Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain.

INTRODUCTION AND OBJECTIVES: The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. METHODS: This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. RESULTS: Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). CONCLUSIONS: In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

Percutaneous Intervention in Diffuse Coronary Disease: Overlapping Versus Single Very Long Stent Technique. Results From the OVERLONG Registry.

BACKGROUND: Both stent length and stent overlap are associated with worse outcomes in the percutaneous treatment of diffuse coronary artery disease (dCAD). However, evidence comparing these issues is scarce. We aimed to compare the results between the use of single very long stent (VLS) and ≥2 overlapping stents (OS) in the treatment of dCAD. METHODS: Seven hundred twenty-four consecutive lesions were included: 275 treated with a single VLS (≥40 mm) and 449 with ≥2 OS. Procedural characteristics were assessed, and survival analysis was performed to compare the incidence of major adverse cardiovascular events (MACE; composite of cardiovascular death, nonfatal myocardial infarction, target lesion revascularization [TLR], or stent thrombosis) during a median follow-up of 31 months. RESULTS: Procedures with VLS required less contrast volume (268 ± 122 vs 302 ± 113 cm3; P < .01), fluoroscopy time (16 ± 8 vs 21 ± 16 minutes; P < .01), and procedure duration (37 ± 18 vs 47 ± 27 minutes; P < .01) than the OS procedures. The VLS group showed lower incidence of MACE (4.4% vs 10.7%; P < .01), driven mainly by lower TLR rate (1.1% vs 4.7%; P < .01). The use of OS was an independent predictor of MACE. CONCLUSIONS: In this study, the use of VLS for the treatment of dCAD was associated with better outcomes compared to OS.

Long-Term Follow-Up of Percutaneous Coronary Intervention With Paclitaxel-Eluting Balloon Catheter.

Drug-eluting balloons currently constitute a therapeutic tool used in percutaneous coronary interventions (PCI). Long-term results remain unknown. We evaluated the prognosis of PCI using a second generation paclitaxel-eluting balloon (PEB) in real-world patients. We included all PCI with PEB in de novo or in-stent restenosis coronary lesions performed in our unit from March 2009 to March 2019. We assessed the composite of major adverse cardiovascular events (MACE) rate after a median follow-up of 42 months. Consecutive patients (n = 320) with 386 lesions were included; 46.9% presented with stable angina and 53.1% acute coronary syndromes; 52.6% of the lesions were in-stent restenosis and 47.3% de novo lesions with a mean diameter of 2.4 ± 0.5 mm. A bare metal stent was implanted in 6.7% and a drug-eluting stent in 8.5% of patients. The MACE rate was 8%: 10 (2.6%) cardiovascular deaths, 13 (3.4%) myocardial infarctions, and 16 (4.1%) target lesion revascularization. The all-cause death rate was 5.2%. No cases of thrombosis were recorded. In conclusion, PEB was a safe and effective tool to treat in-stent restenosis and de novo coronary lesions, especially small vessel disease, during long-term follow-up.

Clinical Prognosis Associated With the Use of Overlapping Stents With Homogenous Versus Heterogeneous Pharmacological Characteristics for the Treatment of Diffuse Coronary Artery Disease.

BACKGROUND: The clinical impact of percutaneous coronary intervention (PCI) and implantation of overlapping stents (OS) using platforms with the same versus different pharmacological characteristics is unknown. Our objective was to compare the outcomes of PCI with OS according to their pharmacological characteristics. METHODS: In this observational single-center registry, we included all PCI performed from April 2014 to December 2018 in which overlapping drug-eluting stents were implanted. Two groups were created according to whether the stents release the same drug [homogeneous: (HO)] or different [heterogeneous: (HE)]. The primary endpoint was the need for target lesion revascularization (TLR). Clinical assessment was performed after the procedure, bianually and at the end of follow-up (June 2019). RESULTS: 381 lesions with OS (HO: 209; HE: 172) were included (75.1% male, 66.7 ±â€¯11.6 years). Clinical presentation was stable coronary artery disease in 49.9%. Syntax score was 23.7 ±â€¯13.3. The number of OS implanted was 2.2 ±â€¯0.5 and the total stent length was 59.5 ±â€¯20.1 mm (HE: 61.5 ±â€¯21.6 vs. HO: 57.8 ±â€¯18.8 mm; p < 0.01). After a median follow-up of 21 months, the HE group showed a lower TLR rate than the HO group (HE:2.3% vs HO:7.2%; p = 0.03). The rates of cardiac death (p = 0.44), myocardial infarction (p = 0.36) and stent thrombosis (p = 0.85) were similar between groups. In the multivariate analysis, the OS with homogeneous-drug devices was an independent predictor of a higher rate of TLR. CONCLUSIONS: PCI using OS with homogeneous pharmacological characteristics was associated with a higher rate of TLR in comparison with the implantation of OS with heterogeneous pharmacological characteristics.

An Unusual Entity: Woven Coronary Artery Anomaly.

The recognition of woven coronary artery anomaly is difficult because of its rare nature. Optical coherence tomography imaging is challenging due to the tortuosity of the channels; however, it is crucial not only for the differential diagnosis but also to guide the treatment approach.

Cocaine-Associated ST-Elevation Myocardial Infarction: Different Pathophysiological Mechanisms.

There are many underlying mechanisms for cocaine-associated myocardial infarction, and the culprit must be elucidated for appropriate therapeutic management. Optical coherence tomography provides unique insights when angiography alone has limited diagnostic value; it also aids in the decision between conservative management and revascularization strategy and guides coronary interventions.

Coronary Artery Tenting After Bypass Grafting: A Key Issue During Percutaneous Coronary Intervention of a Chronic Total Occlusion.

This image series shows how bypass grafts may tent the vessel to which they are anastomosed, potentially changing the expected course of the native coronary vessel. This fact must be taken into account during CTO-PCI, and this case emphasizes the importance of careful analysis of coronary anatomy with several angiographic projections.

Comparison of Clinical Outcomes Between Very Long Stents and Overlapping Stents for the Treatment of Diffuse Coronary Disease in Real Clinical Practice.

BACKGROUND: The stent length as well as the stent overlap for the percutaneous treatment of diffuse coronary disease have been considered predictors of adverse events. However, there are no comparative data on the use of very long stents or overlapping stents in this scenario. OBJECTIVE: To compare the clinical results of very long stents (≥40 mm) or overlapping stents in real clinical practice. METHODS: We included 643 lesions in 628 consecutive patients treated with a single very long stent (≥40 mm) (251 lesions) or ≥2 overlapped stents (392 lesions). We analyzed the procedural characteristics and the presentation of the combined endpoint [cardiovascular death, non-fatal myocardial infarction, need for target lesion revascularization or stent thrombosis] after a follow-up of 20 months. RESULTS: Total stent length was 54 ±â€¯18 mm and minimum diameter was 2.9 ±â€¯1.2 mm. At the end of follow-up, the rate of adverse events was 8.3% (cardiac death: 4.9%, myocardial infarction: 1.7%, target lesion revascularization: 3.1%, stent thrombosis: 0.7%). There were no significant differences between both groups in the presentation of the combined endpoint. Procedures with overlapping stents had more contrast volume (309 ±â€¯115 vs 273 ±â€¯127 ml; p = 0.002), longer duration (47 ±â€¯22 vs 39 ±â€¯18 min; p < 0.0001), higher fluoroscopy time (20 ±â€¯13 vs 16 ±â€¯9 min; p < 0.0001) and higher number of stents to treat the index lesion (2.2 ±â€¯0.5 vs 1; p < 0.0001). CONCLUSIONS: New designs of very long stents allow not only treating increasingly complex lesions, but also simplifying the procedure and decreasing the number of stents with very favorable results similar to those obtained with stent overlap.

Systematic isolated post-dilatation of the side branch as part of the provisional stent technique in the percutaneous treatment of coronary bifurcations. CR12 Registry.

AIMS: To analyse systematic isolated post-dilatation of the side branch as a part of provisional stent technique. METHODS: 1960 angioplasties performed in two centres were prospectively registered, of which 382 were coronary bifurcations with a side branch>2mm. In centre A, isolated post-dilatation of the side branch was performed regardless its impairment after main vessel stenting. In centre B, side branch post-dilatation was performed only if it was severely affected after stent implantation. RESULTS: There was no difference between the two centres in the rate of side branch affection after stent implantation (A: 44.6 vs B: 49.3%, p=0.48) nor in the procedural success rate (A: 98.6% vs B: 96.7%, p=0.45). After one-year follow-up, a reduction of cardiovascular events was observed in centre A (A: 4.4% vs B: 10.4%, p=0.043) with a trend towards lower cardiac mortality (A: 2.2% vs B: 6.5%, p=0.093) and stent thrombosis (A: 0% vs B: 2.6%, p=0.077). There were no differences in the rate of myocardial infarction related to the treated artery (A: 1.4% vs B: 3.9%, p=0.29), or target lesion revascularization (A: 1.4% vs. B: 3.2%, p=0.45). CONCLUSIONS: Systematic isolated post-dilatation of the side branch in the provisional stent technique was associated with a high angiographic success rate, and a low rate of cardiovascular events during follow-up. Although the study design does not allow definitive conclusions, this strategy could be considered a valid option in some cases or even as part of the provisional stent technique.

Coronary Artery Aneurysm After Mini-Crush Drug-Eluting Stent Technique in a Chronic Total Occlusion.

A 53-year-old man underwent percutaneous coronary intervention of a chronic total occlusion of the circumflex artery. A mini-crush stent technique with two drug-eluting stents was performed. To the best of our knowledge, this is the first case of coronary artery aneurysm affecting a bifurcated chronic total occlusion treated with a two-stent technique.

Single coronary artery presenting as acute myocardial infarction.

A single coronary artery is one of the most rarely seen coronary artery anomalies. In addition, the specific subtype (Lipton RII-A) that our patient presented is one of the least common, and its clinical presentation as myocardial infarction and cardiac arrest has not been described in the literature. The case shows that although it is essential to exclude a malignant interarterial course of the vessel, cardiac arrest is a possible clinical presentation produced by myocardial ischemia in the context of acute myocardial infarction and should be managed according to clinical practice guidelines.

Bioresorbable vascular scaffold to treat malignant in-stent restenosis in a patient with nickel allergy.

Nickel is the most frequent allergen in patients with allergic contact dermatitis and nickel allergy has been associated with recurrent in-stent restenosis. However, it is often misdiagnosed because of a low suspicion threshold. It should be discarded in patients with recurrent in-stent restenosis, especially if their medical history reveals prior contact dermatitis. It is also noteworthy and rarely specified that even newer generation stents that use novel metal alloys also contain low amounts of nickel. To avoid the implantation of new stents containing this metal, when percutaneous coronary intervention is indicated, drug eluting balloons or bioresorbable vascular scaffolds associated with small doses of steroids could provide good alternatives of treatment. To the best of our knowledge, this is the first description of this therapeutic alternative in such an exceedingly rare clinical scenario.

¿La implantación del código infarto implica cambios en el tratamiento y el pronóstico de los pacientes con síndrome coronario agudo sin elevación del ST? / Does implementation of the infarction code lead to changes in the treatment and prognosis of patients with non-ST elevation acute coronary syndrome?

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Endoscopic Ultrasound for the Detection of Left Atrial Appendage Thrombus: A Useful Technique in Patients with Transesophageal Echocardiography Contraindication.

Endoscopic ultrasound is a diagnostic and therapeutic technique used in specialized centers for patients that have undergone digestive procedures. This technique enables highly precise real-time imaging of the digestive tract wall and surrounding organs. Endoscopic ultrasound is also useful in patients with cardiovascular diseases such as atrial fibrillation. In patients with contraindication for transesophageal echocardiography due to high risk of esophageal bleeding or complications that may require immediate intervention, endoscopic ultrasound may be a safer option for visualizing atrial chambers to rule out the presence of left atrial appendage thrombi before cardioversion.

Effectiveness of the implementation of a simple radiation reduction protocol in the catheterization laboratory.

BACKGROUND AND PURPOSE: A reduction in radiation doses at the catheterization laboratory, maintaining the quality of procedures is essential. Our objective was to analyze the results of a simple radiation reduction protocol at a high-volume interventional cardiology unit. METHODS: We analyzed 1160 consecutive procedures: 580 performed before the implementation of the protocol and 580 after it. The protocol consisted in: the reduction of the number of ventriculographies and aortographies, the optimization of the collimation and the geometry of the X ray tube-patient-receptor, the use of low dose-rate fluoroscopy and the reduction of the number of cine sequences using the software "last fluoroscopy hold". RESULTS: There were no significant differences in clinical baseline features or in the procedural characteristics with the exception of a higher percentage of radial approach (30.7% vs 69.6%; p<0.001) and of percutaneous coronary interventions of chronic total occlusions after the implementation of the protocol (2.1% vs 6.7%; p=0,001). Angiographic success was similar during both periods (98.3% vs 99.2%; p=0.2). There were no significant differences between both periods regarding the overall duration of the procedures (26.9 vs 29.6min; p=0.14), or the fluoroscopy time (13.3 vs 13.2min; p=0.8). We observed a reduction in the percentage of procedures with ventriculography (80.9% vs 7.1%; p<0.0001) or aortography (15.4% vs 4.4%; p<0.0001), the cine runs (21.8 vs 6.9; p<0.0001) and the dose-area product (165 vs 71 Gyxcm(2); p<0.0001). CONCLUSIONS: With the implementation of a simple radiation reduction protocol, a 57% reduction of dose-area product was observed without a reduction in the quality or the complexity of procedures.

La ecografía endoscópica, una alternativa a la ecografía transesofágica para pacientes con varices esofágicas durante el intervencionismo estructural / Endoscopic ultrasound: an alternative to transesophageal echocardiography for patients with esophageal varices during a structural interventional procedure

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