Percutaneous management of long and diffused coronary lesions using newer generation drug-eluting stents in routine clinical practice: long-term outcomes and complication predictors.

INTRODUCTION: Long and diffuse coronary lesions (LDCLs) are routinely subjected to percutaneous management, but long­term clinical outcomes and complication predictors with the use of contemporary stents and techniques remain undetermined. OBJECTIVES: The aim of the study was to address long­term effects of percutaneous management of LDCLs, using contemporary devices and optimization techniques. PATIENTS AND METHODS: Long and diffuse coronary lesion was defined as a lesion requiring an implantation of 30 mm or longer total stent(s) length (TSL) into one coronary artery (bailouts excluded). There were 290 LDCL interventions with the use of newer generation drug­eluting stents (DESs; cobalt chromium everolimus- or zotarolimus-eluting stents) performed between January 2013 and January 2016. RESULTS: The mean (SD) TSL was 55.5 (16.8) mm. The use of intravascular ultrasound / optical coherence tomography was 17.1%, rotablation, 6.9%, and noncompliant balloon, 88.9%. The median (range) follow­up duration was 831 (390-1373) days. All­cause mortality and cardiac death rates were 11.7% and 6.9%, respectively. The myocardial infarction (MI) rate was 6.6%, including target­vessel MI in 4.1%. The rate of clinically­driven repeat revascularization was 13.8%, and of definite or probable LDCL stent thrombosis, 7.2%. Overall patient­oriented adverse event rate (any death, MI, or repeat revascularization) was 25.5%, and device­oriented rate (cardiac death, target vessel­MI, or target lesion restenosis), 13.4%. Adverse outcome predictors were chronic kidney disease, acute coronary syndrome as an indication for the procedure, chronic heart failure with reduced left ventricular ejection fraction, multivessel disease, and coexisting peripheral artery disease, but not lesion­related factors, such as bifurcation, calcification, chronic total occlusion, or TSL. CONCLUSIONS: Adverse outcomes following contemporary LDCL management using newer generation DESs in routine clinical practice are associated with clinical patient characteristics rather than lesion characteristics or TSL. We identified high­risk patient cohorts that may benefit from enhanced surveillance.

Clostridium difficile infection: review.

Clostridium difficile (C. difficile) is a Gram-positive, spore-forming, anaerobic bacillus, which is widely distributed in the intestinal tract of humans and animals and in the environment. In the last decade, the frequency and severity of C. difficile infection has been increasing worldwide to become one of the most common hospital-acquired infections. Transmission of this pathogen occurs by the fecal-oral route and the most important risk factors include antibiotic therapy, old age, and hospital or nursing home stay. The clinical picture is diverse and ranges from asymptomatic carrier status, through various degrees of diarrhea, to the most severe, life threatening colitis resulting with death. Diagnosis is based on direct detection of C. difficile toxins in feces, most commonly with the use of EIA assay, but no single test is suitable as a stand-alone test confirming CDI. Antibiotics of choice are vancomycin, fidaxomicin, and metronidazole, though metronidazole is considered as inferior. The goal of this review is to update physicians on current scientific knowledge of C. difficile infection, focusing also on fecal microbiota transplantation which is a promising therapy.

Lymphocyte and monocyte subpopulations in severe aortic stenosis at the time of surgical intervention.

INTRODUCTION: Aortic stenosis (AS) is the most common acquired valvular heart disease in adults. Immune system involvement becomes evident during AS development. We sought to investigate the role of different circulating lymphocyte and monocyte subpopulations, with focus on CD4+CD8+ and natural killer T (NKT) cells, in AS. MATERIAL AND METHODS: Blood samples and aortic valves were obtained from patients undergoing elective aortic valve surgery. Valves were dissected and underwent genetic analyses and calcium content assessment. Lymphocytes and monocytes subsets were assessed by flow cytometry. RESULTS: Thirty-eight AS patients were studied. Maximal transvalvular pressure gradient (PGmax) as well as mean transvalvular pressure gradient (PGmean) correlated with the CD4+CD8+ lymphocyte count (r=0.35, P=.03 and r=0.43, P=.006, respectively) and fraction (r=0.43, P=.007 and r=0.48, P=.002, respectively). PGmax and PGmean correlated with CD16+CD56+CD3+ NKT cell count (r=0.39, P=.01 and r=0.43, P=.007, respectively) and fraction (r=0.49, P=.002 and r=0.47, P=.003, respectively). The classical monocyte subpopulation increased after the surgery by 68% (P<.0001). Patients after mini-sternotomy surgery had 47% lower nonclassical monocyte counts than those with full-sternotomy (P=.03). Patients treated with statins had significantly lower postoperative levels of both classical (-25%, P=.04) and nonclassical monocytes (-37%, P=.004) than nontreated individuals. CONCLUSIONS: In patients with severe isolated AS, CD4+CD8+ T cells and CD16+CD56+CD3+ NKT cells are associated with AV pressure gradients. Postoperative monocyte levels are affected by procedure invasiveness and use of statins.

Protein N-linked homocysteine is associated with recurrence of venous thromboembolism.

BACKGROUND: Recently, protein N-linked homocysteine (Hcy) has been measured in healthy subjects and patients with marked hyperhomocysteinemia. Since elevated total Hcy (tHcy) levels are associated with increased risk of venous thromboembolism (VTE), we aimed to investigate protein N-linked Hcy levels in patients with VTE. METHODS: We studied 200 consecutive patients with VTE (89 men, 111 women, aged from 17 to 83 years), including 57 subjects with a subsequent episode of VTE (recurrent VTE) during 24 months of follow-up. Protein N-linked Hcy was assayed using high-performance liquid chromatography with an on-column derivatization with o-phthaldialdehyde and fluorescence detection. RESULTS: The median protein N-linked Hcy was 1.404 µM (interquartile range [IQR] 0.859-2.066), while the median tHcy (IQR) was 9.1 µM (6.8-11.2). In the whole group protein N-linked Hcy correlated only with C-reactive protein (CRP; r = 0.44, p < 0.0001). In patients with recurrent VTE protein N-linked Hcy correlated with C-reactive protein (r = 0.43, p < 0.0001), tHcy (r = 0.42, p = 0.001) and age (r = 0.32, p = 0.014), but not with thrombophilia, unprovoked VTE or the current anticoagulation. Hyperhomocysteinemia, defined as tHcy ≥ 15 µM (n = 14.7%), was not associated with higher protein N-linked Hcy. Patients with recurrent VTE had higher levels of protein N-linked Hcy compared to those who experienced a single episode of VTE (1.553 µM, 1.157-2.445 vs. 1.27 µM, 0.826-1.884; p = 0.002). Multiple regression adjusted for potential confounders showed that the only independent predictor of protein N-linked Hcy in the upper quartile was CRP > 3mg/L (odds ratio 3.04, 95% confidence interval 2.12-4.36, p < 0.0001). CONCLUSION: Elevated protein N-linked Hcy concentrations, indicating enhanced protein homocysteinylation in vivo, characterize patients with recurrent VTE and this phenomenon is associated with enhanced inflammatory state.