Atrial septal aneurysm contribution to the risk of cryptogenic stroke in patients with patent foramen ovale: A brief updated systematic review and meta-analysis

Atrial septal aneurysms (ASA) play an important role in cryptogenic stroke (CS) in patients with patent foramen ovale (PFO) but its contribution remains still not fully clarified in current literature. We sought to evaluate the contribution of ASA to the risk of CS in PFO patients based on studies published so far by means of a systematic review and metanalysis. A literature search, based on PubMed, Google Scholar and EMBASE databases, was performed to locate articles, published English language between 2000 and 2021, analysing the relationship between ASA and CS. The final research was conducted in September 2021. A total of 577 articles were retrieved after excluding duplicates. The initial screening excluded 215 articles because they did not meet inclusion criteria, leaving 362 articles to assess for eligibility. Subsequently, after evaluation of the full-text articles, 354 were excluded and 8 investigations met the inclusion criteria. Overall, 822 patients (mean age 48.3 years) were enrolled in the reviewed manuscripts with a prevalence of males of 48.7% and a normal distribution of the classical cardiovascular risk factors. ASA was present in 25.3% (208 subjects) of the patients enrolled, while the association of PFO+ASA was observed in 24.3% (200 subjects) of patients enrolled. PFO Patients with ASA were at higher risk of CS compared to those without (odd ratio: 3.38, 95% CI: 2.72-5.51, p<0.001, I2=4.3%,). The relative funnel plot did not show any evident asymmetry, confirming absence of publication bias. Our updated metanalysis enhances the importance of ASA contribution to stroke in patients with patent foramen ovale, being present in a third of patients with symptomatic PFO to whom it confers an additional odd ratio of 3.38.

Technical Complications of Coronary Bifurcation Percutaneous Interventions

Coronary bifurcation percutaneous interventions (PCI) comprise a challenging subset of patients with coronary artery disease. Beyond the well-known debate about single versus double stent strategies, which have different outcomes on mid- and long-term follow up, both strategies may be subject, although rarely, to several different technical complications, rarely reported in clinical trials, which need to be defined, classified, and understood by cardiovascular professionals involved in the management of patients with coronary bifurcation disease. The present paper aims to broaden the knowledge of the range of intraprocedural complications and relative treatment during PCI of coronary bifurcations.

Single versus Double Stenting in NSTEMI Patients with Complex Left Main Bifurcation Disease

Background: Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long-term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods: We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results: Four hundred and forty-five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow-up of 37.1 months (IQR 22.1-39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions: Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long-term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2-stent strategy.

Gender-related differences in clinical outcomes after either single or double left main bifurcation stenting

We sought to examine the impact of gender differences in clinical outcomes at 3 years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Crossover provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT) techniques between January 1st, 2008 and May 1st 2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Five hundred and sixty-seven patients (251 females, mean age 70.0 ± 10 years, mean Syntax score 31.6 ± 6.3) were evaluated. Crossover, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98 (17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri-procedural items among gender. At a mean follow-up of 37.1 ± 10.8 months (range 22.1-39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3-year follow-up either using a single or double stent technique.

Pooled prevalence of three major cardiovascular risk factors in patients undergoing left main bifurcation stenting: a systematic review and meta-analysis

BACKGROUND

Prevalence of the major risk factors in patients with Left Main (LM) bifurcation disease has not been yet clearly assessed, although it would important for building up bifurcation computational models. We perform a systematic review and metaanalysis on the three major cardiovascular risk factors in patients treated for LM bifurcation disease using either single or 2-stent strategy.

MEHTODS

In accordance with the PRISMA guidelines, Cochrane Library, Embase, PubMed and Google Scholar were queried to locate articles published between January 2015 to October 2020, comparing single- versus 2-stent strategy and reporting the prevalence of arterial hypertension (HT), hyperlipidaemia (HyperL) and diabetes mellitus (DM).

RESULTS

Out of a total of 230 articles, 7 articles were included into the final analysis. A total of 4559 patients were enrolled: 2666 (58.4%, mean age 60.4 years, 2318 males) and 1933 patients (42.3%, mean age 64.8 years, 1763 males) received a single- and 2-stent stenting strategies, respectively. A random effect model revealed a pooled prevalence of HT, HyperL and DM in 69.4%, 38.9% and in 31% of cases, respectively. Prevalence of HT was lower in patients treated with single versus 2-stent strategy (63 versus 66.7% of patients, p=0.01) while HyperL and DM were more represented in single versus 2-stent strategy: 41.6 versus 34.1% (p<0.001), and 32.5 versus 31.8% of patients (p=0.61), respectively.

CONCLUSIONS

In patients with LM bifurcation disease undergoing either single or 2- stent strategy, HT, HyperL and DM are frequent comorbidities. In severe LM disease requiring 2-stent technique, HT is the most prevalent risk factor.

Occurence of left main occlusion on Tuesday: Chronobiology of acute myocardial infarction due to left main disease

Objectives

The existence of a “weekend effect” for onset of acute myocardial infarction (AMI) has been suggested in the past, but the relation with the culprit vessel has not been investigated. MI due to left main coronary artery lesion represents a particularly serious life-threatening condition. Our study was aimed to assess the chronobiology of admission to the emergency department for AMI considered to be induced by a left main culprit lesion.

Methods

We retrospectively reviewed patients who experienced an AMI due to a left main culprit lesion between January 1, 2008 and January 1, 2018 stratifying them according to the day of admission, on the basis of the symptom onset time; the 30-day cardiovascular mortality was also analyzed on the basis of the time of symptom onset.

Results

Out of 1789 patients with AMI, 130 (7.2%, 104 males and 26 females, mean age 74.5 ± 8.1 years) had left main disease as the culprit lesion. Tuesday was significantly over-represented as the admission day (p < 0.001 for Tuesday vs. other days; p = 0.009 for Tuesday vs. Sunday, respectively). The 30-day cardiovascular survival was not different between patients admitted on Tuesday and those admitted on remaining days (Log-rank, Mantel Cox, p = 0.43; Chi-square = 0.611). A significant difference was noted in patients with AMI on Sunday versus remaining days (Log-rank, Mantel-Cox, p = 0.005; Chi-square = 7.96). The diameter of the left main artery was larger in patients admitted on Tuesdays than on Sundays (p < 0.01).

Conclusion

The relation between AMI onset and the day of the week is confirmed by our study, which also suggests that in case of a left main lesion, some delay of the weekend effect might be expected.

Impact of number of run-off vessels on interwoven nitinol mesh stents patency in the femoropopliteal segment

Objective

To evaluate the impact of run-off vessels number on the outcomes of Supera stent (Abbott Vascular, Santa Clara, Calif, USA) for treatment of femoropopliteal occlusive disease.

Methods

We retrospectively evaluated the medical records of 188 consecutive patients (mean age 68.2 ± 9.6 years, 100 males) undergone angiography and woven mesh stent implantation in femoral or popliteal arteries or both arterial segments, in our institution between January 1 2014 and January 1 2018. Target lesion revascularization and major adverse limb events at 12-month were evaluated comparing patients with 1-, 2- or 3-run-off vessels in the foot.

Results

Interventional success was achieved in 100%. Stent implantation involved in the femoral site in 56 patients (30.3%), the femoropopliteal in 92 patients (48.9%) and the popliteal site in 40 patients (21.3%). A significant improvement of ankle-brachial index (0.29 ± 0.6 vs. 0.88 ± 0.3, P < 0.001) and Rutherford class (5.3 ± 0.8 vs. 0.7 ± 1.9, P < 0.01) were observed before discharge. The median follow-up duration was 12.3 months (inter quartile range: 11.0 to 13.9). During the follow-up period, 52 patients (27.6%) had clinical events. Primary patency at 12 months was 72.4%. The primary patency significantly increased when the runoff status. Comparing the number of events among patients with different number of run-off vessels, a significant difference (P < 0.001) was observed for patients having one (24.0%) and two run-off vessels (15.0%).

Conclusions

The outcomes of Supera stent in femoropopliteal occlusive disease depend strictly on the number of run-off vessels.

One- and 3-year outcomes of percutaneous bifurcation left main revascularization with modern drug-eluting stents: a systematic review and meta-analysis

AIMS

Optimal percutaneous coronary intervention (PCI) strategy for coronary left main (LM) bifurcation lesions remains controversial. We performed systematic review and meta-analysis comparing one and 3-year clinical outcomes of 1- and 2- stent strategies using modern drug eluting stents (DESs) for revascularization of LM bifurcation disease.

METHODS

We systematically identified all investigations published between January 2015 and February 2020 comparing the use of single versus double-stent strategies for the revascularization of LM bifurcation lesions. The primary endpoint was 1- and 3-years all-cause mortality. Secondary outcomes included target lesion revascularization (TLR), target lesion failure (TLF), major adverse cardiovascular vents (MACEs) and cardiovascular (CV) mortality while the tertiary outcome was overall occurrence of stent thrombosis (ST) at 1- and 3-years.

RESULTS

No significant differences were observed between the two groups in terms of all-cause mortality rate both at 1 and 3-year follow-up. Single stent strategy was associated with a significantly lower risk of TLR (OR 0.78, 95% CI 0.62- 0.97, p = 0.03, I² = 61%) as well as of MACEs (OR 0.78, 95% CI 0.63-0.97, I² = 24%) compared to 2-stent strategy. Conversely no significant differences between the two groups were observed in terms of TLF, CV mortality and ST during the same follow-up period.

CONCLUSIONS

In patients with LM bifurcation disease, single stent strategy demonstrated lower rate of MACEs and TLR but was not superior to 2-stent strategy in terms of CV mortality, TLF and ST at 1 and 3-year follow-up.

Biomechanical Evaluation of Different Balloon Positions for Proximal Optimization Technique in Left Main Bifurcation Stenting

BACKGROUND

Proximal optimization technique (POT) is a key step during left main (LM) bifurcation stenting. However, after crossover stenting, the ideal position of POT balloon is unclear. We sought to evaluate the biomechanical impact of different POT balloon positions during LM cross-over stenting procedure.

METHODS

We reconstructed the patient-specific LM bifurcation anatomy, using coronary computed tomography angiography data of 5 consecutive patients (3 males, mean age 66.3 ± 21.6 years) with complex LM bifurcation disease, defined as Medina 1,1,1, evaluated between 1st January 2018 to 1st June 2018 at our center. Finite element analyses were carried out to virtually perform the stenting procedure. POT was virtually performed in a mid (marker just at the carina cut plane), proximal (distal marker 1 mm before the carina) and distal (distal marker 1 mm after the carina) position in each investigated case. Final left circumflex obstruction (SBO%), strut malapposition, elliptical ratio and stent malapposition were evaluated.

RESULTS

The use of both proximal and distal POT resulted in a smaller LM diameter compared to the mid POT. SBO was significantly higher in both proximal and distal configurations compared to mid POT: 38.3 ± 5.1 and 29.3 ± 3.1 versus 18.3 ± 3.6%, respectively. Similarly stent malapposition was higher in both proximal and distal configurations compared to mid POT: 1.3 ± 0.4 and 0.82 ± 1.8 versus 0.78 ± 1.2, respectively.

CONCLUSIONS

Mid POT offers the best results in terms of LCx opening maintaining slightly smaller but still acceptable LM and LAD diameters compared to alternative POT configuration.

Outcomes of Left Main Bifurcation Stenting Depends on Both Length of Dual Antiplatelet Therapy and Stenting Strategy

Data regarding the optimal dual antiplatelet therapy (DAPT) duration in patients treated with a 1- versus a 2-stent strategy in LM bifurcation PCI are scant. A literature search based on Cochrane Library, Embase, PubMed and Google Scholar was performed to locate articles published between January 2015 and January 2020. The following MeSH terms were used for the search: "Left Main" AND "DAPT Duration" AND "stent" OR "stenting". The analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Occurrence of major adverse cardiovascular events (MACEs) according to length of DAPT and stenting strategy was analysed. A total of 256 articles were retrieved and after evaluation, 3 articles evaluating the results of 8 large registries were included into the analysis including a final population of 4117 patients [mean age 65.7 years, 3133 (76.0%) males]. A short-term DAPT resulted in a lower risk of MACEs in patients treated with a single stent strategy (OR: 0.49, 95% CI [0.33-0.67], p < 0.001, I2 = 0%), whereas a DAPT >12 months resulted in a significant higher risk of MACEs in the same group (OR: 7.39, 95% CI [5.09-10.7], p < 0.001, I2 = 61%) compared to double stent strategy. The available data support the use of short DAPT in single cross-over LM stenting whereas a long DAPT seems to be more appropriate after a double stenting strategy in LM bifurcation PCI.

Light anti-thrombotic regimen for prevention of device thrombosis and/or thrombotic complications after interatrial shunts device-based closure

AIMS

The optimal antiplatelet therapy after atrial septal defect (ASD) or patent foramen ovale device closure (PFO) remain to be established. We evaluated the safety and effectiveness of 6-month 100 mg Aspirin (ASA) regimen in the very long-term follow up after intracardiac echocardiography (ICE) -aided interatrial shunt closure in a large retrospective cohort.

METHODS

Single-center retrospective analysis which included medical and instrumental data of 789 consecutive patients referred to our institution over a 15 years period due interatrial shunt catheter-based closure.

RESULTS

Finally, 734 patients were included in the analysis (mean age 46.1 ± 14.6 years, 398 females): ASD and PFO closure were successfully performed in 281 and 453 patients, respectively. Over the follow-up period, no major bleeding events were observed while the rate of minor bleeding events was 0.9%. Tolerance problems were detected in 3.4% of cases (n==28). In 11 patients (1.5%) an abnormal complete blood count was detected and monitored up to normalization. On a mean follow -up of 10.3 ± 3.0 years (range 1-15), 10 patients (1.36%) had a persistent moderate shunt 12 months after closure and maintained Aspirin 100 mg life-long, whereas the remaining 724 suspended the treatment after 6 months. Device thrombosis in ASD and PFO groups were 0% and 0.2%, respectively. A cerebral ischemic event occurred in 0.4% of the entire cohort.

CONCLUSIONS

A regimen of 100 mg of ASA for six months after ASD/PFO closure appeared to be both safe and effective in preventing device thrombosis and major bleedings.

Optimal Site for Proximal Optimization Technique in Complex Coronary Bifurcation Stenting: A Computational Fluid Dynamics Study

BACKGROUND/PURPOSE

The optimal position of the balloon distal radio-opaque marker during the post optimization technique (POT) remains debated. We analyzed three potential different balloon positions for the final POT in two different two-stenting techniques, to compare the hemodynamic effects in terms of wall shear stress (WSS) in patients with complex left main (LM) coronary bifurcation.

METHODS/MATERIALS

We reconstructed the patient-specific coronary bifurcation anatomy using the coronary computed tomography angiography (CCTA) data of 8 consecutive patients (6 males, mean age 68.2± 18.6 years) affected by complex LM bifurcation disease. Subsequently a virtual bench test was performed in each patient using two different double stenting techniques represented by the DK and Nano crush using the reconstruction of Orsiro stents (Biotronik IC, Bulack, Switzerland).

RESULTS

A significant reduction in the mean WSS values in all the lesion's sites was observed when the final POT was performed 1 mm distally the carina cut plane in both techniques. Moreover, a significant improvement in the mean WSS values of the entire SB (e.g. LCX) was obtained performing the POT 1 mm distally to the carina cut plane. The proximal POT resulted in larger area of lower WSS values at the carina using both the Nano crush and the DK crush techniques.

CONCLUSIONS

In patients with complex LM bifurcation disease the use of a final POT performed 1 mm distally to the carina cut plane might results in more favorable WSS patterns (i.e. higher WSS values) along all stented segments and, especially, along the entire LCX lesions.