Same-day CIED implantation and discharge: Is it possible? The E-MOTION trial (Early MObilization after pacemaker implantaTION).

BACKGROUND: Despite the increasing number of cardiac implantable electronic devices (CIED) procedures worldwide, no guideline assessed postoperative mobilization protocols. Lacking evidences in literature, many centers require 24-hour immobilization and bed rest to minimize the risk of pacing lead (PL) dislodgement. Prolonged immobilization may futilely delay discharge, induce pain and reduced joint mobility especially in elderly patients. We examined whether early mobilization at 3-h after CIED surgery would result in higher complication rates, compared with standard 24-hour immobilization. METHODS: Consecutive patients undergoing CIED implantation were randomized to early (3-h) mobilization protocol with an arm sling support (E-motion group, EMG) vs. standard (24-h) immobilization (control group, CG). The primary end-point was 24-month PL dislodgement. Secondary safety end-point was any major intra-procedural complication (cardiac perforation, pericardial tamponade, valve damage, haemothorax, pneumothorax, myocardial infarction, peripheral embolus, TIA/stroke or death). RESULTS: Among 200 enrolled patients, 86% underwent pacemaker implantation (28% single-chamber, 72% dual-chamber device), 14% underwent ICD implantation (75% single-chamber, 25% dual-chamber device). PL fixation was mostly passive (97% atrial PL, 88% ventricular PL), without differences between EMG and CG (p = 0.99). No differences were observed in the incidence of 24-month PL dislodgement (3% in the EMG vs. 4% in the CG, p = 0.99). No major intra-procedural complications were observed. CONCLUSIONS: Early mobilization at 3-h following CIED surgery is safe and feasible compared with standard immobilization and is not associated with an increased risk of intra-procedural complications or 24-month lead dislodgment. So, same-day implantation and discharge might be possible.

Contrast-induced kidney injury: how does it affect long-term cardiac mortality?

AIMS: Contrast-induced acute kidney injury (CIAKI) is a common complication after coronary angiography or percutaneous revascularization (PCI). This study aimed to investigate the association of CIAKI with long-term cardiovascular adverse events. METHODS: In total, 980 patients undergoing coronary angiography/PCI were assessed in this prospective cohort study. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) and cardiac death (CVD) during an 8-year follow-up. Glomerular filtration rate change during the follow-up was the secondary endpoint.CIAKI was defined as a serum creatinine increase at least 0.3 mg/dl in 48 h or at least 50% in 7 days. RESULTS: CIAKI was observed in 69 patients (7%). Chronic kidney disease [relative risk (RR) = 4, P < 0.01], reduced ejection fraction (RR = 2.88, P < 0.01), CIAKI risk score at least 4 (RR = 2.64, P = 0.02), and emergency coronary angiography/PCI (RR = 3.87, P < 0.01) increased CIAKI risk, whereas statins were protective (RR = 0.32, P < 0.01).Patients with CIAKI had higher rates of 8-year cardiovascular adverse events: 54 versus 15% MACCE (RR = 6.67, P < 0.01), 38 versus 4% CVD (RR = 15.73, P < 0.01). Among other factors, CIAKI was the strongest predictor of 8-year MACCE (RR = 3.16, P < 0.01) and CVD (RR = 7.34, P < 0.01).During the follow-up, glomerular filtration rate declined drastically in CIAKI patients: 70 versus 39% had chronic kidney disease stage worsening (P < 0.01) and 8 versus 0.3% started hemodialysis (P < 0.01). CONCLUSION: We found a strong correlation between CIAKI and poor long-term cardiac outcomes. Apparently showing up as a transient, functional impairment of kidney function, CIAKI implies an organic damage with structural modifications leading to significant kidney deterioration over time, responsible for an increased risk of long-term cardiac events. Statins significantly reduced CIAKI occurrence. A careful management of high-risk patients is needed to limit long-term complications of coronary angiography/PCI.

AKIGUARD (Acute Kidney Injury GUARding Device) trial: in-hospital and one-year outcomes.

AIMS: Contrast-induced acute kidney injury (CIAKI) in patients with chronic kidney disease undergoing coronary angiography or percutaneous coronary intervention is a common iatrogenic complication associated with increased morbidity and mortality. This study compares sodium bicarbonate/isotonic saline/N-acetylcysteine/vitamin C prophylaxis (BS-NAC) against high-volume forced diuresis with matched hydration in CIAKI prevention. METHODS: One-hundred and thirty-three consecutive patients undergoing coronary angiography or percutaneous coronary intervention with estimated glomerular filtration rate less than 60 mL/min/1.73m were randomized to the study group receiving matched hydration (MHG) or to the control group receiving BS-NAC. MHG received in vein (i.v.) 250 mL isotonic saline bolus, followed by a 0.5 mg/kg furosemide i.v. bolus to forced diuresis. A dedicated device automatically matched the isotonic saline i.v. infusion rate to the urinary output for 1 h before, during and 4 h after the procedure. RESULTS: MHG had the lowest incidence of CIAKI (7 vs. 25%, P = 0.01), major adverse cardiac and cerebrovascular events at 1 year (7 vs. 32%, P < 0.01) and readmissions to cardiology/nephrology departments (8 vs. 25%, P = 0.03; hospitalization days 1.0 ±â€Š3.8 vs. 4.9 ±â€Š12.5, P = 0.01). Three months after the procedure the decrease in the estimated glomerular filtration rate was 0.02% for MHG versus 15% for the control group. CONCLUSION: Matched hydration was more effective than BS-NAC in CIAKI prevention. One-year follow-up showed that matched hydration was associated also with limited chronic kidney disease progression, major adverse cardiac and cerebrovascular events and hospitalizations.

Cryptogenic ischemic stroke and prevalence of asymptomatic atrial fibrillation: a prospective study.

BACKGROUND: Atrial fibrillation is responsible for up to one-third of ischemic strokes, and is also associated with silent cerebral infarctions and transient ischemic attacks (TIAs). The self-terminating and often asymptomatic nature of paroxysmal atrial fibrillation (PAF) may lead to its underdiagnosis. A continuous and long-term heart rhythm monitoring can be useful in unmasking PAF episodes. OBJECTIVE: Prevalence of asymptomatic PAF in patients suffering a cryptogenic stroke, at risk for atrial fibrillation but without any history of arrhythmia or palpitations, using a continuous electrocardiographic monitoring. METHODS: One hundred and forty-two consecutive patients were admitted to the Stroke Unit of 'Città della Salute e della Scienza' Hospital of Turin between June 2010 and March 2013 and discharged with the diagnosis of ischemic cryptogenic stroke. Sixty fulfilled predefined inclusion criteria. Follow-up was carried on and completed for the 54 patients who consented to implantable loop recorder (ILR) implantation. After ILR implantation, trans-telephonic data were collected monthly. RESULTS: Atrial fibrillation episodes lasting more than 5 min were recorded in 25 patients (46%), median detection time was 5.4 months (range 1-18) and median duration of atrial fibrillation episodes was 20 h (range 7 min-8 days) with 19 patients (76%) remaining asymptomatic and the others experiencing weakness and dyspnoea but not palpitations. CONCLUSION: Long-term heart rhythm monitoring is successful in unmasking silent atrial fibrillation in 46% of patients suffering a cryptogenic stroke with concomitant atrial fibrillation risk factors, but without history of arrhythmia or palpitations.

The beneficial effect of extracorporeal shockwave myocardial revascularization in patients with refractory angina.

OBJECTIVES: The incidence of patients with refractory angina (RA) is increasing. Medical therapy for RA is limited and prognosis is poor. Experimental data suggest that the use of Extracorporeal shockwave myocardial revascularization (ESMR) may contribute to angiogenesis and improve symptoms of angina in patients with RA. Purpose of our study is to determine the efficacy of cardiac shock wave therapy (ESMR) in the management of patients with nonrevascolarized coronary artery disease (CAD). METHODS: We performed a prospective cohort study to examine the efficacy of ESMR applcation in patients with RA despite optimal medical therapy, not suitable for further PCI or CABG. Characteristics such as angina class scores (CCS class score), nitroglycerin consumption and hospitalization rate among cases (patients with RA who received ESMR) and controls (patients with RA who did not receive ESMR) were compared at baseline and 6 months after ESMR therapy. In patients receiveing d ESMR the effect of on cardiac perfusion was assessed. RESULTS: There were 43 patients in the case group and 29 patients in the control group. The mean age of the patients was 70 ± 9.5 years in the case group and 71 ± 5.3 years in the control group. Other characteristics (diabetes, coronary artery bypass graft, percutaneus coronary intervention, baseline CCS class score) were similar in both groups. There was a significant improvement in CCS class score (1.33 ± 0.57 in cases and 1.92 ± 0.69 in controls; p = 0.0002), nitroglycerin consumption (20% in case cases, and 44.8% in controls; P < 0.03) and hospitalization rate significantly reduced (13.9% in case cases, and 37.9% in controls; P < 0.03). The patients who received ESMR, there was a significantly improvement in myocardial perfusion after 6 months with a 33% relative reduction of summed stress score (SSS) (p = 0.002). CONCLUSION: This case control study demonstrates the beneficial effect of ESMR therapy on cardiac symptoms, myocardial perfusion and reduced hospitalization in patients with refractory angina. Ther current study supports a role for ESMR as a non-invasive therapuetic option for patients with RA.

Real time triplane echocardiography in the assessment of the functional area of prosthetic aortic valves: reliability and feasibility.

PURPOSE: Our study is aimed at evaluating the feasibility and reliability of a simple method for the measurement of the functional area of prosthetic aortic valves (EOA). Three-dimensional echocardiography has proven accurate for left ventricular volume, stroke volume, and aortic valve area measurement. We studied the feasibility and reliability of real time simultaneous triplane echocardiography (RT3P) for assessing the EOA with a fast formula based on the principle of continuity equation, in which we replaced Doppler-derived stroke volume (SV) with SV directly measured with RT3P. METHODS AND RESULTS: EOA of prosthetic aortic valves were measured in 23 consecutive patients requiring periodical follow up. EOA was calculated using Doppler continuity equation (DCE) and the RT3P method by replacing Doppler-derived SV with SV measured with real time triplane echocardiography. We compared functional areas obtained with the two methods with the prosthetic area indicated in the manufacturer's specifications and with the mean transprosthetic gradient. Both methods had a good correlation with the area indicated by the manufacturer. RT3P revealed an inverse correlation between functional area and mean gradient that was better than DCE (P = 0.0359). Inter- and intraobserver variability was not different between the two methods. Execution time was significantly shorter for RT3P. CONCLUSIONS: RT3P is a simple method that can be performed quite rapidly, and can complement the overall assessment of prosthetic valve function. Further studies can confirm our technique.

Real time triplane echocardiography in aortic valve stenosis: validation, reliability, and feasibility of a new method for valve area quantification.

AIMS: The aim of the study was to validate a novel formula for aortic valve area (AVA) based on the principle of continuity equation, that substitutes Doppler-derived stroke volume (SV) by SV directly measured with real time simultaneous triplane three-dimensional echocardiography (RT3P). RT3P has proved accuracy for left ventricular volume calculation. So far, however, neither this potential has been applied to hemodynamic assessment, nor RT3P has succeeded in the evaluation of aortic valve disease. METHODS AND RESULTS: AVA was measured in 21 patients with aortic stenosis using Gorlin's equation, Doppler continuity equation (two-dimensional echocardiography), the novel RT3P method, and by substituting Doppler-derived SV by SV measured with two-dimensional stroke volume (2DSV). RT3P has the best linear association (R(2)= 0.61) and the best correlation with Gorlin of all noninvasive methods (even if not statistically significant). RT3P carries significantly lower mean differences with catheterization, as compared with 2D and 2DSV (Table 4). Standard deviations of mean differences between RT3P and catheterization and between the other echocardiographic methods are not statistically different, even if RT3P seems to be nearer to catheterization. Inter- and intraobserver variability were, respectively, 0.03 +/- 0.11 cm(2) and 0.02 +/- 0.03 cm(2), better than 2D and 2DSV. CONCLUSIONS: RT3P has revealed to be more accurate than two-dimensional method in AVA quantification, with a better intraobserver agreement. In addition, it allows simple and fast image acquisition.

Results of percutaneous drug-eluting stent implantation for unprotected left main coronary disease according to left ventricular systolic function.

OBJECTIVES: We aimed to appraise the early and long-term outcome after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in patients with unprotected left main disease (ULM) and left ventricular systolic dysfunction (LVD). BACKGROUND: PCI with DES has being performed with increasing frequency in subjects with ULM and LVD, but few specific data are available. SETTING AND PATIENTS: We identified patients undergoing PCI with DES for ULM at our Center and distinguished those with ejection fraction (EF) >50% from those with 40% 50%, 32.0% with 40% 50%, 41.6% in those with 40%

Impact of routine angiographic follow-up after percutaneous coronary drug-eluting stenting for unprotected left main disease: the Turin Registry.

BACKGROUND: Most cardiologists performing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main disease (ULM) mandate mid-term angiographic follow-up, yet there are few data supporting this approach. We aimed to retrospectively compare the outcome of patients with ULM treated with DES according to their follow-up management strategy. METHODS: Patients with ULM stenosis undergoing PCI with DES and surviving up to 6 months were retrospectively identified from our ongoing database. We distinguished those undergoing clinical follow-up only, those with clinically driven angiographic follow-up, and those with routine angiographic follow-up. The primary end-point was the long-term rate of major adverse cardiac events (MACE, i.e., death, myocardial infarction, bypass surgery, or repeat ULM PCI). RESULTS: A total of 198 patients were included: 55 (28%) in the clinical follow-up group, 64 (32%) in the clinically driven angiographic follow-up group, and 79 (40%) in the routine angiographic follow-up group. After 37.0 +/- 15.7 months, mortality was similar in the 3 groups (respectively 7.3, 4.7, and 5.9%, p = 0.27). However, MACE were significantly more common in the clinically driven angiographic follow-up group (42.2 vs. 7.3 and 26.1%, p = 0.02), mainly due to the expected increase in repeat revascularization in those undergoing angiographic follow-up (23.4 vs. 1.8 and 13.14%). Notably, there were no differences in the rate of stent thrombosis across the three groups, with rates of 3.1 vs. 1.8 and 2.5% (p = 0.35). CONCLUSIONS: An expectant management can be safely adopted in most patients with ULM treated percutaneously, as long as a low threshold for control coronary angiography is maintained.

Quantitative coronary angiography in the current era: principles and applications.

Coronary angiography, despite its inherent invasiveness and need for contrast media and radiographic exposure, is still routinely employed every year for the diagnostic and therapeutic management of millions of patients with or at risk for coronary artery disease. Whereas approximate visual estimation is the most common way to evaluate coronary angiography findings, since the late 1980s a number of investigators have developed and investigated methods of quantitative coronary angiography (QCA) analysis exploiting automated or semi-automated edge detection. Despite the inherent drawback of QCA due to its focus on the contrast-filled lumen of the vessel, QCA has offered and continues to offer important insights for clinical research and, in selected cases, clinical practice. This review aims thus to provide a comprehensive and updated viewpoint on the actual role of QCA.

Impact of multivessel stenting on top of percutaneous revascularization for unprotected left main disease in the drug-eluting stent era: insights from the Turin registry.

OBJECTIVE: Drug-eluting stents (DESs) are commonly used in patients with unprotected left main (ULM) disease. Although multivessel disease and stenting are frequent in this population, pertinent details on short-term and long-term outcomes are lacking. SETTING AND PATIENTS: We identified consecutive patients with DES treatment for ULM. We distinguished patients presenting isolated ULM stenting (group A) from those with additional treatment of at least another major vessel (group B). The primary end point was major adverse cardiovascular events (i.e. death, myocardial infarction or target vessel revascularization). We compared the impact of a DES-only versus a hybrid DES and bare metal stent strategy for non-ULM lesions. RESULTS: A total of 189 patients were included, 25% in group A and 75% in group B. In-hospital events were similarly favorable (cardiac death in 0 and 2%, respectively, P = 0.58). A total of 99% patients were followed for a median of 25 months, yielding major adverse cardiovascular events in 17 and 37.5% (P = 0.011). Specifically, death occurred in 4 and 8.5% (P = 0.52), cardiac death in 0 and 7% (P = 0.12), myocardial infarction in 6.5 and 9% (P = 0.76) and target vessel revascularization in 4.3 and 22% (P = 0.006). Adoption of a systematic DES-only strategy for non-ULM lesions conferred significant benefits on major adverse cardiovascular events and repeat non-ULM revascularizations in comparison to a hybrid strategy (22 versus 45%, P < 0.001, and 9 versus 19%, P = 0.004, respectively), at both bivariate and multivariable analyses. CONCLUSION: Multivessel stenting on top of DES implantation for ULM can be performed with favorable early results. Systematic DES implantation for both ULM and non-ULM lesions is pivotal to maximize clinical results and minimize long-term recurrences.

Impact of diabetes mellitus on early and long-term results of percutaneous drug-eluting stent implantation for unprotected left main coronary disease.

BACKGROUND: We aimed to appraise the outcomes of diabetic patients with unprotected left main (ULM) disease treated with drug-eluting stents. Percutaneous coronary intervention with drug-eluting stent implantation is increasingly used for ULM disease. However, there are no data on the clinical results of drug-eluting stents for ULM disease in patients with diabetes. METHODS: We collected baseline and outcome data from all patients undergoing percutaneous coronary intervention with drug-eluting stents for ULM disease at our institution since 2002. We identified three groups: insulin-requiring diabetes mellitus patients, noninsulin-requiring diabetes mellitus patients, and nondiabetes mellitus individuals. The primary end point was the rate of major adverse cardiac events, that is, cardiac death, myocardial infarction, or target vessel revascularization. We also appraised stent thrombosis according to the Academic Research Consortium. RESULTS: A total of 185 patients were enrolled, 25/185 (14%) insulin-requiring diabetes mellitus patients, 30/185 (16%) noninsulin-requiring diabetes mellitus patients, and 130/185 (70%) nondiabetes mellitus individuals. In-hospital adverse events were overall uncommon and not significantly different across groups. After a median follow-up period of 23.1 months, major adverse cardiac events had occurred in similar rates across groups: 6/25 (24%) insulin-requiring patients with diabetes mellitus, 8/30 (27%) noninsulin-requiring patients with diabetes mellitus, and 31/128 (24%) nondiabetes mellitus individuals (P = 0.96). No case of definite or probable stent thrombosis was adjudicated. Intriguingly, possible stent thrombosis was nonsignificantly more common among insulin-requiring diabetes mellitus patients than among noninsulin-requiring diabetes mellitus patients or nondiabetes mellitus individuals [1/25 (4%) vs. 0/30 (0%) and 1/128 (0.8%), respectively, P = 0.30]. CONCLUSION: Drug-eluting stents provide favorable early and long-term results in both selected patients with diabetes and nondiabetic individuals undergoing percutaneous coronary intervention for ULM disease. Nonetheless, further randomized data are eagerly awaited to definitely confirm or disprove these findings.