The role of drug-coated balloons for coronary bifurcation management: results from the prospective EASTBOURNE-BIF study.

BACKGROUND: Coronary bifurcation lesions are associated with less favourable outcome as compared to other lesion subsets. The role of drug-coated balloons (DCB) for bifurcation lesions has been only investigated in small studies so far, which reported encouraging results. We here describe the results of EASTBOURNE-BIF prospective registry, in which a sirolimus-DCB was used for the treatment of bifurcation lesions. METHODS: Overall, 194 patients with bifurcations lesions identified in the EASTBOURNE study (Medina 1.1.1/1.1.0/1.0.1/0.1.1/0.1.0) were compared with 1049 patients with de-novo lesions from the same registry. Both a blended-strategy using a drug-eluting stent in the main branch and a DCB in the side branch as well as a full-DCB approach were used in the treatment of bifurcation lesions. RESULTS: At one year of follow-up the study primary endpoint, target-lesion revascularization occurred at a similar rate in the bifurcation group versus the de-novo group (4.2 vs. 2%, P=0.28). Similar outcomes were observed in terms of all-cause death (3.3 vs. 1.4%, P=0.138), major adverse cardiovascular events (8.8 vs. 5.2%, P=0.081) and the rate of spontaneous myocardial infarction (2.8 vs. 1.0%, P=0.117). CONCLUSIONS: The results of EASTBOURNE-BIF study show how the use of this DCB alone or in combination with drug eluting stents could represent a safe and effective alternative to stents for the treatment of bifurcations.

A 2024 scientific update on the clinical performance of drug-coated balloons.

Continuous advances in the field of interventional cardiology have led to the development of drug-coated balloons (DCB). These represent a promising device for overcoming the well-known limitations of traditional metallic stents, which are associated with a persistent yearly increased risk of adverse events. This technology has the ability to homogeneously transfer the drug into the vessel wall in the absence of a permanent prosthesis implanted in the coronary vessel. Robust data support the use of DCB for the treatment of in-stent restenosis, but there is also currently growing evidence from long-term follow-up of large randomised clinical trials regarding the use of these devices in other scenarios, such as de novo small and large vessel disease, complex bifurcations, and diffuse coronary disease. Other critical clinical settings such as diabetes mellitus, high bleeding risk patients and acute coronary syndromes could be approached in the upcoming future by using DCB, alone or as part of a blended strategy in combination with drug-eluting stents. There have been important scientific and technical advances in the DCB field in recent years. The purpose of this paper is to review the most current data regarding the use of DCB, including the mid- and long-term follow-up reports on the safety and efficacy of this novel strategy in different clinical and angiographic scenarios.

Peripheral Artery Disease Ultrasound Assessment in Predicting the Severity of Coronary Artery Disease.

Atherosclerosis in a progressive disease that is systemic in nature, and hence the simultaneous presentation of coronary artery disease (CAD) and peripheral artery disease (PAD) is not uncommon. As clinically manifested PAD is associated with worse cardiovascular outcomes, the timely identification of subclinical atherosclerosis seems of utmost importance. Ultrasonography (US) is an ideal imaging modality for assessing PAD that is easy to use, accurate, widely available and avoids unnecessary exposure to radiation. Several US parameters have been proposed in the assessment of PAD, with varying prognostic usefulness, depending on disease location. The aim of this review is to summarize the most important evidence available on the association between US-detected atherosclerosis in different vascular sites and the presence and severity of CAD, as well as the impact of the early detection of PAD on the outcomes of patients presenting with CAD.

Correlation between Ultrasound Peak Systolic Velocity and Angiography for Grading Internal Carotid Artery Stenosis.

(1) Background: The success of carotid revascularization depends on the accurate grading of carotid stenoses. Therefore, it is important for every vascular center to establish its protocols for the same. In this study, we aimed to determine the peak systolic velocity (PSV) thresholds that can predict moderate and severe internal carotid artery (ICA) stenoses. (2) Methods: To achieve this, we enrolled patients who underwent both duplex ultrasound (DUS) and invasive carotid artery digital subtraction angiography (DSA). The degree of ICA stenosis was assessed using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) protocols. The PSV thresholds were determined using receiver operating characteristic (ROC) curves. (3) Results: Our study included 47 stenoses, and we found that the PSV cut-off for predicting ≥70% NASCET ICA stenoses was 200 cm/s (sensitivity 90.32%, specificity 93.75%). However, PSV did not correlate significantly with ≥50% NASCET ICA stenoses. On the other hand, the optimal PSV threshold for predicting ≥80% ECST ICA stenoses was 180 cm/s (sensitivity 100%, specificity 81.82%). (4) Conclusions: Based on our findings, we concluded that PSV is a good and simple marker for the identification of severe stenoses. We found that PSV values correlate significantly with severe NASCET and ECST stenoses, with 200 cm/s and 180 cm/s PSV thresholds. However, PSV was not reliable with moderate NASCET stenoses. In such cases, complementary imaging should be used.

Portable microfluidic plasmonic chip for fast real-time cardiac troponin I biomarker thermoplasmonic detection.

Acute myocardial infarction is one of the most serious cardiovascular pathologies, impacting patients' long-term outcomes and health systems worldwide. Significant effort is directed toward the development of biosensing technologies, which are able to efficiently and accurately detect an early rise of cardiac troponin levels, the gold standard in detecting myocardial injury. In this context, this work aims to develop a microfluidic plasmonic chip for the fast and accurate real-time detection of the cardiac troponin I biomarker (cTnI) via three complementary detection techniques using portable equipment. Furthermore, the study focuses on providing a better understanding of the thermoplasmonic biosensing mechanism taking advantage of the intrinsic photothermal properties of gold nanoparticles. Specifically, a plasmonic nanoplatform based on immobilized gold nanobipyramids was fabricated, exhibiting optical and thermoplasmonic properties that promote, based on a sandwich-like immunoassay, the "proof-of-concept" multimodal detection of cTnI via localized surface plasmon resonance, surface enhanced Raman spectroscopy and thermoplasmonic effects under simulated conditions. Furthermore, after the integration of the plasmonic nanoplatform in a microfluidic channel, the determination of cTnI in 16 real plasma samples was successfully realized via thermoplasmonic detection. The results are compared with a conventional high-sensitivity enzyme-linked immunosorbent clinical assay (ELISA), showing high sensitivity (75%) and specificity (100%) as well as fast response features (5 minutes). Thus, the proposed portable and miniaturized microfluidic plasmonic chip is successfully validated for clinical applications and transferred to clinical settings for the early diagnosis of cardiac diseases, leading towards the progress of personalized medicine.

Anthracycline's Effects on Heart Rate Variability in Children with Acute Lymphoblastic Leukemia: Early Toxicity Signs-Pilot Study.

Anthracycline treatments are known to cause cardiotoxic long-term side effects in cancer survivors. Recently, a decrease in heart rate variability (HRV) has been identified in these patients, signaling autonomic dysfunction and altered cardiac fitness. This study aimed at evaluating changes in HRV in children treated with anthracyclines. A total of 35 pediatric patients with acute lymphoblastic leukemia were evaluated by means of a 24 h Holter ECG, at baseline and after reaching half the total cumulative dose of doxorubicin equivalent (120 mg/m2). Parameters of HRV were assessed, as well as any arrhythmic episodes, bradycardia and tachycardia percentages. The results showed a significant decrease in both time-domain and frequency-domain HRV parameters, following anthracycline treatment. The low-frequency (LF) to high-frequency (HF) parameters' ratio also displayed a significant difference (p = 0.035), suggestive of early cardiac autonomic dysfunction. Of note, none of the patients presented symptoms of heart disease or elevated troponins, and only two patients presented echocardiographic signs of diastolic dysfunction. The present study showed that cardiac autonomic nervous system regulation is compromised in children treated with anthracyclines even before reaching the total cumulative dose. Therefore, HRV parameters could be the first indicators of subclinical cardiac toxicity, making Holter ECG monitoring of the oncological patient a necessity.

Superficial Calcified Plates Associated to Plaque Erosions in Acute Coronary Syndromes.

This study investigates the clinical relevance and therapeutic implications of the OCT identification of intracoronary superficial calcified plates (SCPs) in acute coronary syndromes (ACSs). In 70 consecutive ACS patients (pts), we studied the three main underlying ACS mechanisms: plaque erosion (PE), plaque rupture and eruptive calcified nodule (CN). The PE lesions, occurring on an intact fibrous cap overlying a heterogeneous substrate, were identified in 12/70 pts (17.1%). PE on superficial calcified plates (PE-SCP) represented 58.3% of the PE lesions (7/12 pts) and had a 10% overall incidence in the culprit lesions (7/70 pts). PE-SCP lesions occurred mostly on the left anterior descending artery, correlated with white thrombi (85.7%) and had a proximal intraplaque site (71.4%). PE-SCP lesions were treated conservatively, as nonsignificant lesions, in 4/7 pts. Our study emphasizes that the coronary calcium-related ACS risk is not only associated with the spotty calcifications or CN but also with the PE-SCP lesions.

The role of optical coherence tomography in guiding percutaneous coronary interventions- is left main the final challenge?

Left main (LM) coronary artery disease is a high-risk lesion subset, with important prognostic implications for the patients. Recent advances in the field of interventional cardiology have narrowed the gap between surgical and percutaneous approach of this complex lesion setting. However, the rate of repeat revascularization remains higher in the case of percutaneous coronary intervention (PCI) on long-term follow-up. As such, the need for better stent optimization strategies has led to the development of intravascular imaging techniques, represented mainly by intravascular ultrasound (IVUS) and optical coherence tomography (OCT). These techniques are both able to provide excellent pre- and post-PCI guidance. While IVUS is an established modality in optimizing LM PCI, and is recommended by international revascularization guidelines, data and experience on the use of OCT are still limited. This review paper deeply analyzes the current role of OCT imaging in the setting of LM disease, particularly focusing on its utility in assessing plaque morphology and distribution, vessel dimensions and proper stent sizing, analyzing mechanisms of stent failure such as malapposition and underexpansion, guiding bifurcation stenting, as well as offering a direct comparison with IVUS in this critical clinical scenario, based on the most recent available data.

Distinctive Morphological Patterns of Complicated Coronary Plaques in Acute Coronary Syndromes: Insights from an Optical Coherence Tomography Study.

Optical coherence tomography (OCT) is an ideal imaging technique for assessing culprit coronary plaque anatomy. We investigated the morphological features and mechanisms leading to plaque complication in a single-center observational retrospective study on 70 consecutive patients with an established diagnosis of acute coronary syndrome (ACS) who underwent OCT imaging after coronary angiography. Three prominent morphological entities were identified. Type I or intimal discontinuity, which was found to be the most common mechanism leading to ACS and was seen in 35 patients (50%), was associated with thrombus (68.6%; p = 0.001), mostly affected the proximal plaque segment (60%; p = 0.009), and had no distinctive underlying plaque features. Type II, a significant stenosis with vulnerability features (inflammation in 16 patients, 84.2%; thin-cap fibroatheroma (TCFA) in 10 patients, 52.6%) and a strong association with lipid-rich plaques (94.7%; p = 0.002), was observed in 19 patients (27.1%). Type III, a protrusive calcified nodule, which was found to be the dominant morphological pattern in 16 patients (22.9%), was found in longer plaques (20.8 mm vs. 16.8 mm ID vs. 12.4 mm SS; p = 0.04) and correlated well with TCFA (93.8%; p = 0.02) and inflammation (81.3%). These results emphasize the existence of a wide spectrum of coronary morphological patterns related to ACS.

Interventional Management of a Rare Combination of Nutcracker and Wilkie Syndromes.

Nutcracker and Wilkie syndromes are rare mesoaortic compression entities, and their association is even less common. Data on interventional treatment of these pathologies are still scarce, but results from limited case series are encouraging. We report the case of a previously healthy 45-year-old woman diagnosed with nutcracker and Wilkie syndromes who presented with macroscopic hematuria, intermittent pain in the left flank and hypogastric region, postprandial nausea, and unexplained significant weight loss. A successful endovascular approach with stent implantation in the left renal vein was performed, but the stent migrated toward the left kidney, and this acute complication was managed through an interventional strategy as well. At the three-month follow-up, the patient described a marked improvement in all symptoms, except for the macroscopic hematuria. As it was our strong belief that the approach was efficient, we further investigated the "hematuria", which eventually led to the diagnosis of endometrial carcinoma. A hysterectomy and bilateral adnexectomy were planned, and chemoradiotherapy was initiated with the goal of preoperative tumor reduction. To our knowledge, this is the first reported case in which both Wilkie and nutcracker syndromes were effectively treated by stent implantation in the left renal vein, complicated with very early stent migration due to inadequate apposition to the less compliant venous lumen. The treatment of the duodenal compression was indirectly included in the stenting of the left renal vein, as reclaiming the venous lumen widened the aortomesenteric angle. The aim of this review is to discuss our center's transcatheter experience with these rare disorders and explore the literature in order to establish the benefits and limitations of such an approach.

High-Sensitivity Troponin: A Review on Characteristics, Assessment, and Clinical Implications.

The use of high-sensitivity cardiac troponin (hs-cTn) assays has become part of the daily practice in most of the laboratories worldwide in the initial evaluation of the typical chest pain. Due to their early surge, the use of hs-cTn may reduce the time needed to recognise myocardial infarctions (MI), which is vital for the patients presenting in the emergency departments for chest pain. The latest European Society of Cardiology Guidelines did not only recognise their central role in the diagnosis algorithm but also recommended their use for rapid rule-in/rule-out of MI. High-sensitivity cardiac troponins are also powerful prognostic markers for long-term events and mortality, not only in a wide spectrum of other cardiovascular diseases (CVD) but also in several non-CVD pathologies. Moreover, these biomarkers became a powerful tool in special populations, such as paediatric patients and, most recently, COVID-19 patients. Although highly investigated, the assessment and interpretation of the hs-cTn changes are still challenging in the patients with basal elevation such as CKD or critically ill patients. Moreover, there are still various analytical characteristics not completely understood, such as circadian or sex variability, with major clinical implications. In this context, the present review focuses on summarizing the most recent research in the current use of hs-cTn, with a main consideration for its role in the diagnosis of MI but also its prognostic value. We have also carefully selected the most important studies regarding the challenges faced by clinicians from different specialties in the correct interpretation of this biomarker. Moreover, future perspectives have been proposed and analysed, as more research and cross-disciplinary collaboration are necessary to improve their performance.

Safety and efficacy of systematic lesion preparation with a novel generation scoring balloon in complex percutaneous interventions: results from a prospective registry.

BACKGROUND: Coronary lesions predilatation with semicompliant (SC) or non-compliant balloons (NC) may be insufficient to obtain an optimal stent expansion, which can lead to in-stent restenosis or thrombosis. Moreover, increasing evidence supporting an optimal lesion preparation is mandatory when drug coated balloons (DCB) are used. To this extent, more "aggressive tools" such as cutting/scoring balloons, atherectomy or lithotripsy may play an important role and improve outcomes. METHODS: We enrolled 78 consecutive patients from March 2020 to October 2020 with calcific/fibrotic or ostially-located lesions, which were prepared using scoring balloons, in addition to SC/NC balloons and other plaque modification strategies. The final treatment consisted in either stent or DCB usage. The primary endpoint was the rate of clinically-driven target lesion revascularization. Secondary endpoints entailed the procedural success and the individual rates of major adverse cardiac events (MACE) at 12 months. RESULTS: Most of the patients had left main (LM) or ostial lesions, 65% of them being moderate/severely calcified, with further debulking strategies being required in 15 (19.2%) patients (rotational atherectomy, 3.8% or coronary intravascular lithotripsy, 15.3%). A high-rate of DCB usage was reported. Angiographic and procedural success was obtained in 77 and 76 patients, respectively. We encountered one vessel perforation, which was sealed with a covered stent, without consequence. During follo- up, we observed only 6 MACE, 6 target lesion revascularizations (TLR) and 2 cardiovascular deaths. CONCLUSIONS: Among patients with high complexity and calcific lesions, an optimal lesion preparation using a dedicated scoring balloon was associated with low clinical events at mid-term follow-up and may be considered to improve immediate procedural success rate.