Spontaneous coronary artery dissection: long-term follow-up of a large series of patients prospectively managed with a "conservative" therapeutic strategy.

OBJECTIVES: This study sought to assess the long-term clinical outcome of patients with spontaneous coronary artery dissection (SCD) managed with a conservative strategy. BACKGROUND: SCD is a rare, but challenging, clinical entity. METHODS: A prospective protocol, including a conservative management strategy, was followed. Revascularization was only considered in cases with ongoing/recurrent ischemia. Inflammatory/immunologic markers were systematically obtained. RESULTS: Forty-five consecutive patients (incidence 0.27%) were studied during a 6-year period. Of these, 27 patients (60%) had "isolated" SCD (I-SCD), and 18 had SCD associated with coronary artery disease (A-SCD). Age was 53 ± 11 years, and 26 patients were female. Most patients presented with an acute myocardial infarction. SCD had a diffuse angiographic pattern (length: 31 ± 23 mm). In 11 patients, the diagnosis was confirmed by intracoronary imaging techniques. Sixteen patients (35%) required revascularization during initial admission. One patient died after surgery, but no additional patient experienced recurrent myocardial infarction. No significant inflammatory/immunologic abnormalities were detected. At follow-up (median 730 days), only 3 patients presented with adverse events (1 died of congestive heart failure, and 2 required revascularization). No patient experienced a myocardial infarction or died suddenly. Event-free survival was similar (94% and 88%, respectively) in patients with I-SCD and A-SCD. Notably, at angiographic follow-up, spontaneous "disappearance" of the SCD image was found in 7 of 13 (54%) patients. CONCLUSIONS: In this large prospective series of consecutive patients with SCD, a "conservative" therapeutic strategy provided excellent long-term prognosis. Clinical outcome was similar in patients with I-SCD and A-SCD. The natural history of SCD includes spontaneous healing with complete resolution.

Combined use of optical coherence tomography and intravascular ultrasound imaging in patients undergoing coronary interventions for stent thrombosis.

OBJECTIVE: This prospective study sought to assess the diagnostic value of optical coherence tomography (OCT) compared with intravascular ultrasound (IVUS) in patients presenting with stent thrombosis (ST). DESIGN AND SETTING: Although the role of IVUS in this setting has been described, the potential diagnostic value of OCT in patients suffering ST remains poorly defined. Catheterization Laboratory, University Hospital. PATIENTS AND INTERVENTIONS: Fifteen consecutive patients with ST undergoing rescue coronary interventions under combined IVUS/OCT imaging guidance were analysed. MEAN OUTCOME MEASURES: Analysis and comparison of OCT and IVUS findings before and after interventions. RESULTS: Before intervention, OCT visualised the responsible thrombus in all patients (thrombus area 4.7±2.5 mm(2), stent obstruction 82±14%). Minimal stent area was 4.7±2.1 mm(2) leading to severe stent underexpansion (expansion 60±21%). Although red or mixed thrombus (14 patients) induced partial strut shadowing (total length 12.3±6 mm), malapposition (six patients), inflow-outflow disease (five patients), uncovered struts (nine patients) and associated in-stent restenosis (five patients, four showing neoatherogenesis) was clearly recognised. IVUS disclosed similar findings but achieved poorer visualisation of thrombus-lumen interface and strut malapposition, and failed to recognise uncovered struts and associated neoatherosclerosis. After interventions, OCT demonstrated a reduced thrombus burden (2.4±1.6 mm(2)) and stent obstruction (24±14%) with improvements in stent area (6.8±2.9 mm(2)) and expansion (75±21%) (all p<0.05). IVUS and OCT findings proved to be complementary. CONCLUSIONS: OCT provides unique insights on the underlying substrate of ST and may be used to optimise results in these challenging interventions. In this setting, OCT and IVUS have complementary diagnostic values.

Implantation of a drug-eluting stent with a different drug (switch strategy) in patients with drug-eluting stent restenosis. Results from a prospective multicenter study (RIBS III [Restenosis Intra-Stent: Balloon Angioplasty Versus Drug-Eluting Stent]).

OBJECTIVES: This study sought to assess the effectiveness of a strategy of using drug-eluting stents (DES) with a different drug (switch) in patients with DES in-stent restenosis (ISR). BACKGROUND: Treatment of patients with DES ISR remains a challenge. METHODS: The RIBS-III (Restenosis Intra-Stent: Balloon Angioplasty Versus Drug-Eluting Stent) study was a prospective, multicenter study that aimed to assess results of coronary interventions in patients with DES ISR. The use of a different DES was the recommended strategy. The main angiographic endpoint was minimal lumen diameter at 9-month follow-up. The main clinical outcome measure was a composite of cardiac death, myocardial infarction, and target lesion revascularization. RESULTS: This study included 363 consecutive patients with DES ISR from 12 Spanish sites. The different-DES strategy was used in 274 patients (75%) and alternative therapeutic modalities (no switch) in 89 patients (25%). Baseline characteristics were similar in the 2 groups, although lesion length was longer in the switch group. At late angiographic follow-up (77% of eligible patients, median: 278 days) minimal lumen diameter was larger (1.86 ± 0.7 mm vs. 1.40 ± 0.8 mm, p = 0.003) and recurrent restenosis rate lower (22% vs. 40%, p = 0.008) in the different-DES group. At the last clinical follow-up (99% of patients, median: 771 days), the combined clinical endpoint occurred less frequently (23% vs. 35%, p = 0.039) in the different-DES group. After adjustment using propensity score analyses, restenosis rate (relative risk: 0.41, 95% confidence interval [CI]: 0.21 to 0.80, p = 0.01), minimal lumen diameter (difference: 0.41 mm, 95% CI: 0.19 to 0.62, p = 0.001), and the event-free survival (hazard ratio: 0.56, 95% CI: 0.33 to 0.96, p = 0.038) remained significantly improved in the switch group. CONCLUSIONS: In patients with DES ISR, the implantation of a different DES provides superior late clinical and angiographic results than do alternative interventional modalities.

Diagnosis of spontaneous coronary artery dissection by optical coherence tomography.

OBJECTIVES: This study sought to assess the diagnostic value of optical coherence tomography (OCT) in patients with suspected spontaneous coronary artery dissection (SCAD). BACKGROUND: SCAD is a rare but challenging clinical entity. METHODS: Following a prospective protocol, OCT was performed in 17 consecutive patients with a clinical and angiographic suspicion of SCD from a total of 5,002 patients undergoing coronary angiography. A conservative management strategy was followed. RESULTS: OCT ruled out the diagnosis of SCAD in 6 patients with coronary artery disease (atherosclerotic plaques and/or intracoronary thrombus). In 11 patients (age 48 ± 9 years, 9 female), OCT confirmed the presence of SCAD. A double-lumen or intramural hematoma image was visualized in all cases. However, only 3 patients presented an intimal "flap" on angiography. OCT readily identified the intimal rupture site (n = 7), the thickness (348 ± 84 µm) and length (31 ± 9 mm) of the intimomedial membrane, the area of the true (1.1 ± 0.5 mm(2)) and false lumen (5.9 ± 2.1 mm(2)), the associated intramural hematoma (n = 9), and thrombi in the true or false lumens (n = 11). Most of these findings were angiographically silent. After stenting (n = 4), OCT disclosed adequate stent coverage, expansion, and apposition, but also residual intramural hematoma at the stented site (abluminal) and at the distal vessel. CONCLUSIONS: OCT provides unique insights in patients with SCAD that allow an early diagnosis and adequate management. Most of these findings are undetectable by angiography.

Treatment of a giant coronary artery aneurysm: intravascular ultrasound and optical coherence tomography findings.

A giant coronary aneurysm (GCA) partially thrombosed was demonstrated in a 77-year-old patient evaluated for an inferior myocardial infarction. Primary angioplasty (balloon only) with suboptimal result was initially obtained. After triple antiplatelet and anticoagulation therapy (4 days), a new angiography was performed and a fusiform GCA was clearly delineated. A second percutaneous intervention was performed using a "scaffolding technique" with conventional stent and subsequent implantation of 2 polytetrafluoroethylene-covered stents to successfully exclude the aneurysm. This case demonstrates a novel technique to treat long GCA.

[Rapidly evolving techniques for structural heart disease interventions]. / Técnicas de rápido desarrollo en intervencionismo estructural.

Structural heart disease interventions are the transcatheter techniques used for treating non-coronary heart disease. In recent years, these techniques have generated considerable interest even though they still comprise only a small percentage of the total volume of interventions performed in interventional cardiology departments. The level of interest in these techniques is high probably because their application is characterized by a number of special features: a) the need for multidisciplinary teams; b) the need for specialized education and training; c) the requirement for special skills developed through education and experience, and d) the limited number of referral centers at present. This article describes four specific techniques: a) percutaneous closure of perivalvular leaks; b) percutaneous left atrial appendage obliteration; c) percutaneous treatment of mitral regurgitation, and d) transcatheter implantation of prosthetic aortic valves. We explore the rationale for using the technique, the specific procedures involved and the results obtained.

Detection of very early stent healing after primary angioplasty: an optical coherence tomographic observational study of chromium cobaltum and first-generation drug-eluting stents. The DETECTIVE study.

BACKGROUND: Lack of stent coverage appears to be associated with stent thrombosis, a problem of particular concern in patients with ST elevation myocardial infarction (STEMI). METHODS: The DETECTIVE European Multicenter Registry was set up to address the early modality of stent healing in the setting of STEMI. The Registry compared, with an early optical coherence tomography (OCT) evaluation performed at 3-7 days, the patterns of coverage and apposition of the first generation of drug-eluting stents (DESs) and cobalt chromium non-drug-eluting stents (CCSs) that were deployed in culprit lesions and in non-culprit segments. The Registry included only patients with a multi-vessel disease to allow, at 3-7 days from the first angioplasty, a deferred OCT examination and a staged intervention in another vessel. RESULTS: 28 stented lesions (15 patients) eventually entered the final OCT assessment. 13 stents were first-generation DESs, while the remaining 15 were CCSs. 18 stents (64%) were deployed at culprit STEMI lesions, and the remaining 10 (36%) were deployed at non-culprit sites. The distribution of clinical and procedural variables in DES and CCS as well as in culprit and non-culprit sites was not different. In total, 27,019 struts were analysed in 28 stents. The percentage of stent uncoverage in the overall analysis was 11.7%, while the percentage of malapposition and that of struts covered with thrombus were 4.8% and 2.2%, respectively. A low percentage of strut uncoverage was found in all the four studied subgroups: DES 12.8%, CCS 10.9%, stents deployed in culprit lesions 13.2% and stents deployed in non-culprit lesions 8.7%. CONCLUSIONS: In conclusion, our data show that in patients with STEMI, a very high percentage of stent struts is covered by an early thin rim of tissue within 7 days after stent positioning. The present data bring new insights in the mechanism and timing of strut coverage.

Coronary dissection healing patterns: from complete resolution to restenosis, insights from optical coherence tomography.

A 68-year-old patient presented a long, type C coronary dissection after balloon angioplasty of a focal lesion in a distal marginal branch. Due to the small vessel size the dissection was left untreated. At angiographic follow-up the dissection had completely disappeared, but a localised restenosis was found in the proximal vessel. Optical coherence tomography (OCT) confirmed the complete healing of the dissection and revealed a normal vessel wall (restitutio ad integrum). This technique also provided unique insights into the underlying substrate of the proximal restenosis unravelling a complicated plaque with associated thrombus.

Técnicas de rápido desarrollo en intervencionismo estructural / Rapidly evolving techniques for structural heart disease interventions

El intervencionismo estructural se refiere a las técnicas intervencionistas que van dirigidas a enfermedades cardiacas no coronarias. En los últimos años está teniendo un interés muy considerable, aunque todavía representa un porcentaje muy pequeño del volumen total de intervencionismo de un departamento de terapia endovascular. A pesar del pequeño volumen relativo, el interés es muy grande, probablemente debido a las características peculiares que rodean a estas técnicas: a) necesidad de equipos multidisciplinarios; b) formación y entrenamiento específicos; c) requiere habilidades especiales derivadas de la formación y experiencia, y d) escaso volumen en el momento actual que aconseja centros dereferencia. En este capítulo desarrollamos cuatro apartados específicos: a) cierre percutáneo del leak perivalvular (LP);b) obliteración percutánea de la orejuela; c) tratamiento percutáneo de la insuficiencia mitral, y d)implantación transcatéter de prótesis valvulares aórticas. Exploramos las razones de la técnica, los procedimientos específicos y los resultados obtenidos (AU)

Structural heart disease interventions are the transcatheter techniques used for treating non-coronary heart disease. In recent years, these techniques have generated considerable interest even though they still comprise only a small percentage of the total volume of interventions performed in interventional cardiology departments. The level of interest in these techniques is high probably because their application is characterized by a number of special features: a) the need for multidisciplinary teams; b) the need for specialized education and training; c) the requirement for special skills developed through education and experience, and d) the limited number of referral centers at present. This article describes four specific techniques: a) percutaneous closure of perivalvular leaks; b) percutaneous left atrial appendage obliteration;c) percutaneous treatment of mitral regurgitation, and d) transcatheter implantation of prosthetic aorticvalves. We explore the rationale for using the technique, the specific procedures involved and the results obtained (AU)