Bivalirudin or Unfractionated Heparin in Acute Coronary Syndromes

BACKGROUND

Conflicting evidence exists on the efficacy and safety of bivalirudin administered as part of percutaneous coronary intervention (PCI) in patients with an acute coronary syndrome.

METHODS

We randomly assigned 7213 patients with an acute coronary syndrome for whom PCI was anticipated to receive either bivalirudin or unfractionated heparin. Patients in the bivalirudin group were subsequently randomly assigned to receive or not to receive a post-PCI bivalirudin infusion. Primary outcomes for the comparison between bivalirudin and heparin were the occurrence of major adverse cardiovascular events (a composite of death, myocardial infarction, or stroke) and net adverse clinical events (a composite of major bleeding or a major adverse cardiovascular event). The primary outcome for the comparison of a post-PCI bivalirudin infusion with no post-PCI infusion was a composite of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events.

RESULTS

The rate of major adverse cardiovascular events was not significantly lower with bivalirudin than with heparin (10.3% and 10.9%, respectively; relative risk, 0.94; 95% confidence interval [CI], 0.81 to 1.09; P=0.44), nor was the rate of net adverse clinical events (11.2% and 12.4%, respectively; relative risk, 0.89; 95% CI, 0.78 to 1.03; P=0.12). Post-PCI bivalirudin infusion, as compared with no infusion, did not significantly decrease the rate of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events (11.0% and 11.9%, respectively; relative risk, 0.91; 95% CI, 0.74 to 1.11; P=0.34).

CONCLUSIONS

In patients with an acute coronary syndrome, the rates of major adverse cardiovascular events and net adverse clinical events were not significantly lower with bivalirudin than with unfractionated heparin. The rate of the composite of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events was not significantly lower with a post-PCI bivalirudin infusion than with no post-PCI infusion. (Funded by the Medicines Company and Terumo Medical; MATRIX ClinicalTrials.gov number, NCT01433627.).

Clinical Performance of the New Gore Septal Occluder in Patent Foramen Ovale Closure: A Single-Center Experience

BACKGROUND

Several progressively refined percutaneous devices for patent foramen ovale (PFO) closure have been recently developed. We describe our single-center experience with the new Gore septal occluder (GSO).

METHODS

Between January 2012 and May 2013, all consecutive patients with a PFO and previous cerebral thromboembolic events underwent percutaneous closure with the GSO system. Device implantation was performed under local anesthesia with combined fluoroscopic and intracardiac echographic monitoring. Follow-up schedule was: transthoracic echo at day 1 and day 30, as well as transcranial Doppler at 6 months and 12 months, all with clinical concomitant evaluation.

RESULTS

Twenty-two patients (11 males and 11 females) with a mean age of 51.2 ± 13.9 years (range, 40-74 years) had PFO closure. At baseline, 4 and 18 subjects had medium-grade and large-grade right to left permanent shunt, respectively; isolated PFO was present in 13 patients and PFO with atrial septal aneurysm was present in 9 patients. Device placement was successful in all patients. Median procedural and fluoroscopic times were 40.5 minutes (range, 22-92 minutes) and 6.5 minutes (range, 3-16 minutes), respectively. Clinical and instrumental follow-up data were obtained at 12 months in 22 patients (100%). A low-grade (<5 microbubbles) permanent residual shunt was registered in 5 patients at 6 months and in 2 patients (during Valsalva only) at 12-month follow-up. Functional PFO occlusion was thus obtained in all patients.

CONCLUSION

This single-center initial experience suggests that the GSO is a safe and effective closure device, straightforward to implant with quick deployment and minimal imaging, and suitable for a range of atrial septal anatomies. Incidence and entity of residual shunts at follow-up were consistent with functional PFO occlusion in all patients.

Management and Long-Term Prognosis of Spontaneous Coronary Artery Dissection

The optimal management and short- and long-term prognoses of spontaneous coronary artery dissection (SCAD) remain not well defined. The aim of this observational multicenter study was to assess long-term clinical outcomes in patients with SCAD. In-hospital and long-term outcomes were assessed in 134 patients with documented SCAD, as well as the clinical impact and predictors of a conservative rather than a revascularization strategy of treatment. The mean age was 52 ± 11, years and 81% of patients were female. SCAD presented as an acute coronary syndromes in 93% of patients. A conservative strategy was performed in 58% of patients and revascularization in 42%. On multivariate analysis, distal versus proximal or mid location of dissection (odds ratio 9.27) and basal Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 or 3 versus 0 or 1 (odds ratio 0.20) were independent predictors of conservative versus revascularization strategy. A conservative strategy was associated with better in-hospital outcomes compared with revascularization (rates of major adverse cardiac events 3.8% and 16.1%, respectively, p = 0.028); however, no significant differences were observed in the long-term outcomes. In conclusion, in this large observational study of patients with SCAD, angiographic features significantly influenced the treatment strategy, providing an excellent short- and long-term prognosis.

Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial

BACKGROUND

It is unclear whether radial compared with femoral access improves outcomes in unselected patients with acute coronary syndromes undergoing invasive management.

METHODS

We did a randomised, multicentre, superiority trial comparing transradial against transfemoral access in patients with acute coronary syndrome with or without ST-segment elevation myocardial infarction who were about to undergo coronary angiography and percutaneous coronary intervention. Patients were randomly allocated (1:1) to radial or femoral access with a web-based system. The randomisation sequence was computer generated, blocked, and stratified by use of ticagrelor or prasugrel, type of acute coronary syndrome (ST-segment elevation myocardial infarction, troponin positive or negative, non-ST-segment elevation acute coronary syndrome), and anticipated use of immediate percutaneous coronary intervention. Outcome assessors were masked to treatment allocation. The 30-day coprimary outcomes were major adverse cardiovascular events, defined as death, myocardial infarction, or stroke, and net adverse clinical events, defined as major adverse cardiovascular events or Bleeding Academic Research Consortium (BARC) major bleeding unrelated to coronary artery bypass graft surgery. The analysis was by intention to treat. The two-sided α was prespecified at 0·025. The trial is registered at ClinicalTrials.gov, number NCT01433627.

FINDINGS

We randomly assigned 8404 patients with acute coronary syndrome, with or without ST-segment elevation, to radial (4197) or femoral (4207) access for coronary angiography and percutaneous coronary intervention. 369 (8·8%) patients with radial access had major adverse cardiovascular events, compared with 429 (10·3%) patients with femoral access (rate ratio [RR] 0·85, 95% CI 0·74-0·99; p=0·0307), non-significant at α of 0·025. 410 (9·8%) patients with radial access had net adverse clinical events compared with 486 (11·7%) patients with femoral access (0·83, 95% CI 0·73-0·96; p=0·0092). The difference was driven by BARC major bleeding unrelated to coronary artery bypass graft surgery (1·6% vs 2·3%, RR 0·67, 95% CI 0·49-0·92; p=0·013) and all-cause mortality (1·6% vs 2·2%, RR 0·72, 95% CI 0·53-0·99; p=0·045).

INTERPRETATION

In patients with acute coronary syndrome undergoing invasive management, radial as compared with femoral access reduces net adverse clinical events, through a reduction in major bleeding and all-cause mortality.

FUNDING

The Medicines Company and Terumo.

Primary PCI for the treatment of ectatic infarct-related coronary artery

AIM

There is lack of information on the outcome of patients treated with primary angioplasty for lesions located in an ectatic coronary artery segment in the setting of acute myocardial infarction. The aim of this study was to analyse the 2-year follow-up of this specific patient population.

METHODS

By means of a systematic review of the databases and cine-films of 5912 primary angioplasties performed in eight Italian cardiac centers we identified 101 patients with infarct-related coronary artery ectasia. Ectasia was defined as a dilatation exceeding the 1.5-fold of normal adjacent segment and was classified according to its severity. The primary end point was the composite rate of cardiac death, recurrence of acute myocardial infarction and a new revascularisation at 2-year.

RESULTS

The procedure was successful in 70.3% of cases, unsuccessful or complicated in 29.7%. The primary endpoint was met in 6.9% of cases during hospitalization (95% CI: 2.0-11.8), in 17.8% (95% CI: 10.3-25.3) at 1 year, and in 38.5% (95% CI: 29.0-48.0) at 2 years. Nine patients had a stent thrombosis: 3 acute and 6 sub-acute. A statistically significant correlation between the dimensions of the stent and stent thrombosis was observed (P=0.005).

CONCLUSION

In subjects undergoing primary angioplasty for acute myocardial infarction the rate of patients treated on lesions located in an ectatic coronary artery segment is very small (1.7%). The procedural success was low, whereas the rate of events at follow-up was quit high reflecting the complexity of this disease.

The Virtual histology In CaroTids Observational RegistrY (VICTORY) study: a European prospective registry to assess the feasibility and safety of intravascular ultrasound and virtual histology during carotid interventions

BACKGROUND

Carotid occlusive disease is the most common determinant of thromboembolic stroke. However, limited insights in vivo into the pathophysiology and pathology of carotid plaques are available. We designed a prospective multicenter registry to appraise the safety and feasibility of intravascular ultrasound (IVUS) and IVUS-virtual histology (IVUS-VH) imaging before and immediately after carotid stenting.

METHODS

Symptomatic and asymptomatic patients scheduled for carotid stenting were included. IVUS-VH pullbacks were performed before and after stenting. Angiographic, IVUS and IVUS-VH analyses were performed. The primary objective was to appraise feasibility and safety of IVUS-VH, and secondary objectives were to correlate plaque composition and plaque type derived from IVUS-VH with acute and 30-day complications.

RESULTS

A total of 119 patients were enrolled. IVUS-VH could be performed in all cases (100%), with additional runs after completion of the stenting procedure in 85%. Most plaques were stable by IVUS-VH, with vulnerable ones at minimum lumen area in 7%. Conversely, vulnerable plaques were significantly more common elsewhere in the internal carotid artery (ICA, 24% of patients, p<0.001). Acute and 30-day adverse events were uncommon (2 strokes, 1 transient ischemic attack), with no significant association between these and IVUS-VH features.

CONCLUSIONS

IVUS and IVUS-VH examinations during carotid interventions are feasible and safe, and provide important insights on qualitative and quantitative compositions of carotid plaques. Whether carotid IVUS-VH can predict clinical events remains uncertain, awaiting long-term follow-up of the VICTORY study and additional clinical trials.

[Indications for percutaneous myocardial revascularization]

Indications and timing of myocardial revascularization procedures are discussed based on the case of a 78-year-old woman suffering from effort angina due to three-vessel coronary artery disease with normal left ventricular function. At present, atherosclerotic patients have a relatively long history of their disease, so that physicians should organize therapeutic strategies resulting from a right trade-off between guidelines of international scientific societies and the peculiar clinical requirements of the individual patient in the particular stage of his/her disease. This kind of tailored therapy may result from a multidisciplinary approach (heart team), which should involve many specialists as comorbidities and frailty of the patients are numerous and significant.

A Guide to the Use of Left Ventricular Analysis with 3D Echo in Dyssynchrony

Data from single-centre studies suggest that echocardiographic parameters of mechanical dyssynchrony may improve patient selection for cardiac resynchronisation therapy (CRT). To our knowledge, the only published multicentre trial that compared 12 echocardiographic methods, the Predictors of response to cardiac resynchronization therapy (PROSPECT) trial, stated that none of the echocardiographic measurements of ventricular dyssynchrony applied in the study were able to distinguish responders from non-responders. Realtime 3D echocardiography is able to measure left ventricular (LV) size, function and dyssynchrony to identify the presence and extension of scar tissue and to evaluate where the site of latest mechanical activation is. After CRT device implantation, it also allows physicians to detect where the first mechanical activation secondary to LV pacing is located. Indeed, it can be useful in interventricular (VV) delay optimisation of the device after the implantation and, in single-centre studies, it was able to predict response to CRT and to identify responders from non-responders. Care must be taken to optimise temporal resolution, but now volume rates of 70–80vps can be easily obtained in the majority of cases. VV optimisation using realtime 3D echocardiography is feasible and intuitive, but time-consuming compared with traditional methods based on Doppler or algorithms. In this article we illustrate our approach to LV analysis with realtime 3D echocardiography in the study of dyssynchrony.

Usefulness of primary angioplasty in nonagenarians with acute myocardial infarction

The optimal reperfusion strategy in very elderly patients with ST-segment elevation myocardial infarction is still a subject of debate. The aim of this multicenter study was to determine the medium-term outcomes of nonagenarians after primary percutaneous intervention for ST-segment elevation myocardial infarction. A systematic review of the databases of 7 Italian centers showed that these had performed 5,023 primary angioplasties over the previous 5 years, 100 of which (2%) involved patients > or =90 years old. Thirty-five subjects were in Killip class III or IV at time of presentation, 78 had multivessel coronary artery disease, and mean ejection fraction was 0.40 +/- 0.12%. In-hospital mortality was 19% and was significantly higher in patients with shock (58% vs 10%, p <0.001). Survival rate after 6 months was 68%: 16% in those with Killip class IV at admission and 81% in the remaining patients (p <0.001). Cox regression analysis identified 3 independent predictors of 6-month mortality: cardiogenic shock at presentation (hazard ratio [HR] 10.82, 95% confidence interval [CI] 4.51 to 25.93, p <0.001), Thrombolysis In Myocardial Infarction myocardial flow after percutaneous coronary intervention (HR 0.19, 95% CI 0.07 to 0.50, p = 0.001), and abciximab administration (HR 0.32, 95% CI 0.13 to 0.78, p = 0.01). In conclusion, the results of this multicenter study suggest that selected nonagenarians with acute myocardial infarction benefit from successful primary angioplasty. The treatment does not affect the poor prognosis of patients presenting with cardiogenic shock, but the administration of abciximab seems to have a positive effect on 6-month mortality.

Proximal protection in recanalization of totally occluded saphenous vein grafts in acute coronary syndrome

Percutaneous treatment of old, degenerated saphenous vein grafts (SVG) is associated with a high likelihood of major adverse cardiac events. When an acute coronary syndrome (ACS) develops in a patient with old SVG, fresh thrombus may superimpose on an old, degenerative atheroma: a sudden increase in the athero-thrombotic burden ensues with consequent, frequent total occlusion of the lumen. In this scenario, transluminal recanalization of the graft is usually associated with the highest chance of distal embolization and no-reflow and positioning of an embolic protection device (EPD) is almost mandatory. However, distal EPD are difficult to place when the vessel is totally occluded and do not completely avoid distal embolization. We report two cases of totally occluded SVG in patients admitted for ACS that were recanalized with the aid of a proximal EPD system with angiographic and clinical success.

[Takotsubo cardiomyopathy: a consensus document]

Takotsubo cardiomyopathy is a syndrome characterized by acute regional systolic dysfunction of the left ventricle, frequently related to psycho-physical acute stress, and usually reversible. This rare syndrome involves more often the female sex with the highest frequency of occurrence between the seventh and eighth decade of life. Etiology has not been clarified yet and several hypotheses have been postulated: multiple epicardial coronary artery damage, abnormal coronary microcirculation, catecholamine-mediated cardiac toxicity, and neurogenic stunning. Clinical presentation is not easy to distinguish from an acute coronary syndrome: chest pain at rest or dyspnea, new-onset electrocardiographic changes, characterized by ST-segment elevation or T-wave inversion. Coronary angiography, which should be performed within 48 h of symptom onset in order to be diagnostic, excludes the presence of significant atherosclerotic stenosis or plaque rupture. Ventricular angiography shows the typical regional wall motion abnormalities (apical akinesia and hyperkinesia of the mid-basal segments) that give to the syndrome its name (takotsubo is a traditional Japanese octopus trap or pot). Echocardiography performed in the acute phase also evidences wall motion abnormalities that characteristically regress in the following days. There is no specific treatment for this syndrome, but supportive and symptomatic therapy is usually administered.

An unusual case of acute fatal pulmonary congestion: oesophageal stenting

Extrinsic left atrial compression with consequent hemodynamic compromise has been described secondary to aortic aneurysm, huge gastroesophageal distension and neoplastic diseases involving mediastinum. Prompt correction of the primary pathology usually leads to reversal of hemodynamic alterations. We report the case of a lady, who, in order to treat a stenosis of the lower third of the oesophagus, underwent stenting with subsequent hemodynamic deterioration due to compression of the posterior left atrial wall disclosed by echocardiography. The sudden recovery of the oesophageal lumen at the expense of the left atrial volume with the impossibility of prompt removal of the stent led to a progressive and fatal deterioration of the hemodynamic picture. Stenting of the lower part of the oesophagus should be performed only when reciprocal anatomic relationship between heart and oesophagus itself is clearly elucidated and possibly well maintained.

17-beta-estradiol eluting stent versus phosphorylcholine-coated stent for the treatment of native coronary artery disease

In this study we randomly compared the estradiol eluting stent (17-beta-E) with phosphorylcholine (PC)-coated stents in native coronary arteries. The incidence of angiographic restenosis was 23% in the 17-beta-E group and 31% in the PC group (p = 0.34). The major adverse cardiovascular event rates were also similar in the 2 groups (17% in the 17-beta-E group vs 22% in the PC group, p = 0.47). The mid-term clinical and angiographic outcomes did not indicate superiority of the 17-beta-E eluting stent over the control PC stent.

[Stress-induced transient left ventricular apical ballooning]

Transient left ventricular apical ballooning is a quite rare clinical event mostly described in the Japanese population. It is also known as tako-tsubo-like syndrome due to the peculiar shape on endsystolic left ventriculogram which is like a tako-tsubo, an ancient device used for trapping octopuses in the Japanese sea. The clinical features of this cardiomyopathy, which mimicked an acute coronary syndrome in an Italian 78-year-old man, are described. Acute left ventricular dysfunction with the typical left ventriculogram and normal epicardial coronary arteries followed an acute emotional and physical stress: the patient felt off his boat, while lifted well up above the water of a great Italian lake during routinary servicing, with consequent chest and head traumas. The combination of emotional and physical stress with the dive in the lake cold water could have caused a brisk and marked increase in catecholamines with possible direct myocardial injury. The occurrence of a rare case of a Japanese cardiomyopathy, also mentioned by a device used in sea-fishing, in an Italian patient following an accidental dive in a lake, appears at least peculiar.

The treatment of carotid artery bifurcation stenoses with systematic stenting: experience of first 100 consecutive cardiological procedures

Carotid endarterectomy still represents the gold standard treatment of carotid artery bifurcation stenosis but percutaneous angioplasty with stenting is rapidly growing as a non-invasive alternative. In this paper we report the results of systematic application of carotid stenting performed in a cardiological setting, particularly as regards clinical management of patients and technical approach. One-hundred (100) procedures of carotid artery stenting (CAS) on 94 consecutive patients, both symptomatic and asymptomatic, with a carotid stenosis > 70%, were performed over a period of 30 months. The technical approach was directly derived from coronary angioplasty with use of large lumen guiding catheters, 0.014 in. intravascular guidewires and distal protection devices usually employed in coronary interventions. In 3 cases, a post-carotid endarterectomy restenosis and in 97 cases, a de-novo lesion, were treated respectively; in 71 cases, the degree of stenosis was 71-89% and in 29 cases, 90-99%. Cerebral protection was obtained with a distal to the lesion endovascular filter in 63 cases. Immediate technical success, i.e. residual stenosis of the treated vessel < 30% and no significant pathologic acceleration of blood flow (< 1.5 m/sec) at the Doppler ultrasound evaluation, was achieved in all procedures (100%). Ninety-six (96) procedures were totally uncomplicated; in-hospital cerebral complications were 1 TIA, 2 minor and 1 major strokes; at 30-day follow-up one additional major stroke occurred. Despite a particularly high incidence of comorbidities, neither unfavorable cardiological complications nor neurologic deaths were reported. Systematic CAS is a feasible treatment of the carotid artery bifurcation stenosis with high procedural success and low perioperative and short term complications. Its performance in a cardiological setting can combine satisfying procedural results and potentially successful handling of cardiovascular complications.

Percutaneous treatment of early occlusion of a complex arterial coronary graft: a case report

The internal mammary arteries are now widely used for surgical myocardial revascularization. Because of its excellent long-term patency rates, re-do surgery is rarely requested and transluminal percutaneous angioplasty of these arterial grafts is still relatively infrequent. This procedure is performed mainly at the distal anastomotic site but also at the origin of the vessel from the subclavian artery, frequently just to treat a local traumatic dissection due to the catheter. We here report the case of a successful angioplasty and stenting of the body of the graft for an early total occlusion of a complex, bifurcated arterial bypass to the left coronary system.

Cardiogenic shock due to acute left main coronary artery occlusion: successful treatment with primary angioplasty

A 56-year-old patient was admitted with cardiogenic shock due to an acute anterior myocardial infarction. Cardiac catheterization with coronary angiography disclosed a thrombotic occlusion of the left main coronary artery. Prompt mechanical recanalization of the infarct-related artery with multiple stent implantations associated with prolonged circulatory and respiratory supports allowed for a partial recovery of the left ventricular function and the discharge of the patient.

Italian BiodivYsio open registry (BiodivYsio PC-coated stent): study of clinical outcomes of the implant of a PC-coated coronary stent

Rapid technological developments have made new materials available for percutaneous coronary intervention procedures. The coronary stent in particular has undergone progressive structural improvements leading to the recent availability of a third generation of stents, namely, coated stents. The rapid evolution of the stent has often made its evaluation problematical, since trials are frequently confined to small groups of patients in single centers. The purpose of this registry was to verify the safety and efficacy of the BiodivYsio stent (a stent coated with phosphorylcholine polymer) in a broad population of patients who reflect the daily reality of coronary intervention in a cardiac catheterization laboratory.

METHODS AND RESULTS

The registry was designed to collect the principal angiographic and clinical data of a consecutive series of Oreal worldO patients. Patients were treated with a BiodivYsio stent (Biocompatibles, Galway, United Kingdom) in 12 centers (11 Italian and 1 Swiss) between January 1998 and January 1999. Procedural, in-hospital, 30-day and six-month follow-up data were collected. The monitoring, data entry and statistical analyses were carried out by an independent center. During the study, 218 patients were enrolled; 165 (76%) male and 53 (24%) female, with an average age of 61.6 +/- 9.4 years (range, 36Eth 84 years). A total of 258 stents were implanted in 233 lesions (1.1 stents per lesion), of which 233 (90%) were the BiodivYsio PC coated stent, the remaining 25 implants were of other stent types. The percutaneous transluminal coronary angioplasty and stenting procedure were carried out in 109 (50%) patients with unstable angina, 65 (30%) with stable angina, 29 (13%) with acute myocardial infarction, and 15 (7%) patients with silent ischemia. Procedural success was achieved in 217/218 (99.5%) patients. Optimal results were achieved in 212 (97.7%) patients. In 34 (15.6%) cases, patients were treated with periprocedural abciximab. During the hospitalization period, one (0.4%) death occurred on day 7 due to subacute occlusion of the stent, and 3 (1.4%) myocardial infarctions were reported. At 30-day follow-up, 211 (97.2%) patients were asymptomatic, as were 189 (87%) patients at clinical follow-up at 6 months.

CONCLUSIONS

This study evaluated the safety and efficacy of a third-generation stent. The results demonstrate a high procedural success rate and a low incidence of major adverse cardiac events at short- and medium-term follow-up. It appears that the BiodivYsio stent should be considered safe in clinical and/or anatomical situations with a high risk of complications, confirming the hypothesis that PC may have non-thrombogenic properties. To corroborate these results, an appropriately designed study would be required to measure the stentOs efficacy in the most suitable clinical context, i.e., clinical situations that are at the highest risk of ischemic relapse.

The LAST operation is safe and effective: MIDCABG clinical and angiographic evaluation

BACKGROUND

The aim of this study was to prospectively evaluate the angiographic results of a cohort of consecutive patients who underwent minimally invasive coronary artery revascularization.

METHODS

From May 1997 to December 1998, 150 consecutive patients underwent left internal mammary artery to left anterior descending artery anastomosis through a left minithoracotomy on a beating heart in the Cardiovascular Department of Cliniche Gavazzeni, Bergamo, Italy. The mean age was 61.6 years (range, 36 to 84 years); 121 patients (81%) were men. Isolated left anterior descending artery disease was present in 74 patients.

RESULTS

In-hospital patency was observed in 100% of the 149 angiographically controlled patients with no anomalies in 99.3% of the anastomoses. Anastomosis was performed on a diseased tract of the target vessel in 3 patients and a stenosis of the target vessel beyond the anastomosis was documented in 3 patients. In one case early angiographic control was not performed due to death of the patient on the 1st postoperative day. The morbidity included postoperative bleeding that required reopening (3.3%) and intraoperative myocardial infarction (2%).

CONCLUSIONS

A left internal mammary artery to left anterior descending artery anastomosis on a beating heart through a left minithoracotomy is an alternative approach to myocardial revascularization. Surgical invasiveness is limited, cardiopulmonary bypass risks are avoided, and the procedure is safe and effective. In our consecutive series, postoperative angiographic controls demonstrated graft patency in all patients and very high quality anastomoses. Midterm clinical follow-up (14 months) appears favorable.

Refractory coronary artery spasm with superimposed thrombosis: successful treatment with Palmaz-Schatz stent

Prinzmetal variant angina due to epicardial coronary artery spasm is a disease usually treated with drug therapy with successful results. A case of variant angina, refractory to conventional pharmacological treatment, and complicated by coronary artery thrombosis, was treated with percutaneous transluminal coronary angioplasty and stenting with good immediate and late clinical results.