Three-year Clinical Impact of Murray Law-Based Quantitative Flow Ratio and OCT- or FFR-Guidance in Angiographically Intermediate Coronary Lesions

BACKGROUND

The FORZA trial (FFR or OCT Guidance to Revascularize Intermediate Coronary Stenosis Using Angioplasty) prospectively compared the use of fractional flow reserve (FFR) or optical coherence tomography (OCT) for treatment decisions and percutaneous coronary intervention (PCI) optimization in patients with angiographically intermediate coronary lesions. Murray law-based quantitative-flow-ratio (μQFR) is a novel noninvasive method for the computation of FFR. In the present study, we evaluated the clinical impact of μQFR, FFR, or OCT guidance in FORZA trial lesions at 3-year follow-up.

METHODS

μQFR was assessed at baseline and, in the case of a decision to intervene, after (FFR- or OCT-guided) PCI. The baseline μQFR was considered the final μQFR for deferred lesions, and post-PCI μQFR value was taken as final for stented lesions. The primary end point was target vessel failure ([TVF]; cardiac death, target-vessel-related myocardial infarction, and target-vessel-revascularization) at a 3-year follow-up.

RESULTS

A total of 419 vessels (199 OCT-guided and 220 FFR-guided) were included in the FORZA trial. μQFR was evaluated in 256 deferred lesions and 159 treated lesions (98 OCT-guided PCI and 61 FFR-guided PCI). In treated lesions, post-PCI μQFR was higher in OCT-group compared with FFR-group (median, 0.93 versus 0.91; P=0.023), and the post-PCI μQFR improvement was greater in FFR-group (0.14 versus 0.08; P<0.0001). At 3-year follow-up, OCT- and FFR-guided treatment decisions resulted in comparable TVF rate (6.7% versus 7.9%; P=0.617). Final μQFR was the only predictor of TVF. μQFR ≤0.89 was associated with 3× increase in TVF (11.6% versus 3.7%; P=0.004). PCI was a predictor of higher final μQFR (odds ratio, 0.22 [95% CI, 0.14-0.34]; P<0.001).

CONCLUSIONS

In vessels with angiographically intermediate coronary lesions, OCT-guided PCI resulted in comparable clinical outcomes as FFR-guided PCI. μQFR estimated at the end of diagnostic or interventional procedure predicted 3-year TVF.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01824030.

Impact of thrombus aspiration on left ventricular remodeling and function in patients with ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials

BACKGROUND

Routine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI).

METHODS

PubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA.

RESULTS

A total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to -0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to -3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = -2.13, p = 0.03; z = -3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04).

CONCLUSION

TA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.

22 Diagnostic monocular occlusion in patients with binocular vision

To determine if angle of deviation changes significantly after diagnostic monocular occlusion (DMO) in patients with BSV (binocular single vision).We retrospectively analysed data from 136 patients with esotropia and 110 with exotropia, divided in BSV and non-BSV. Near and distance angles were measured over 3 visits and then after 2 hours monocular occlusion. Data were analysed with t-test and linear regression.Esotropes with BSV had significantly larger increases in deviation after DMO than non-BSV patients for near (5 PD vs 3 PD, 95%CI 3-7 PD, paired t-test p=0.0318) and for distance (6 PD vs 3 PD, 95%CI 4-8 PD, p=0.005). There was a significant correlation between the amount of change after occlusion and the initial angle for near (p=0.006) and for distance (p=0.010) in BSV patients only.In exotropes, there was no significant difference after DMO between BSV and non-BSV patients for near (p=0.09) and distance (p=0.532). There was a significant correlation between initial near angle of deviation and change in deviation after DMO in BSV patients(p=0.0009) but not in the non-BSV group (p=0.07). Distance angle of deviation before DMO was significantly correlated to the amount of change in deviation after DMO for both BSV (p=0.022) and non BSV patients (p=0.015).Our study shows that diagnostic monocular occlusion should be performed in all exotropes with initial angles of deviation of less than 30 PD. In esotropes, DMO is more likely to show significant increases in deviation in BSV patients, especially for smaller initial angles (less than 25 PD before DMO). These changes should be taken into account when planning surgery.

19 Unilateral lateral rectus resection as preferred procedure to treat patients with acquired distance esotropia

To report the results of a series of patients with acquired distance esotropia (ET) who underwent lateral rectus resection.We retrospectively analysed data from 21 symptomatic patients with acquired esotropia who did not tolerate prisms. Twelve patients had myopic esotropia, 5 patients decompensated esophoria and 4 patients age-related distance esotropia. Patients were divided in two groups; myopic and non myopic. Two patients in each group had undergone surgery to medial recti muscles previously. Near and distance angles were measured over 2 visits. Data were analysed with t-test (paired and unpaired).Average age was 47 (myopes), 77 (distance ET) and 26 years (esophoria). Mean spherical equivalent was -4.00 DS (myopes) and + 1 SD (non myopes). Lateral rectus resection ranged between 6 and 8 mm with an average of 7 mm in the myopic group and between 4 and 8 mm with an average of 6 mm in the non-myopic group.The distance angle was reduced from 19 PD to 6 PD in myopes (mean difference 12 PD, p<0.0001) and from 19 PD to 8 PD in non myopes (mean difference 12 PD, p=0.0011). There was no difference in reduction of distance angle between myopes and non-myopes (p=0.771). All patients had complete resolution of diplopia after surgery without needing prisms. Near angle was also fully corrected in 19 patients. One patient with myopia and one patient with distance esotropia went on to have medial rectus recession.Unilateral lateral rectus resection is an effective procedure for acquired distance esotropia in myopic and non-myopic patients.

Gender may be related to the side of the motor syndrome and cognition in idiopathic Parkinson's disease

BACKGROUND

and Sex and cognitive profile may be related to the laterality of motor symptoms in idiopathic Parkinson's disease.

INTRODUCTION

Parkinson's disease (PD) is well recognised as an inherently asymmetric disease with unilateral onset of motor symptoms. The laterality of motor symptoms may be linked to sex, clinical and demographic variables, and neuropsychological disorders. However, the available data are inconsistent. This study aimed to explore the potential association between the laterality of motor symptoms and clinical and demographic variables and deficits in specific cognitive domains.

MATERIAL AND METHODS

We retrospectively recruited 97 participants with idiopathic PD without dementia; 60 presented motor symptoms on the left side and 37 on the right side. Both groups were comparable in terms of age, age at disease onset, disease duration, and severity of the neurological deficits according to the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr scale.

RESULTS

Participants with left-side motor symptoms scored lower on the Schwab and England Activities of Daily Living scale. Our sample included more men than women (67% vs. 33%). Both sexes were not equally represented in the 2 groups: there were significantly more men than women in the group of patients with left-side motor symptoms (77% vs. 23%), whereas the percentages of men and women in the group of patients with right-side motor symptoms were similar (51% vs. 49%). Both groups performed similarly in all neuropsychological tasks, but women, independently of laterality, performed better than men in the naming task.

CONCLUSION

We found a clear prevalence of men in the group of patients with left-side motor symptoms; this group also scored lower on the Schwab and England Scale. Female sex was predictive of better performance in the naming task. Sex should always be considered in disorders that cause asymmetric involvement of the brain, such as PD.

Pre-stenting residual thrombotic volume assessed by dual quantitative coronary angiography predicts microvascular obstruction in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Microvascular obstruction (MVO) is a frequent occurrence after primary percutaneous coronary intervention (pPCI), and is associated with adverse left ventricular remodeling and worse clinical outcome. Distal embolization of thrombotic material is one of the most important underlying mechanisms. The aim of this study was to investigate the relation between the thrombotic volume evaluated by dual quantitative coronary angiography (QCA) prior to stenting and the occurrence of MVO as assessed by cardiac magnetic resonance (CMR).

METHODS

Forty-eight patients with ST-segment elevation myocardial infarction (STEMI) undergoing pPCI and receiving CMR within 7 days from admission were included. Pre-stenting residual thrombus volume at the site of the culprit lesion was measured by applying automated edge detection and video-assisted densitometry techniques (i.e., dual-QCA), and patients were categorized into tertiles of thrombus volume. The presence of delayed-enhancement MVO, as well as its extent (MVO mass), were assessed by CMR.

RESULTS

Pre-stenting dual-QCA thrombus volume was significantly greater in patients with MVO than in those without (5.85 mm³ [2.05-16.71] vs. 1.88 mm³ [1.03-6.92], P=0.009). Patients in the highest tertile showed greater MVO mass compared to those in the mid and lowest tertiles (113.3 gr [0.0-203.8] vs. 58.5 g [0.00-144.4] vs. 0.0 g [0.0-60.225], respectively; P=0.031). The best cut-off value of dual-QCA thrombus volume for prediction of MVO was 2.07 mm³ (AUC: 0.720). The addition of dual-QCA thrombus volume to the traditional angiographic indices of no-reflow enhanced the prediction of MVO by CMR (R=0.752).

CONCLUSIONS

Pre-stenting dual-QCA thrombus volume is associated with the presence and extent of MVO detected by CMR in patients with STEMI. This methodology may aid the identification of patients at higher risk of MVO and guide adoption of preventive strategies.

541 A CASE REPORT OF ACUTE CORONARY SYNDROME: VERY LATE STENT THROMBOSIS DUE TO MAJOR STENT MALAPPOSITION

Rational

The occurrence of stent thrombosis (ST) is a rare event, but it remains one of the most catastrophic complications following percutaneous coronary intervention (PCI). Coronary angiography has limited value in differentiating the causative factors responsible for ST.

Technical resolutions

We report a case of a 78-year-old male, hypertensive and dyslipidemic who underwent PCI with stenting of the mid left anterior descending artery (LAD) due to chronic coronary syndrome (CCD) two years before. He was admitted to our emergency department for syncopal episode occurred at rest followed by chest pain radiating to the left arm and to the neck. At the time of admission, his electrocardiogram showed diffuse ST-segment elevation in V2-V6 and DI-aVL, therefore patient was urgently sent to the cath lab. Coronary angiography showed LAD occlusion at the proximal edge of the previously implanted stent with TIMI flow grade 0 and TIMI thrombus grade 5. Multiple thrombus aspiration passes were performed with distal flow restoration, followed by intracoronary abciximab administration. After additional thrombus aspiration passes, ST-segment resolution was observed and chest pain improved significantly. OCT imaging of mid-to-proximal LAD was then performed to better characterize the cause of thrombosis. OCT revealed in stent-thrombosis with mixed thrombus (6 mm length, arc &gt;270°) associated with major stent malapposition (maximum malapposition distance: 1.3 mm) at the proximal edge of the previous implanted stent, without evidence of neoatherosclerosis and/or residual disease with unstable features at the stent edges. Additional thrombus aspiration was performed, further reducing the thrombotic burden. As te patient was hemodynamically stable and asymptomatic, with TIMI flow grade 3 at coronary angiography, we decided to start dual antiplatelet therapy (ASA+ticagrelor) plus continuous heparin i.v. infusion, and to defer PCI, planning a control coronary angiography after 72 hours. After 72 hours, OCT revealed almost complete thrombus resolution, and guided PCI with a 4.0/8 mm everolimus-eluting stent in overlap with the previously implanted stent, postdilated with a 4.5 semi-compliant balloon at 18 atm. Revascularization was completed with an OCT-guided PCI of the proximal left circumflex during the same procedure.

Clinical implications

Our case demonstrates the utility of OCT in determining thrombus burden and assessing the causes of late stent failure, guiding PCI. In this case, OCT was useful as diagnostic tool to identify the mechanism underlying the very-late ST, and as guidance for treatment. It enabled to exclude neoatherosclerosis and/or unstable plaques at stent edges, leaving us more confident to defer PCI after 72 h of antithrombotic therapy.

Perspectives

The occurrence of ST is rare, but it remains one of the most catastrophic complications following PCI. Coronary angiography has limited value in differentiating the causative factors responsible for ST, while OCT allows to detect and characterize the causes of stent thrombosis (i.e., evaluate thrombus burden, presence of neoatherosclerosis, stent malapposition/underxpansion, uncovred stent struts, significant disease and/or unstable plaques at the stent edges, etc.). A better understanding of the pathophysiological mechanism underlying ST is an important clinical need. The increasing availability of high-resolution intravascular imaging techniques such as OCT provides new opportunities for tailoring treatment strategy and guiding PCI.

1150 SEX-BASED DIFFERENCES IN CORONARY PLAQUE PHENOTYPE AND HEALING AT OPTICAL COHERENCE TOMOGRAPHY (OCT) ANALYSIS

Introduction

Atherosclerotic plaque healing is a dynamic process that promotes plaque repair after destabilization. Previous studies showed that healed plaques are more common in patients with chronic coronary syndrome than in those with acute coronary syndrome, suggesting that they might be a marker of clinical stability. The mechanisms underlying plaque healing are not completely understood. The aim of the present study was to evaluate sex-based differences in plaque phenotype and healing of non-culprit coronary lesions by optical coherence tomography.

Methods

In this observational, single-center cohort study, we enrolled patients from the OCT Registry of the Fondazione Policlinico A Gemelli IRCCS. A total of 205 patients with both acute coronary syndromes or chronic coronary syndromes undergoing coronary angiography and intravascular OCT imaging of non-culprit vessels were included in the analysis and divided into two groups according to gender.

Results

Of 205 patients, 153 were male (75%) and 52 (25%) female. Compared with male patients, female patients had lower prevalence of lipid-rich plaque (40.4% vs. 57.7%; p=0.030), plaque rupture (7.7% vs. 21.2%; p=0.028) and cholesterol crystal (13.5% vs. 29.5%; p=0.022). Mean lipid arc and calcium depht were significantly lower in female patients than in male ones (118.0° ± 79.9° vs. 135.5° ± 77.9°; p=0.011; and 52.7 µm ± 79.2 µm vs. 72.3 µm ± 93.5 µm; p=0.007) while fibrous cap tended to be thicker (108.2 µm ± 70.4 µm vs. 96.2 µm ± 72.9 µm; p=0.055). Healed plaques were significantly more frequent in female patients than in male patients (51.9% vs 34.6%; p = 0.027). The prevalence of fibrous plaque, thrombi, neovascularization, diffuse calcifications and spotty calcification was not different between the two groups.

Conclusion

Females have a distinct atherosclerotic phenotype and healing capacity compared with male patients, including lower prevalence of lipid-rich plaque, cholesterol crystals and plaque ruptures and higher prevalence of healed plaques in non-culprit coronary lesions.

Advances and Challenges in Biomarkers Use for Coronary Microvascular Dysfunction: From Bench to Clinical Practice

Coronary microvascular dysfunction (CMD) is related to a broad variety of clinical scenarios in which cardiac microvasculature is morphologically and functionally affected, and it is associated with impaired responses to vasoactive stimuli. Although the prevalence of CMD involves about half of all patients with chronic coronary syndromes and more than 20% of those with acute coronary syndrome, the diagnosis of CMD is often missed, leading to the underestimation of its clinical importance. The established and validated techniques for the measurement of coronary microvascular function are invasive and expensive. An ideal method to assess endothelial dysfunction should be accurate, non-invasive, cost-effective and accessible. There are varieties of biomarkers available, potentially involved in microvascular disease, but none have been extensively validated in this heterogeneous clinical population. The investigation of potential biomarkers linked to microvascular dysfunction might improve the assessment of the diagnosis, risk stratification, disease progression and therapy response. This review article offers an update about traditional and novel potential biomarkers linked to CMD.

499 What light through yonder window breaks? Benefits of optical coherence tomography (OCT) in a case of spontaneous coronary artery dissection

Aims

Spontaneous coronary artery dissection (SCAD) is a non-traumatic and non-iatrogenic separation of the coronary arterial walls, creating a false lumen. SCAD is an infrequent and often missed diagnosis especially in women presenting with acute coronary syndrome and in the majority of cases angiography alone could be insufficient for identification.

Methods and results

A 43-year-old woman presented to the Emergency Department of Fondazione Policlinico Universitario A. Gemelli IRCCS (Rome, Italy) for oppressive acute chest pain radiated to the right jaw, resolved spontaneously within a few minutes. Physical examination, including cardiovascular evaluation, was normal. High-sensitivity troponin was 152 ng/l and 250 ng/l in two serial determination (reference range, 0.0–37 ng/l). EKG showed sinus rhythm with no significant ST-segment alterations. Echocardiography revealed preserved biventricular systolic function with mild hypokinesia of the apical segments of the left ventricle. A diagnosis of NSTEMI was made based on clinical and laboratory parameters. Thus, urgent coronary angiography was performed, which demonstrated a single vessel disease with an eccentric, and angiographically complex stenosis of the proximal left anterior descending (LAD) artery with an image of plus compatible with a plaque ulceration. In order to define the extension of the disease and ostium involvement for a better procedural planning, OCT imaging was performed. Surprisingly, OCT showed a intramural haematoma extending from the ADA ostium to the proximal tract (approximately 22 mm) with ulceration in the body, minimal lumen area (MLA) 2.0 mm2 and evidence of normal trilaminar structure of the vessel both on downstream and upstream of the lesion. The angiographic features were compatible with type 2A SCAD. The therapeutic management was conservative with continuation of the double antiplatelet therapy and remote CT monitoring. Three days later, because of a new onset of chest pain and slight elevation of the ST segment on EKG, was performed a coronarographic control: the angiographic appearance of the lesion was substantially unchanged; OCT showed unmodified longitudinal extension of the lesion (about 22 mm) and relative increase in the endoluminal caliber compared to the previous examination (MLA 4.0 mm2).After 2 weeks, coronary CTA control was carried out, which documented the stability of the intramural hematoma in the proximal LAD, extended for 22 mm and with a maximum thickness of 2 mm, determining lumen narrowing of 40–45% The patient was discharged on medical therapy and no events occurred during the follow-up. Six month later, repeat CTA showed a complete resorption of the intramural haematoma.

Conclusions

In this case we highlight the utility of intravascular imaging, in particular OCT, in the evaluation of angiographic lesions of non-univocal interpretation and how its use can change the management and prognosis of ACS patients. Furthermore, the spontaneous resolution of the clinical and anatomical scenario through conservative treatment additionally confirms spontaneous healing as the natural history of SCAD and foreground the role of precise diagnosis (and intravascular imaging showed to improve it) for therapy shift and calibration.

734 Have I lost my large rupture cavity? The fingerprint of atherosclerotic plaque healing detected by serial optical coherence tomography imaging

A 64-year-old man, prior smoker, with a history of paroxysmal atrial fibrillation was referred to our hospital due to worsening dyspnoea, progressively worsening angina, and a positive stress EKG testing. Coronary angiography (CAG) showed an angiographically intermediate stenosis of the mid left anterior descending (LAD) artery and a focal, complex lesion of the distal right coronary artery (RCA) (Figure 1A and B, red arrow). Treatment of the LAD stenosis was deferred based on a negative fractional flow reserve value (i.e. 0.85). Optical coherence tomography (OCT) imaging (ILUMIEN OPTIS, Abbott Vascular, Santa Clara, CA) was performed to better characterize the RCA lesion, which disclosed a ruptured thin-cap fibroatheroma (TCFA) with a large ‘empty’ cavity (Figure 1C–G, red arrows) and overlying ‘layered’ tissue (Figure 1H, white arrowheads). Based on these OCT findings, suggestive of initial plaque healing, and on a large residual lumen dimension (i.e. minimum lumen area, MLA, at the rupture site: 7.7 mm2), this lesion was not treated with percutaneous coronary intervention. The patient was discharged on aspirin, edoxaban, metoprolol, rosuvastatin, and ezetimibe, and remained clinically stable for more than 1 year. Due to angina recurrence, a new CAG was performed 18 months after the first admission, revealing a progression of the mid LAD stenosis that was treated with a 2.5/28 mm drug-eluting stent, and an improvement of the RCA lesion angiographic appearance (smooth contour) (Figure 1A′–B′). RCA OCT imaging was repeated demonstrating a complete healing of the large rupture cavity with all the hallmarks of the reparative process (Figure 1C′–H′): (1) re-established fibrous cap integrity and smooth vessel lumen profile; (2) thickening of the fibrous cap and reduction of lipid burden (i.e., transformation of TCFA into thick-cap fibroatheroma, ThCFA); (3) replacement of the ‘empty’ cavity with new ‘granulation tissue’; (4) initial calcification of the plaque; (5) heterogeneous signal-rich layers with distinct optical-signal intensity (layered, ‘onion-like’ pattern); and (6) mild lumen narrowing (MLA at the rupture site: 6.9 mm2).

Collapse

698 Acute coronary syndrome in neoatherosclerosis with major stent malapposition and OCT-guided PCI

Aims

Due to its bidimensional nature, angiography is not always sufficient to accurately define coronary lesions, in particular when they are ambiguous or indeterminate. Intracoronary imaging, such as intravascular ultrasound or optical coherence tomography (OCT), is often useful in these cases to better characterize the ambiguous angiographic images, to identify the culprit lesion during acute coronary syndrome (ACS) and to guide percutaneous coronary intervention (PCI).

Methods and results

We report a case of a 61-year-old male with multiple cardiovascular risk factors and a previous ST-segment elevation myocardial infarction treated by PCI of the right coronary artery (RCA) about 7 years before, wo was admitted to our emergency department after acute onset chest pain. At the time of admission, his ECG was normal and cardiac troponin was below the upper reference limit of normality with positive molecular SARS-CoV-2 diagnostic test. Echocardiogram disclosed a mild left ventricular dysfunction with inferior wall hypokinesia. Coronary angiography showed a moderate in-stent restenosis at mid RCA and a hazy, undetermined image at the proximal edge of the previously implanted stent. Left coronary artery angiography showed only diffuse atherosclerotic disease without significant stenoses and a myocardial bridge at the mid tract of left anterior descending artery. OCT pullback of RCA to better characterize the undetermined lesions shown by angiography. OCT revealed significant neointima hyperplasia and a focal area of neoatherosclerosis with unstable features (fissure/microthrombi) at mid RCA. Severe stent strut malapposition embedded neointimal hyperplasia was observed at the proximal stent edge, resulting in ‘dual’ lumen appearance. The two lesions were treated with a single 3.5/48 mm everolimus-eluting stent (stent-in-stent), which was post-dilated with a 3.5/20 mm non-compliant balloon (18 atm) in the mid-to-distal segments, and 4.5/15 mm (16 atm) and 5.0/8 mm (14 atm) semi-compliant balloons in the proximal stent segment. Post-PCI OCT imaging confirmed good stent expansion and apposition. Our case demonstrates the utility of OCT in clarifying the aetiology of ambiguous angiographic lesions and as a guide for PCI. Indeed, the ‘hazy’ appearance on the angiograms corresponded to the major stent malapposition covered by neointima disclosed by OCT as a ‘dual-lumen’. Of note, OCT allowed to confirm the correct guidewire position in the ‘true’ lumen preventing a crush of the previously implanted stent. OCT was also useful as a diagnostic modality for the identification and characterization of the mechanism underlying the ACS (neoatherosclerosis instability).

Conclusions

Due to its unprecedented spatial resolution, OCT enables an ‘optical biopsy’ of the coronary artery wall and intrastent tissue. Therefore, OCT imaging should be considered when lesions are ambiguous or indetermined by coronary angiography to guide the diagnosis and treatments of ACS patients. OCT imaging is also useful to guide stenting and to optimize PCI result, and its impact on clinical outcome is under investigation in large randomized clinical trials.

713 Culprit plaque morphology and healing capacity in patients with and without preinfarction angina: an optical coherence tomography imaging study

Aims

The relationship between culprit plaque morphology, healed culprit plaques prevalence and clinical presentation of acute myocardial infarction (AMI) remains largely unexplored. We hypothesized that angina preceding the occurrence of AMI (pre-infarction angina, PIA) may reflect a distinct morphologic phenotype of culprit plaques and potentially different healing capacity.

Methods and results

We conducted a retrospective observational study in patients with AMI who underwent intracoronary optical coherence tomography (OCT) imaging of the culprit lesion before PCI at the Fondazione Policlinico A. Gemelli–Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome. Based on the clinical history, patients were classified into two groups: (i) PIA group, defined as either intermittent chest pain within 6 h preceding the final episode of chest pain, or unstable angina (or both) in the week preceding AMI or (ii) no-PIA group, defined as a single episode of chest pain without prodromal symptoms in the preceding week. Culprit plaques were classified as plaque rupture (PR) or intact fibrous cap (IFC), and presence of layered appearance (healed plaque, HP) was assessed. Thrombus burden (TB) was estimated, and prevalence of diffuse calcification, neovascularization, and OCT-defined macrophage accumulation were evaluated. A total of 102 patients with AMI were included (50 PIA, 52 no-PIA). Patients with PIA showed a higher prevalence of IFC than PR (58% vs. 42%, P = 0.030). PR in patients with PIA were more frequently associated with macrophage accumulation (71.4% vs. 28.6% P = 0.001), and TB tended to be lower [22.0 (15.8–30.3) vs. 38.5 (12.8–67.5), P = 0.145]. Diffuse calcifications were significantly less frequent in patients with PIA (22.0% vs. 40.4%, P = 0.045), while neovascularization tended to be more frequent (58.0% vs. 42.3%, P = 0.113). HPs prevalence was significantly higher in the PIA than in the no-PIA group (66.0% vs. 25.0%, P &lt; 0.001).

Conclusions

Patients with PIA have a distinct culprit plaque phenotype, more frequently characterized by IFC and a relatively lower TB, with a significantly higher prevalence of plaque healing.

103 Coronary plaque healing and diabetes: insights from optical coherence tomography imaging

Aims

Atherosclerotic plaque healing is a dynamic process developing after plaque rupture or erosion, which aims to prevent lasting occlusive thrombus formation and to promote plaque repair. We hypothesized that diabetes mellitus, one of the major conventional cardiovascular risk factors, may influence the healing capacity after plaque destabilization.

Methods and results

In this single-centre observational cohort study, patients with acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) who underwent optical coherence tomography (OCT) imaging at Fondazione Policlinico A. Gemelli–IRCCS, Rome, were included. Patients were divided into two groups (i.e. diabetes vs. no diabetes), and stratified based on diabetes medications (i.e. insulin, vs. oral antidiabetic drugs). OCT analysis of non-culprit coronary segments was performed. 105 patients were included (44 diabetes, 61 no diabetes). Prevalence of HCPs was not significantly different between patients with and without diabetes (3.6% vs. 3.8%, P = 0.854). However, patients with diabetes on insulin showed a lower prevalence of HCPs both at patient-based (7.1% vs. 26.4%, P = 0.116) and at segment-based analysis (1.2% vs. 4.2%, P = 0.020). When comparing HbA1c levels based on the presence or absence of healed plaque at the non-culprit lesions, patients with healed plaque showed significantly lower levels of HbA1c compared to patients without healed plaques (43.5 ± 12.1% vs. 61.2 ± 10.4%, P &lt; 0.001). At segment-based analysis, normal vessel structure, pathological intimal thickening (PIT), and spotty calcifications were significantly less prevalent in diabetic patients (2.1% vs. 5.1%, P = 0.001; 7.2% vs. 9.5%, P = 0.05; 9.9% vs. 13.6%, P = 0.02, respectively), whereas neovascularization was significantly higher (19.2% vs. 15.6%, P = 0.035).

Conclusions

Patients with diabetes have a distinct coronary non-culprit plaque phenotype. Healing capacity may be impaired in patients with advanced diabetes on insulin therapy and in those with a suboptimal control of the disease. Further prospective, larger scale studies are warranted to confirm these findings.

Systemic Capillary Leak Syndrome triggered by SARS-CoV2 infection: Case Report and Systematic Review

Objective: Systemic capillary leak syndrome (SCLS) is a severe condition characterized by the coexistence of hypovolaemic shock, haemococentration, and hypoalbuminaemia, without albuminuria, that may progress to multiorgan failure and an unfavourable outcome. Its development is often triggered by viral infections, such as influenza A virus, but it is unclear whether it is also triggered by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). We aimed to investigated the association between SARS-CoV-2 and SCLS.Method: We present the case of a 55-year-old-woman affected by SARS-CoV-2 infection who developed SCLS. Moreover, we performed a systematic review of the literature to identify any common features with other cases and to describe clinical characteristics and outcomes.Results: We found three other cases of SCLS occurring during SARS-CoV-2 infection in 2020. Taking all cases together, the mean age was 50 years (range 38-63), with a 1:1 gender ratio. Respiratory manifestations were the most common symptom, and all patients required admission to the intensive care unit. The mortality rate was 50%.Conclusions: SARS-CoV-2 infection may trigger SCLS disease, either by an overproduction of proinflammatory cytokines or by direct viral infection of the endothelium. Since SCLS may have a poor prognosis, in every SARS-CoV-2-infected patient presenting the suggestive triad of hypovolaemic shock, haemoconcentration, and hypoproteinaemia, an SCLS diagnosis should be considered and early treatment initiated.

Prevalence and characteristics of myocardial injury during COVID-19 pandemic: A new role for high-sensitive troponin

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a pandemic disease that is causing a public health emergency. Characteristics and clinical significance of myocardial injury remain unclear.

METHODS

This retrospective single-center study analyzed 189 patients who received a COVID-19 diagnosis out of all 758 subjects with a high sensitive troponin I (Hs-TnI) measurement within the first 24 h of admission at the Policlinico A.Gemelli (Rome, Italy) between February 20th 2020 to April 09th 2020.

RESULTS

The prevalence of myocardial injury in our COVID-19 population is of 16%. The patients with cardiac injury were older, had a greater number of cardiovascular comorbidities and higher values of acute phase and inflammatory markers and leucocytes. They required more frequently hospitalization in Intensive Care Unit (10 [32.3%] vs 18 [11.4%]; p = .003) and the mortality rate was significantly higher (17 [54.8%] vs. 15 [9.5%], p < .001). Among patients in ICU, the subjects with myocardial injury showed an increase need of endotracheal intubation (8 out of 9 [88%] vs 7 out of 19[37%], p = .042). Multivariate analyses showed that hs-TnI can significantly predict the degree of COVID-19 disease, the intubation need and in-hospital mortality.

CONCLUSIONS

In this study we demonstrate that hs-Tn can significantly predict disease severity, intubation need and in-hospital death. Therefore, it may be reasonable to use Hs-Tn as a clinical tool in COVID-19 patients in order to triage them into different risk groups and can play a pivotal role in the detection of subjects at high risk of cardiac impairment during both the early and recovery stage.

Gender may be related to the side of the motor syndrome and cognition in idiopathic Parkinson's disease

BACKGROUND

and Sex and cognitive profile may be related to the laterality of motor symptoms in idiopathic Parkinson's disease.

INTRODUCTION

Parkinson's disease (PD) is well recognised as an inherently asymmetric disease with unilateral onset of motor symptoms. The laterality of motor symptoms may be linked to sex, clinical and demographic variables, and neuropsychological disorders. However, the available data are inconsistent. This study aimed to explore the potential association between the laterality of motor symptoms and clinical and demographic variables and deficits in specific cognitive domains.

MATERIAL AND METHODS

We retrospectively recruited 97 participants with idiopathic PD without dementia; 60 presented motor symptoms on the left side and 37 on the right side. Both groups were comparable in terms of age, age at disease onset, disease duration, and severity of the neurological deficits according to the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr scale.

RESULTS

Participants with left-side motor symptoms scored lower on the Schwab and England Activities of Daily Living scale. Our sample included more men than women (67% vs. 33%). Both sexes were not equally represented in the 2 groups: there were significantly more men than women in the group of patients with left-side motor symptoms (77% vs. 23%), whereas the percentages of men and women in the group of patients with right-side motor symptoms were similar (51% vs. 49%). Both groups performed similarly in all neuropsychological tasks, but women, independently of laterality, performed better than men in the naming task.

CONCLUSION

We found a clear prevalence of men in the group of patients with left-side motor symptoms; this group also scored lower on the Schwab and England Scale. Female sex was predictive of better performance in the naming task. Sex should always be considered in disorders that cause asymmetric involvement of the brain, such as PD.

Pleiotropic effects of ticagrelor on microRNA expression in acute coronary syndrome on long term follow up

Background

PLATO study showed that Ticagrelor (Ti) significantly reduced the rate of death from vascular causes, myocardial infarction or stroke without a significant increase of major bleeding vs Clopidogrel (Cl). Previous studies demonstrated the stronger direct anti-platelet effect of Ti versus Cl. Few data exist about the indirect anti-platelet properties and pleiotropic effects, eventually involved in the positive effect of Ti on acute coronary syndrome (ACS) outcome.

Aim

As Ti has multiple pleiotropic effects, we sought to assess whether the different outcome of Ti versus Cl in NSTE-ACS patients could be explained, at least in part, by different modulation of circulating microRNA (miRNA). The primary endpoint was to characterize the effect of the two different P2Y12 inhibitors on miRNA expression. Secondary endpoint was to correlate miRNA profile to clinical outcome.

Methods

Thirty-one patients with a diagnosis of NSTE-ACS were enrolled in this study. Patients were randomized for Ti or Cl assumption before undergoing PCI. Clinical characteristics were homologues between Ti and Cl groups. Blood samples were drawn at different time point (T0, T1 and T2) to test miRNA modulation and stability (T0, at baseline; T1, three hours after drug administration; T2, twenty-four hours after coronarography). Plasma RNA was extracted and pooled for microarray PCR based panel of ninety miRNA analysis. MiRNA expression was normalized on the global mean of each patient. Levels of circulating miRNAs were compared using statistical tests, assuming significance at P&lt;0,05.

Results

A panel of seven circulating miRNAs associated with atherosclerosis, thrombosis and inflammation were selected for validation (miR-652-3p; miR-26-5p; miR-25-3p; miR-let7c; miR-155-5p; miR-222-3p; miR-223-3p). Microarray analysis showed an opposite modulation of most miRNAs at T0, T1 and T2 in patients with Cl or Ti treatment. In particular, Cl group showed an upregulation of most miRNAs, while Ti administration caused their down-regulation. Of the seven miRNA selected for validation, miR-652-3p, expression at T1 showed a significantly modulation in patients in Cl treatment compared to Ti (T1 Cl 2,637±1,092, T1 Ti 0,660±0,171; p=0.03). MiRNA-652-3p has a validated pro-atherogenic role. On five-years follow, an higher rate (40%) of cardiovascular events (new ACS, recurrent ischemia and stent thrombosis) was reported in the Cl group compare to Ti. Indeed, no one death or bleeding occurred.

Conclusion

This data suggest that Ti has a protective role down-regulating pro-atherogenic and pro-thrombotic miRNAs (miR-652-3p, miR-let7c, miR-223-3p, miR-155-5p) and promoting the expression of anti-atherogenic miRNAs (miR-25-3p) when compared to Cl. This may contribute to explain the positive effect on clinical outcome of Ti. Although the small number of patients, this pilot study gives another evidence about the multiple positive pleiotropic effect of Ti.

Figure 1. miRNA 652-3p expression

Funding Acknowledgement

Type of funding source: None

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - endorsed by the European Academy of Neurology

BACKGROUND AND PURPOSE

Current guidelines on cerebral venous thrombosis (CVT) diagnosis and management were issued by the European Federation of Neurological Societies in 2010. We aimed to update the previous European Federation of Neurological Societies guidelines using a clearer and evidence-based methodology.

METHOD

We followed the Grading of Recommendations, Assessment, Development and Evaluation system, formulating relevant diagnostic and treatment questions, performing systematic reviews and writing recommendations based on the quality of available scientific evidence.

RESULTS

We suggest using magnetic resonance or computed tomographic angiography for confirming the diagnosis of CVT and not routinely screening patients with CVT for thrombophilia or cancer. We recommend parenteral anticoagulation in acute CVT and decompressive surgery to prevent death due to brain herniation. We suggest preferentially using low-molecular-weight heparin in the acute phase and not direct oral anticoagulants. We suggest not using steroids and acetazolamide to reduce death or dependency. We suggest using antiepileptics in patients with an early seizure and supratentorial lesions to prevent further early seizures. We could not make recommendations concerning duration of anticoagulation after the acute phase, thrombolysis and/or thrombectomy, therapeutic lumbar puncture, and prevention of remote seizures with antiepileptic drugs. We suggest that, in women who have suffered a previous CVT, contraceptives containing oestrogens should be avoided. We suggest that subsequent pregnancies are safe, but use of prophylactic low-molecular-weight heparin should be considered throughout pregnancy and puerperium.

CONCLUSIONS

Multicentre observational and experimental studies are needed to increase the level of evidence supporting recommendations on the diagnosis and management of CVT.

Pregnancy outcome after a first episode of cerebral vein thrombosis

Essentials Little is known about recurrences and pregnancy outcome after cerebral vein thrombosis (CVT). We studied a cohort of pregnant women with CVT. Women with CVT appear at increased risk of late obstetrical complications despite prophylaxis. Risks of recurrent thrombosis and bleeding in women on heparin prophylaxis while pregnant are low.

SUMMARY

Background The risk of recurrent thrombosis and bleeding episodes in women with previous cerebral vein thrombosis (CVT) on antithrombotic prophylaxis with low-molecular-weight heparin (LMWH) during pregnancy is not established and little information is available on pregnancy outcome. Objectives The aims of this study were to evaluate the risk of obstetrical complications, recurrent venous thrombosis and bleeding in a cohort of pregnant women on LMWH after a first episode of CVT. In addition, to estimate the relative risk of obstetrical complications, patients were compared with healthy women without thrombosis and with at least one pregnancy in their life. Patients We studied a cohort of 52 patients and 204 healthy women. Results The risk of developing late obstetrical complications was 24% (95% CI, 18-38%), leading to a relative risk of 6.09 (95% CI, 2.46-15.05). The risk of miscarriage was not increased. The higher risk of late obstetrical complications in patients appeared unrelated to a previous history of obstetrical complications, to the carriership of thrombophilia abnormalities, or to the presence of co-morbidities. The incidence of termination observed in patients with thrombophilia was double that observed in those without. No recurrent thrombosis or bleeding episodes were observed. Conclusions Women with previous CVT on LMWH prophylaxis during pregnancy have a low risk of developing recurrent thrombosis or bleeding episodes, but seem to have an increased risk of late obstetrical complications.

Early ficolin-1 is a sensitive prognostic marker for functional outcome in ischemic stroke

BACKGROUND

Several lines of evidence support the involvement of the lectin pathway of complement (LP) in the pathogenesis of acute ischemic stroke. The aim of this multicenter observational study was to assess the prognostic value of different circulating LP initiators in acute stroke.

METHODS

Plasma levels of the LP initiators ficolin-1, -2, and -3 and mannose-binding lectin (MBL) were measured in 80 stroke patients at 6 h only and in 85 patients at 48 h and later. Sixty-one age- and sex-matched healthy individuals served as controls. Stroke severity was measured on admission using the National Institutes of Health Stroke Scale (NIHSS). The outcome was measured at 90 days by the modified Rankin Scale (mRS).

RESULTS

Ficolin-1 was decreased in patients compared with controls measured at 6 h (median 0.13 vs 0.33 μg/ml, respectively, p < 0.0001). At 48 h, ficolin-1 was significantly higher (0.45 μg/ml, p < 0.0001) compared to the 6 h samples and to controls. Likewise, ficolin-2 was decreased at 6 h (2.70 vs 4.40 μg/ml, p < 0.0001) but not at 48 h. Ficolin-3 was decreased both at 6 and 48 h (17.3 and 18.23 vs 21.5 μg/ml, p < 0.001 and <0.05, respectively). For MBL no difference was detected between patients and controls or within patients at the different time points. In multivariate analysis, early ficolin-1 was independently associated with unfavorable mRS outcome (adjusted odds ratio (OR): 2.21, confidence interval (CI) 95 % 1.11-4.39, p = 0.023). Early ficolin-1 improved the discriminating ability of an outcome model including NIHSS and age (area under the curve (AUC) 0.95, CI 95 % 0.90-0.99, p = 0.0001).

CONCLUSIONS

The ficolins are consumed within 6 h after stroke implicating activation of the LP. Early ficolin-1 is selectively related to 3-month unfavorable outcome.

Hypercoagulability and the risk of myocardial infarction and ischemic stroke in young women

BACKGROUND

Myocardial infarction (MI) and ischemic stroke (IS) are acute forms of arterial thrombosis and share some, but not all, risk factors, indicating different pathophysiological mechanisms.

OBJECTIVE

This study aims to determine if hypercoagulability has a differential effect on the risk of MI and IS.

PATIENTS AND METHODS

We reviewed the results from the Risk of Arterial Thrombosis in Relation to Oral Contraceptives study, a population-based case-control study involving young women (< 50 years) with MI, non-cardioembolic IS and healthy controls. From these data, relative odds ratios (ORIS /ORMI ) and their corresponding confidence intervals for all prothrombotic factors that were studied in both subgroups were calculated.

RESULTS

Twenty-nine prothrombotic risk factors were identified as measures of hypercoagulability. Twenty-two of these risk factors (21/29, 72%) had a relative odds ratios > 1; for 12 (41%), it was > 2; and for 5 (17%), it was > 2.75. The five risk factors with the largest differences in associations were high levels of activated factor XI (FXI) and FXII, kallikrein, the presence of lupus anticoagulans, and a genetic variation in the FXIII gene.

CONCLUSION

In young women, prothrombotic factors are associated more with the risk of IS than with MI risk, suggesting a different role of hypercoagulability in the mechanism leading to these two diseases.

Plasma ADAMTS-13 levels and the risk of myocardial infarction: an individual patient data meta-analysis

BACKGROUND

Low ADAMTS-13 levels have been repeatedly associated with an increased risk of ischemic stroke, but results concerning the risk of myocardial infarction are inconclusive.

OBJECTIVES

To perform an individual patient data meta-analysis from observational studies investigating the association between ADAMTS-13 levels and myocardial infarction.

METHODS

A one-step meta-analytic approach with random treatment effects was used to estimate pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs) adjusted for confounding. Analyses were based on dichotomous exposures, with the 5th and 1st percentiles of ADAMTS-13 antigen levels as cut-off values. Quartile analyses, with the highest quartile as a reference category, were used to assess a graded association between levels and risk ('dose' relationship). Additionally, we assessed the risk of the combined presence of low ADAMTS-13 and high von Willebrand factor (VWF) levels.

RESULTS

Five studies were included, yielding individual data on 1501 cases and 2258 controls (mean age of 49 years). Low ADAMTS-13 levels were associated with myocardial infarction risk, with an OR of 1.89 (95% CI 1.15-3.12) for values below the 5th percentile versus above, and an OR of 4.21 (95% CI 1.73-10.21) for values below the 1st percentile versus above. Risk appeared to be restricted to these extreme levels, as there was no graded association between ADAMTS-13 levels and myocardial infarction risk over quartiles. Finally, there was only a minor synergistic effect for the combination of low ADAMTS-13 and high VWF levels.

CONCLUSIONS

Low ADAMTS-13 levels are associated with an increased risk of myocardial infarction.

Gynaecological and obstetrical problems in women with different bleeding disorders

The aim of this case-control study was to analyse the prevalence of gynaecological, obstetrical and other more general bleeding symptoms in 114 women affected by various inherited bleeding disorders, who were compared with 114 apparently healthy women. Retrospective information were collected by means of two specific questionnaires, one on gynaecological and obstetrical bleeding symptoms, with special focus on the presence of menorrhagia as defined by a pictorial blood loss assessment chart (PBAC); and the other on general bleeding symptoms, whose severity was graded by means of the bleeding score (BS). Compared to normal women, the whole group of women with inherited bleeding disorders had a higher prevalence of excessive bleeding at menarche (25% vs. 5%, P < 0.0001) and menorrhagia (59% vs. 46%, P = 0.06). Affected women also had a higher frequency than controls of general bleeding symptoms that scored as severe by a BS > or = 12 (49% vs. 0%, P < 0.0001). In affected women, the BS increased according to the severity of the haemostasis defect. In conclusions, the BS and the PBAC are simple tools to evaluate the severity of general bleeding symptoms and menorrhagia in women with inherited bleeding disorders. These instruments may help to identify those women for whom a therapeutic intervention is warranted.

Open globe injuries: factors predictive of poor outcome

OBJECTIVE

Despite advances in ocular and orbital imaging, instrumentation, materials, and surgical procedures, the management of open globe injuries continues to pose difficult management dilemmas. In this retrospective study, we identify clinical characteristics and outcome of a series of open globe injuries presenting to a major UK centre.

METHOD

Operating department records were reviewed to identify all patients who had undergone repair of an open globe injury from 1 January 1998 to 1 January 2003 at the Manchester Royal Eye Hospital. Case notes were examined to determine demographic data, mechanisms of injury, influence of alcohol/drugs, and location of injury. The Snellen visual acuity on presentation and initial clinical signs were recorded.

RESULTS

In total, 115 cases of open globe injury were identified of which 107 cases notes were available for review. Injury to the eye with a sharp object accounted for 71/107 (66%) cases and blunt mechanisms for 30/107 (28%) cases. In six (6%) cases the cause of injury was unknown. The rate of secondary enucleation in our series of 107 open globe injuries was 13/107 (12%). Significant risk factors on presentation associated with eventual enucleation included relative afferent pupillary defect (P<0.001), absence of a red reflex (P<0.001), presence of a lid laceration (P<0.02), a blunt mechanism of injury (P<0.02), and an initial VA worse than 6/60 (P=0.03).

CONCLUSION

From this retrospective study, we have identified several factors that may aid the clinician in deciding on the prognostic value of primary repair. Blunt injuries associated with adnexal trauma, with poor initial visual acuity, the presence of an RAPD or retinal detachment, and the absence of a red reflex are associated with a significantly higher rate of subsequent enucleation.

The influence of posterior capsule opacification on scanning laser polarimetry

PURPOSE

To evaluate the influence of posterior capsule opacification (PCO) on GDx parameters in a population of pseudophakic, non-glaucomatous patients who underwent Nd:YAG laser capsulotomy (YLC).

METHODS

The posterior capsules were photographed with a Topcon digital camera and each image was then entered into the EPCO 2000 software and evaluated independently by three examiners. The EPCO 2000 software was used to calculate the fibrosis index (FI) and the pearl index (PI) for the central 1.5, 2.5, and 3.5 mm of the posterior capsule. Scanning laser polarimetry was performed with GDx before and after YLC. We compared the GDx readings obtained before and after the YLC using paired Student's t-test. The parameters that varied significantly after YLC were subsequently used for regression analysis. Stepwise multiple linear regression was used to analyse the impact of the change in the amount of FI and PI on change in GDx parameters after YLC.

RESULTS

In total, 158 patients were enrolled (74 men, 84 women). The mean age was 69.46+/-8.83 years (range 46-83 years). The interobserver agreement among the three experts was found to be good (repeatability coefficient R=1.51, 1.49, 1.49 for observer A vs B, A vs C, and B vs C respectively). One-sample Student's t-test show no difference between all GDx parameters before and after YLC except for Symmetry, Superior/Nasal ratio, Inferior Ratio, and Temporal-Superior-Nasal-Inferior-Temporal (TSNIT). Stepwise multiple regression showed that the two variables of greatest significance for changes in Symmetry were the FI in the central 1.5 and the PI in the central 3.5 mm (P=0.02). Superior/nasal ratio was shown to be most strongly correlated to the FI in the central 1.5 mm and PI in the central 3.5 mm (P<0.001), whereas the variable of greatest significance to Inferior Ratio was PI in the central 3.5 mm (P=0.03). Finally, TSNIT was most strongly correlated to FI in the central 1.5 mm and FI in the central 2.5 mm (P<0.001).

CONCLUSION

Presence of capsular fibrosis seems to be more clinically relevant in the central zone, whereas pearls tend to be clinically significant in the central 3.5 mm area. Hence, it might be worthwhile assessing the amount of PCO in pseudophakic patients when performing scanning laser polarimetry. Investigators should ensure that the type of PCO and the size of the area analysed are documented in the notes in order to interpret GDx findings appropriately.

Mortality following exenteration for malignant tumours of the orbit

BACKGROUND

Orbital exenteration is a rare, but disfiguring procedure reserved for the treatment of locally invasive malignancy or potentially life threatening orbital neoplasms, when less destructive techniques are inadequate. The authors report their experience and analyses of 64 cases of orbital exenteration performed over a 13 year period, looking specifically at key factors affecting mortality associated with such a destructive surgical procedure.

METHODS

Records were reviewed retrospectively of all patients who had undergone exenteration of the orbit from 1 January 1991 to 1 April 2004 inclusive, at the Manchester Royal Eye Hospital. In all cases of deceased individuals, the cause of death was determined by liaison with the general practitioner and local health authority. Duplicate death certificates were requested for all deceased patients from the Registrar for Births, Deaths, and Marriages, Southport, UK. Kaplan-Meier analysis was used to estimate survival following exenteration.

RESULTS

Overall, 1 year survival post-exenteration was high at 93%. After 3 years this had fallen to 67%, followed by 57% after 5 years, and 37% at 10 years. 13 patients died as a direct result of the orbital tumour. A further nine died of unrelated medical conditions, and two patients succumbed to malignant processes originating elsewhere in the body. There was no difference in survival rate at 3 years (p=0.99) and 5 years (p=0.454) between those with clear resection margins and those without.

CONCLUSION

In this study it was found that there was an overall mortality rate of 38% over 12 years. The presence of clear surgical margins, although reassuring for the surgeon, should not be regarded as an indication of cure. However, an overall 1 year survival of 93% and a 10 year survival of 37% are reassuring in that a proportion of individuals achieve surgical cure following exenteration. 38% of patients died as a result of other medical causes over the 12 year follow up.

Acute and chronic effects of brimonidine 0.2% on intraocular pressure and pulsatile ocular blood flow in patients with primary open-angle glaucoma: an open-label, uncontrolled, prospective study

BACKGROUND

Brimonidine has been reported to decrease aqueous production and increase uveoscleral outflow; however, the hemodynamic effects of brimonidine are still under investigation.

OBJECTIVE

The purpose of this study was to report the acute and chronic effects of brimonidine 0.2% on intraocular pressure (IOP) and pulsatile ocular blood flow (pOBF) in patients with primary open-angle glaucoma (POAG).

METHODS

Nonsmoking patients aged 45 to 67 years with POAG and normal blood pressure, heart rate, body mass index, and hemorheologic parameters were enrolled in the study. Brimonidine 0.2% was self-administered twice daily for 180 days. IOP and pOBF were determined using Goldmann applanation tonometry and the Langham system. All measurements were taken at baseline and 4, 8, and 12 hours after treatment and were repeated on days 7, 15, 30, 60, 90, 120, 150, and 180 of treatment.

RESULTS

Of the 18 eligible patients, 10 (6 men and 4 women) were enrolled (mean age, 51.5 +/- 4.39; range, 47-64 years). When measured 12 hours after instillation, mean IOP was significantly reduced by 21.5% (P < 0.001) compared with the baseline value. The greatest decrease in IOP (-23.5%) was observed at 8 hours. After 12 hours, a significant increase (P < 0.001) in pOBF was measured. A stable IOP reduction (P < 0.001 vs baseline), as well as an increase in pOBF (P = 0.015), was recorded at the subsequent time points. The pOBF increases ranged from 22.5% at day 30 to 9.2% at day 180 of treatment. No evidence of adverse events was found at any time point.

CONCLUSIONS

In this sample of patients with open-angle glaucoma, brimonidine induced a rapid reduction in IOP that was significant even after 6 months. Moreover, an increase in pOBF was observed from the first day of treatment, and remained consistent throughout the study.

Corneal Temperature Changes During Photorefractive Keratectomy Using the Laserscan 2000 Flying Spot Laser

PURPOSE

To evaluate the thermal variations during photorefractive keratectomy (PRK) induced by a Laserscan 2000 flying spot excimer laser.

METHODS

Thermal changes during PRK were recorded using a non-contact infrared thermometer on 58 eyes with an attempted correction ranging from -1.25 to -9.00 D. The eyes were randomly divided into two groups to test the thermal effects of two different ablation scan techniques: sequential and randomized modes. Thermal measurements were also performed during myopic ablations on polymethylmethacrylate (PMMA) test plates.

RESULTS

On PMMA plates, a significant relationship between the amount of attempted myopic correction and thermal changes was established (P=.017 in sequential mode and P=.007 in randomized mode); this was not established for human eyes. With the sequential mode, an unexpected cooling effect after PRK was reported for each myopia subgroup (P=.003 in the low and high myopia subgroups, P<.001 in the medium myopia subgroup). With the randomized mode, the cooling effect was detected only for low amounts of myopia.

CONCLUSION

Despite a high repetition rate, the Laserscan 2000 flying spot laser minimized thermal shock. In comparison with randomized (nonsequential) pulse application, sequential pulsing showed no increase in the thermal loading of corneas. In fact, a cooling effect during PRK was produced.

A randomised, double masked, clinical trial of high dose vitamin A and vitamin E supplementation after photorefractive keratectomy

AIM

To evaluate the effect of a high dose vitamin A and E supplementation on corneal re-epithelialisation time, visual acuity and haze following photorefractive keratectomy (PRK).

METHODS

Two groups of 20 patients who underwent myopic PRK were supplemented with either 25 000 IU retinol palmitate and 230 mg alpha tocopheryl nicotinate or a placebo. Clinical outcomes were evaluated up to 360 days.

RESULTS

In the vitamin treated group, re-epithelialisation time was significantly faster (p = 0.029) and haze incidence was reduced (p = 0.035), especially for high myopic corrections (p = 0.043). This group also reported a significantly better uncorrected visual acuity (p = 0.043).

CONCLUSIONS

High dose vitamin A and E oral supplementation may accelerate re-epithelialisation time and may reduce corneal haze formation after PRK.

The effect of early steroid treatment after PRK on clinical and refractive outcomes

PURPOSE

To evaluate the effects of steroid treatment administered in the first days after excimer laser keratectomy (PRK) on re-epithelialization time, postoperative pain, haze and refractive outcome.

METHODS

A randomised, double masked trial was carried out on two groups of patients (40 patients each), who underwent PRK. Group A (steroid group) received 0.1% fluorometholone acetate whereas group B (NSAID group) received 0.5% ketorolac tromethamine until re-epithelialization was completed. Subsequently, all 80 patients received the same steroid treatment: 0.1%, fluorometholone acetate for myopic corrections up to -5 D, or dexamethasone for myopic corrections exceeding -5 D. Both drugs were tapered off over approximately 3 months. Follow-up examinations were planned at 1, 3, 6, 12 months after surgery.

RESULTS

Re-epithelialization was completed after three days, without any significant difference between groups. A higher hyperopic shift was shown in the steroid group and a more severe regression was reported in the NSAID group (p<0.001). Haze was significantly reduced in the steroid group (p=0.005), especially for myopic corrections over -5 D (p=0.015). Pain was significantly reduced in the NSAID group (p=0.002).

CONCLUSION

Steroid eyedrops administered in the first days after PRK did not affect re-epithelialization time. Moreover, a modulation of the inflammatory response in this period appears to reduce haze and myopic regression in high myopic patients.

Prospective randomized comparison of simultaneous and sequential bilateral photorefractive keratectomy for the correction of myopia

BACKGROUND AND OBJECTIVE

To evaluate the efficacy and safety of simultaneous bilateral photorefractive keratectomy (PRK).

PATIENTS AND METHODS

There were 52 patients (104 eyes) with myopia less than -6 diopters entered in this prospective trial and randomized to simultaneous or sequential bilateral PRK. Main outcome measures were uncorrected visual acuity (UCVA), percentage of eyes within +/-0.5 D of attempted outcome, present pain intensity (PPI) and total pain rating index (PRI(R)T) scores resulting from McGill the Pain Questionnaire, subjective symptoms, haze, and patient satisfaction. Follow-up extended to 14 months.

RESULTS

There was no significant difference in UCVA (P=0.996) and percentage of eyes within +/-0.5 D of attempted correction (P=0.932). Present pain intensity and PRI(R)T scores were significantly higher in the sequential group (P=0.037; P=0.034). The percentage of satisfied patients after bilateral PRK was significantly higher in the simultaneous group (P=0.036).

CONCLUSIONS

Simultaneous bilateral PRK was safe and effective, without any significant difference from sequential treatment.

A randomized, comparative open-label study on the efficacy of latanoprost and timolol in steroid induced ocular hypertension after photorefractive keratectomy

PURPOSE

To evaluate the effect of 0.005% latanoprost and 0.50% timolol for the treatment of steroid-induced ocular hypertension (SIOH) after excimer laser photorefractive keratectomy (PRK).

METHODS

In this comparative, open-label study we enrolled 29 patients who received steroid therapy after PRK and developed intraocular pressure (IOP) elevation within 30 days of treatment. Fifteen were randomized to 0.005% latanoprost (group A) and 14 to 0.50% timolol (group B). IOP measurements were scheduled at 1, 3, 7, 15, 30, 60, 90 and 120 days of therapy. RESULTS; We did not find any real differences between latanoprost and timolol except at the 7-day and 15-day timepoints, when latanoprost reduced IOP significantly more than timolol (p=0.033, 0.035, respectively). After 7 days of therapy two of the 14 timolol-treated patients had high IOP (24 and 26 mmHg) but these promptly returned to normal when latanoprost was added. No significant differences were observed in the ocular side effects considered.

CONCLUSIONS

0.005% latanoprost is as safe and effective as 0.50% timolol in the treatment of SIOH after PRK. Both drugs provide a significant and stable IOP reduction in the majority of patients after short-term treatment. These findings are encouraging for the use of latanoprost in the management of SIOH after PRK, although further trials are necessary to consider it as a primary treatment.

Contrast sensitivity measured by 2 methods after photorefractive keratectomy

PURPOSE

To study contrast sensitivity in eyes that had flying-spot excimer laser photorefractive keratectomy (PRK) and to compare a subjective method (Vision Contrast Test System [VCTS] 6500) and an objective method (visual evoked potential [VEP]) of measuring contrast sensitivity.

SETTING

Istituto Clinica Oculistica, Università degli Studi, Bari, Italy.

METHODS

Contrast sensitivity changes over time were evaluated in 26 eyes. The baseline values were compared with measurements 3, 6, and 12 months after PRK using the VCTS 6500 and VEP. Contrast threshold and VEP amplitude were classified by myopic correction.

RESULTS

Contrast threshold values changed significantly over time (P <.001). Significant differences were found between mean contrast threshold preoperatively and 12 months postoperatively (P <.001) at all spatial frequencies. A significant relationship was established between baseline and 12 month measurements at 18 cycles per degree. Mean VEP amplitude measurements also changed significantly over time (P <.001) and showed a significant relationship between baseline and 12 month measurements (P <.001). A significant relationship was also established between baseline and 12 month VEP amplitude values at 100% of grating contrast. Patients with high myopia complained significantly more at a lower contrast threshold and at lower VEP amplitude values than patients with low myopia.

CONCLUSIONS

Three months after PRK, contrast threshold and VEP amplitude values were reduced. Partial recovery was established at 6 months, although patients reported permanent impairment under low-contrast conditions, especially if the myopia correction was more than 6.0 diopters.

Retinal nerve fiber layer measurements using scanning laser polarimetry after photorefractive keratectomy

PURPOSE

To assess the effects of corneal depth changes on retinal nerve fiber layer (RNFL) postoperative measurements in myopic patients who had undergone photorefractive keratectomy (PRK).

METHODS

A total of 120 myopic patients underwent PRK for myopia (range -2 to -10 diopters) and were divided into three groups according to their myopic correction: lower than 3 diopters (low myopia group), between 3 and 6 diopters (medium myopia group), over 6 diopters (high myopia group). RNFL parameters were evaluated preoperatively and 5 days, 3 months and 6 months after surgery, using a GDx NFA II scanning laser ophthalmoscope.

RESULTS

Significant changes were seen in the symmetry, superior maximum, and average thickness, comparing baseline with six-month measurements (p=0.008, 0.027, 0.015 respectively). Dividing the sample according to attempted myopic correction, it was found that mean postoperative RNFL thickness was significantly lower after PRK only in the high myopia group. Mean RNFL thickness did not change with time (p=0.884). Ablation depth was correlated with a change in RNFL thickness by the sixth postoperative month for each group. These variables were significantly related only in the high myopia group (p=0.003).

CONCLUSIONS

As polarised light penetrates the ablation area, morphological and functional changes might affect Gdx NFA II measurements. It must always be borne in mind that RNFL thickness can decrease either in cases of glaucoma or after PRK for high myopia, so close attention must be paid to interpreting these measurements in patients who have undergone PRK.

A randomized, comparative study of fluorometholone 0.2% and fluorometholone 0.1% acetate after photorefractive keratectomy

PURPOSE

To compare the efficacy and tolerance of fluorometholone 0.1% acetate and fluorometholone 0.2% eyedrops in the postoperative management of photorefractive keratectomy (PRK).

METHODS

A randomised single-blind comparative study was performed on two groups of 30 patients who underwent myopic PRK. The first group was given fluorometholone 0.1% acetate and the second fluorometholone 0.2%. Uncorrected and best corrected visual acuity, haze, IOP and local tolerance were evaluated. Statistical analysis was done using parametric and non-parametric tests.

RESULTS

Visual acuity did not differ in the two groups; both were homogeneous as far as refractive error and haze were concerned. Three patients (10%) treated with fluorometholone 0.2% and two patients (6.6%) with fluorometholone 0.1% acetate developed ocular hypertension, but this was not statistically significant.

CONCLUSIONS

Fluorometholone 0.1% acetate was effective on inflammation after PRK, with the same efficacy as fluorometholone 0.2%.

[Occupational exposure to asbestos in removal and protective treatment of roof coverings]

In the Province of Varese several operations have been carried out in the last two years for the removal or overcovering of asbestos-cement roofings. The present study assessed the level of exposure of the operators to inhalable asbestos fibres. The concentrations of asbestos fibres were determined by optic and electronic microscope analysis: the analyses showed the presence of mixtures of chrysotile and amosite in varying proportions. The exposure levels were correlated with the work procedures. In handling materials, there is not only fibre dispersion but sometimes also the production of asbestos-cement fragments, which can release inhalable fibres several days later. In order to limit both personal and environmental risk, it is essential to observe the rules of caution and good practice.