnosis and treatment.

Comparison of two- and three-dimensional quantitative coronary angiography to intravascular ultrasound in the assessment of intermediate left main stenosis.

Angiographic evaluation of intermediate left main coronary artery stenosis (LMS) is often limited. Three-dimensional (3D) quantitative coronary angiography has recently developed to overcome 2-dimensional (2D) quantitative coronary angiographic (QCA) limitations. In patients with angiographically intermediate LMS, we investigated whether 3D quantitative coronary angiography was superior to 2D quantitative coronary angiography in predicting the presence of a significant LMS, defined as a minimum luminal area <6 mm(2) at intravascular ultrasound (IVUS). 2D and 3D quantitative coronary angiography were compared in their measurements of minimum luminal area, percent area stenosis, minimum luminal diameter, and percent diameter stenosis and in their prediction of an IVUS minimum luminal area <6 mm(2). In total 58 target lesions were interrogated, 25 (43%) of which had an IVUS minimum luminal area <6 mm(2). Correlation between 3D-QCA minimum luminal area and IVUS minimum luminal area was stronger than the correlation between 2D-QCA minimum luminal area (or minimum luminal diameter) and IVUS minimum luminal area (R = 0.67, p = 0.0001, and R = 0.40, p = 0.001, respectively, p = 0.04 for comparison). To predict IVUS minimum luminal area <6 mm(2), the most accurate 2D-QCA measurement was minimum luminal diameter (area under curve 0.81, cutoff 2.2 mm, p = 0.0001), and the most accurate 3D-QCA measurement was minimum luminal area (area under curve 0.86, cutoff 5.6 mm(2), p = 0.0001). 2D-QCA percent diameter stenosis did not significantly predict IVUS minimum luminal area <6 mm(2) (area under curve 0.56, cutoff 38%, p = 0.45). In conclusion, the accuracy of quantitative coronary angiography in predicting LM IVUS minimum luminal area <6 mm(2) is limited. When IVUS is not available or contraindicated, 3D quantitative coronary angiography may assist in the evaluation of intermediate LMS. Among 2D-QCA parameters, minimum luminal diameter is more accurate than percent diameter stenosis in predicting significant LMS.

Left anterior descending artery percutaneous coronary intervention from the right radial access via the left internal mammary artery: a case report.

BACKGROUND: Trans-radial access in coronary intervention has gained popularity as it grants advantages in patients with higher risk of haemorrhage, especially those with non-cardiac conditions and those treated with oral anticoagulant therapy. CASE REPORT: We report a case of percutaneous coronary intervention (PCI) of the left anterior descending (LAD) artery distal to left internal mammary artery (LIMA) anastomosis from the usually contraindicated right radial approach, in an actively bleeding patient affected by gastric cancer and chronic atrial fibrillation, and with no other available low-risk route. CONCLUSION: LAD trans-LIMA PCI via right radial access can be attempted in selected cases with suitable anatomy.

Differential levels of circulating progenitor cells in acute coronary syndrome patients with a first event versus patients with recurring events.

OBJECTIVE: Pathophysiology of acute coronary syndromes in patients presenting with a first cardiac event (FCE) can be different from patients with a recurring cardiac event (RCE). We assessed inflammatory activation and circulating progenitor cells' (CPC) mobilisation in patients with a FCE versus those with RCE. METHODS: We recruited 41 patients: 18 with FCE and 23 with RCE. Peripheral blood samples were drawn at baseline and at 20 days to measure high sensitivity C-reactive protein (CRP) and to assess CD34+/133+ CPC and CD34+/KDR+ CPC by flow cytometry. RESULTS: CD34+/133+ cells (% number of cells per total number of cytometric events) were similar at baseline, being 0.25% (0.17-0.42%) in the FCE vs 0.23% (0.11-0.43%) in the RCE group, and increased at follow-up only in the FCE group to 0.41% (0.22-0.64%), while in the RCE group they were 0.27% (0.11-0.36%) (p=0.009 for the interaction, p=0.07 for the main effect of time). CD34+/KDR+ cells were similar at baseline in the two groups, did not significantly increase over time (p=0.2), and no differential effect of FCE vs RCE over time was seen (p=0.38). CRP levels, similar at baseline, were consistently reduced at 20 days after ACS (p=0.001), with no differential effect of FCE vs RCE pts (p=0.74). Variation from baseline to follow-up for both CD34+/133+ and CD34+/KDR+ did not correlate with either baseline CRP or delta CRP. CONCLUSIONS: Our data demonstrate a differential CPC mobilization behavior for FCE patients compared to RCE ones, independent of inflammatory activation.

Myeloperoxidase may help to differentiate coronary plaque erosion from plaque rupture in patients with acute coronary syndromes.

Coronary thrombosis is the most frequent final event leading to an acute coronary syndrome. In approximately two-thirds of cases, the thrombus overlies a ruptured plaque, whereas in one-third of cases it overlies an intact plaque with superficial endothelial erosion, a finding showed initially by histopathological postmortem studies and more recently confirmed by in vivo optical coherence tomography imaging. Interestingly, recent observations suggest that mechanisms leading to plaque rupture or erosion are different. In fact, in a recent study, we showed that myeloperoxidase levels in peripheral blood and expression within thrombi overlying the culprit plaque are much higher in patients with plaque erosion than in those with plaque rupture. These observations suggest that innate immunity activation is likely to play a key role, in particular, in plaque erosion and might become a therapeutic target in this subset of patients.

Comparison of the effects of ramipril versus telmisartan on high-sensitivity C-reactive protein and endothelial progenitor cells after acute coronary syndrome.

To compare the anti-inflammatory and endothelial progenitor cell mobilizing effects of ramipril and telmisartan in patients presenting with acute coronary syndrome (ACS), 42 patients with ACS were randomized after successful percutaneous coronary intervention to ramipril 5 mg/day (22 patients) or telmisartan 80 mg/day (20 patients). Peripheral blood samples were drawn at baseline and at 20 days to measure high-sensitivity C-reactive protein and to assess 4 populations of progenitor cells by flow cytometry, namely CD34+/KDR+, CD34+/CD133+, CD34+/CD133+/CD45-, and CD34+/KDR+/CD45- cells. High-sensitivity C-reactive protein levels, similar in the 2 groups at baseline, were significantly more decreased by telmisartan than by ramipril at follow up (p = 0.013 for time-by-drug interaction). The main effect for time was also significant (p <0.001). CD34+/KDR+ and CD34+/CD133+ cells were similar at baseline and did not change over time (p = 0.2 and p = 0.1, respectively). In contrast, for CD34+/KDR+/CD45- and CD34+/CD133+/CD45- cells, a significant increase with time was seen (p = 0.02 and p = 0.002, respectively) and no differential effect of either drug was seen. In conclusion, telmisartan shows a more potent anti-inflammatory effect than ramipril after an ACS. The 2 drugs do not show a differential effect on endothelial progenitor cell mobilization.

Myeloperoxidase: a new biomarker of inflammation in ischemic heart disease and acute coronary syndromes.

Myeloperoxidase (MPO) is an enzyme stored in azurophilic granules of polymorphonuclear neutrophils and macrophages and released into extracellular fluid in the setting of inflammatory process. The observation that myeloperoxidase is involved in oxidative stress and inflammation has been a leading factor to study myeloperoxidase as a possible marker of plaque instability and a useful clinical tool in the evaluation of patients with coronary heart disease. The purpose of this review is to provide an overview of the pathophysiological, analytical, and clinical characteristics of MPO and to summarize the state of art about the possible clinical use of MPO as a marker for diagnosis and risk stratification of patients with acute coronary syndrome (ACS).

Biomarkers in Acute Coronary Syndrome.

BACKGROUND: Evaluation of patients who present to the hospital with acute undifferentiated chest pain or other symptoms and signs suggestive of Acute Coronary Syndrome (ACS) is often a clinical challenge. The initial assessment, requiring a focused history (including risk factors analysis), a physical examination, an electrocardiogram (EKG) and serum cardiac marker determination, is time-consuming and troublesome. Recent investigations have indicated that increases in biomarkers of necrosis, inflammation, ischemia and myocardial stretch may provide earlier assessment of overall patient risk, help in identifying the adequate diagnostic and therapeutic management for each patient and allow for prevention of substantial numbers of new events. APPROACH AND CONTENT: The purpose of this review is to provide an overview of the characteristics of several biomarkers that may have potential clinical utility to identify ACS patients. Patho-physiology, analytical and clinical characteristics have been evaluated for each marker, underlying the properties for potential routine clinical use. SUMMARY: The biomarkers discussed in this review are promising and might lead to improved diagnosis and risk stratification of patients with ACS, however their clinical application requires further studies. It is important to define their clinical role as diagnostic markers, their predictive value and the specificity, standardization and detection limits of the assays.

Cystatin C is associated with an increased coronary atherosclerotic burden and a stable plaque phenotype in patients with ischemic heart disease and normal glomerular filtration rate.

OBJECTIVE: Cystatin C (Cys-C) is an accurate marker of renal function. Recent studies have shown that serum Cys-C levels predict the risk of cardiovascular events. The causes of this association, however, are largely unknown. METHODS AND RESULTS: Seventy consecutive patients (age 62+/-12, male sex 87%) undergoing coronary angiography because of typical chest pain and found to have coronary artery disease were included in the present study. Patients with abnormal creatinine-derived glomerular filtration rate (<90ml/min/1.73m(2)) were excluded in order to avoid the well-known effect of overt renal insufficiency on coronary atherosclerosis. Coronary angiography was evaluated by two expert angiographers who assessed disease severity and extent according to the Sullivan's score and lesion morphology. In all patients, Cys-C and C-Reactive Protein (CRP) serum levels were measured on admission. Multivariable analysis was performed to assess independent predictors of angiographic measures. Diabetes was the only predictor of disease severity (p=0.005), while male sex (p=0.03), hypercholesterolemia (p=0.04), diabetes (p<0.0001) and Cys-C (p<0.0001) were independent predictors of disease extent. Independent predictors of smooth lesions were diabetes (p<0.001) and Cys-C (p=0.005). No correlation was found between Cys-C and CRP serum levels (p=0.6). CONCLUSION: Cys-C is associated with coronary atherosclerosis extent and a smooth lesion morphology. The long-term prognostic role of Cys-C might be accounted for by a greater atherosclerotic burden, a necessary substrate for plaque destabilization.