Cardiovascular health of patients with cancer: challenges abound

Patients with cancer have elevated cardiovascular risks compared to those without cancer. As cancer incidence increases and cancer-related mortality decreases, cardiovascular diseases in patients with a history of cancer will become increasingly important. This in turn is reflected by the exponentially increasing amount of cardio-oncology research in recent years. This narrative review aims to summarize the key existing literature in several main areas of cardio-oncology, including the epidemiology, natural history, prevention, management, and determinants of the cardiovascular health of patients with cancer, and identify relevant gaps in evidence for further research.

The distal radial artery: Versatile vascular access for transcatheter interventions

Conventional transradial access has been established as the gold standard for invasive coronary angiography and percutaneous interventions by the current European and American guidelines. The distal or snuffbox radial artery access represents an alternative transradial access site that allows radial sheath insertion with the patient's hand pronated. Firstly described 40 years ago, it exploded in popularity only recently. Promising additional benefits, the distal radial access is increasingly being adopted in various types of percutaneous interventions, being preferred by many interventional cardiologists and radiologists for its reduced vascular complications and time to hemostasis, and improvement of patient and operator comfort. Other centers consider it a fad, waiting for solid clear evidence and benefits. The evidence is dynamic and discrepant, depending on the center, the operator, and how it was collected (randomized controlled vs observational studies). Another essential aspect raised by "skeptics" was whether distal radial access, by its smaller diameter and more angled course, can support all types of interventions. The aim of this review is to gather all the scenarios where distal radial access has been utilized and to conclude whether this vascular access is feasible across all transcatheter interventions.

Immune checkpoint inhibitors - the revolutionary cancer immunotherapy comes with a cardiotoxic price

The development of immune checkpoint inhibitors (ICIs) has provided a novel and revolutionary treatment option for previously incurable cancers. However, this major advancement is accompanied by a spectrum of cardiotoxic adverse events that are uncommon but potentially fatal. The oncologic indications of ICIs are becoming increasingly complex, requiring robust clinical monitoring to assess for cardiovascular complications. This is reflected in the recent introduction of the first cardio-oncology guidelines, a sign of the cardiovascular community's recognition that seeks to match this dynamic. The aim of this review is to summarize the cardiac side effects of ICI, with an emphasis on prevalence, diagnosis, and treatment options.

Outcomes after stenting of renal artery stenosis in patients with high-risk clinical features

BACKGROUND

In patients with renal artery stenosis, revascularization was seen as a mean to improve outcomes, but large studies failed to show significant benefit in general population. However, data on benefits of renal artery stenting in patients with high-risk features, such as rapidly declining renal function and cardiac destabilization syndromes, are limited, as they were excluded from trials. In this descriptive study, we aimed to evaluate short- and long-term outcomes in high-risk patients with renal artery stenosis, treated by angioplasty and stenting. We have retrospectively interrogated our local databases for renal artery percutaneous interventions; patients at high-risk (rapidly declining renal function; stable chronic renal failure and bilateral renal artery disease; severe hypertensive crisis) were selected for the current analysis.

RESULTS

Of 30 patients undergoing renal artery stenting, 18 patients were deemed "high-risk." On short term, good in-hospital control of hypertension and cardiac stabilization were obtained in all patients. Renal function improved significantly only in patients admitted with rapidly declining renal function, with significant creatinine level fall from median 3.98 mg/dL to 2.02 mg/dL, p = 0.023. However, for the whole group, creatinine change was non-significant (- 0.12 mg/dL, p = NS). On the long term, five patients (27.8%) ended-up on chronic hemodialysis and six patients died (33.3%) after a median of 20 months. No death occurred during the first year after the procedure.

CONCLUSIONS

Percutaneous procedures are feasible and safe in patients with high-risk renal artery stenosis, especially in those with rapidly declining renal function, probably saving some of them from the immediate need for renal replacement therapy, but long-term results are negatively influenced by the precarious general and cardio-vascular status of these patients and by the pre-existing significant renal parenchymal disease, non-related to the renal artery stenosis.

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

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

The Relationship between Tricuspid Annular Longitudinal and Sphincter-like Features of Its Function in Healthy Adults: Insights from the MAGYAR-Healthy Study

INTRODUCTION

The tricuspid valve is an atrioventricular valve located on the right side of the heart, which consists of the fibrous tricuspid annulus (TA), three valvular leaflets and a supporting apparatus, the papillary muscles and the tendinous chords. The TA is an oval-shaped three-dimensional (3D) fibrous structure with a complex spatial movement during the cardiac cycle. Three-dimensional echocardiography (3DE) could help during "en-face" assessment of TA dimensions and related functional properties featuring its "sphincter-like" function. TA plane systolic excursion (TAPSE) is a displacement of the lateral edge of the TA toward the apex in systole measured in apical long-axis using M-mode echocardiography (MME). The aim of this study was to determine potential relationships between TA size and its "sphincter-like" and "longitudinal" functions in healthy adults with no functional tricuspid regurgitation.

METHODS

The present study consisted of 119 healthy patients (age: 34.6 ± 11.5 years, 70 men) who underwent routine echocardiography with M-mode-derived TAPSE measurement and 3DE. Two subgroups of healthy subjects were compared with each other. A total of 29 subjects with TAPSE between 17 and 21 mm were compared with 90 cases with TAPSE ≥ 22 mm.

RESULTS

Subjects with TAPSE of 17-21 mm had tendentiously dilated TA dimensions compared with subjects with TAPSE ≥ 22 mm. Significant differences could be detected in the end-systolic TA area (5.85 ± 1.90 cm2 vs. 3.70 ± 1.22 cm2, p < 0.05), leading to impaired TAFAC (24.8 ± 9.0% vs. 35.1 ± 9.1%, p < 0.05) in subjects with lower TAPSE (17-21 mm) compared with subjects with TAPSE ≥ 22 mm. TAPSE did not show correlations with any TA size or "sphincter-like" functional parameters as determined using 3DE.

CONCLUSIONS

Three-dimensional echocardiography is capable of measuring TA dimensions and functional "sphincter-like" properties, which are associated with MME-derived TAPSE, suggesting a sensitive and harmonic TA function in healthy adults without functional tricuspid regurgitation.

Left ventricular rotational mechanics and left ventricular volumes: is there a relationship in healthy adults?-three-dimensional speckle-tracking echocardiography-derived insights from the MAGYAR-Healthy Study

Background

Left ventricular (LV) rotational mechanics play a crucial role in LV pump function by strengthening and improving its efficacy. Dependence of LV rotational parameters on left atrial volumes has already been demonstrated. The evaluation of the effect of LV rotational mechanics on LV volumes was purposed in a population of healthy subjects by three-dimensional speckle-tracking echocardiography (STE).

Methods

The study comprised 175 healthy subjects with a mean age of 32.8±12.2 years (79 males). All subjects underwent a complete physical examination, laboratory assessments, standard 12-lead electrocardiography and two-dimensional Doppler and three-dimensional STE, the results of these examinations were within the normal range.

Results

Increased basal LV rotation was associated with increased LV volume measured in end-systole and impaired LV ejection fraction. Increased apical LV rotation was associated with reduced LV volumes assessed in end-diastole and in end-systole and increased ejection fraction of the LV. Elevated basal LV rotation showed associations with increased LV mass. In case of increasing basal LV rotation, apical LV rotation showed a decreasing tendency and LV twist showed a tendency of increasing. Similarly, lower basal LV rotation and increased LV twist were seen with increasing apical LV rotation. Increasing LV end-diastolic volume was associated with increasing LV volume measured in end-systole and preserved ejection fraction of the LV. Increasing LV end-systolic volume was associated with increasing LV end-diastolic volume and reduction of LV ejection fraction. Increasing LV volumes were associated with increasing LV mass. While increased LV volumes were associated with reduced apical LV rotation and twist, basal LV rotation did not show significant changes.

Conclusions

LV rotational mechanics are strongly associated with LV volumes in healthy adults suggesting its volume-dependence.

Tricuspid annular and right atrial volume changes are associated in healthy adults-insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Introduction

The tricuspid valve and its annulus (TA) and the right atrium (RA) play a significant role in regulating blood flow in the right heart. However, their effect on each other is not fully understood even in normal circumstances. Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is able to simultaneously assess TA and RA at the same time in a non-invasive way. The present study aimed to examine associations between tricuspid annular (TA) dimensions and right atrial (RA) volumes in healthy adults by 3DSTE.

Methods

The present study comprised 144 healthy subjects (mean age: 34.4 ± 12.6 years, 72 males), who participated in this study on a voluntary basis for screening between 2011 and 2015. In all subjects, electrocardiography, two-dimensional Doppler echocardiography and 3DSTE have been performed.

Results

With increasing end-systolic maximum RA volume, all end-systolic and end-diastolic TA dimensions showed simultaneous increase, but in various degrees resulting in (non-significant) reduction of TA functional properties. Similarly, with increasing diastolic pre-atrial contraction and minimum RA volumes, TA dimensions increased simultaneously (except end-diastolic TA diameter), but in various degrees resulting in reduced TA fractional shortening and fractional area change. With increasing RA dimensions, end-systolic and end-diastolic TA dimensions showed simultaneous increase, but in different, sometimes not significant degrees. While RA stroke volumes showed increasing pattern with TA dilation, RA emptying fractions have not changed substantially.

Conclusions

3DSTE is suitable for non-invasive assessment of TA dimensions and RA volumes at the same time using the same 3D echocardiographic dataset. Significant associations between TA size and RA volumes exist in healthy circumstances. Strong associations in case of dilation of TA in the presence of higher RA volumes could partly explain functional tricuspid regurgitation later developing in subjects in sinus rhythm.

Superficial Calcified Plates Associated to Plaque Erosions in Acute Coronary Syndromes

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

Coronary steal: how many thieves are out there?

The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Complexity of left ventricular strains in response to elevated volumes in healthy adults - Detailed analysis from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Introduction

Cardiac haemodynamics is described by the Frank-Starling law, which states that the strength of the left ventricular (LV) systolic contraction is related to the LV diastolic filling, with other words LV stroke volume increases as LV volume increases due to the stretching of the myocyte. The purpose of the present study was to examine how the increasing LV volumes affect LV contractility represented by three-dimensional (3D) speckle-tracking echocardiography (3DSTE) -derived LV strains in healthy adults.

Methods

This is post-hoc analysis of the MAGYAR-Healthy Study employing a novel method for technical analysis of echocardiographic datasets. The present study consisted of 301 healthy adults. Due to inferior image quality, 127 subjects have been excluded, therefore the remaining population included 174 subjects (mean age: 32.9 ± 12.1 years, 80 males). All cases have undergone complete two-dimensional Doppler echocardiography extended with 3DSTE.

Results

LV global longitudinal (gLS) and area (gAS) strains were lowest in case of the highest LV end-diastolic volume (EDV). LV global radial (gRS) and 3D (g3DS) strains tendentiously increased with increasing LV-EDV. When segmental analysis was performed, increased LV-EDV was associated with increase of basal LV-RS and LV-3DS. Increased LV strains were associated with increased LV ejection fraction (EF) due to higher LV-EDV for LV-gRS (and LV-g3DS), lower LV-ESV for LV-gCS and lower LV-EDV and LV-ESV for LV-gLS (and LV-gAS). With increasing LV-gRS, LV-gCS and LV-g3DS, all LV strains increased except LV-gLS. With increasing LV-gLS, LV-gRS did not show any increase, LV-gCS and LV-g3DS were the highest when LV-gLS was the highest, while LV-gAS increased simultaneously. With increasing LV-gAS, all LV strains increased.

Conclusions

There is a complex contractility pattern of LV segments/regions in response to elevated LV volumes in healthy circumstances.

Conservative Treatment for Cavity Spilling Coronary Perforations

Coronary perforation leading to shunting to other cardiac chambers is a rare complication of percutaneous coronary intervention (PCI), and most cases reported aggressive treatment with either a covered stent, coiling, or protamine injection. We report herein two cases, one of a fairly large cavity-spilling perforation of the left anterior descending coronary artery into the right ventricle and one spilling in the coronary vein. Both iatrogenic shunts were treated conservatively, and angiographic follow-up showed spontaneous resolution, suggesting that the outcome in this type of perforation may be favorable with conservative therapy. We also propose a management strategy on how to differentiate such contrast extravasations, find which cavity is communicating with the vessel and when to intervene more decisively. SOCIAL MEDIA ABSTRACT: We report herein two "fortunate" perforations, one of a fairly large cavity-spilling perforation from the left anterior descending coronary artery into the right ventricle and one spilling in the coronary vein. The angiographic follow-up showed spontaneous healing due to spilling in low-pressure cavities. A "no-touch" strategy is preferred if the patient remains asymptomatic and the pericardium free of fluid.

Safe and predictable transcatheter removal of broken coronary guidewires: the 'knuckle-twister' technique: a case series report

Background

Guidewire fracture and loss is a rare but well-known and feared complication of percutaneous coronary interventions. With the increasing number of complex coronary interventions and procedures for chronic total occlusions, operators face new challenges and boundaries, and the need for solutions to otherwise rare complications is increasing.

Case summary

We have developed a simple and practical method for retrieving fractured and lost guidewires, called the 'knuckle-twister' technique. This article summarizes seven cases in which guidewires lost in the coronary vasculature have been successfully removed and describes this technique in detail. The goal was to gather different clinical scenarios: free wire lost in situ, wire jailed behind stent struts, wire in small branches, part of the wire protruding into the aorta, 'invisible' guidewire microfilaments/coils, etc.

Discussion

The innovation of the knuckle-twister consists in folding a polymer-jacketed guidewire and transforming it into an open lasso that tightens when twisted. In vitro, its grip strength and pulling force was tested and exceeded 1.5 kg. Moreover, in all in vivo cases, the lost material could be efficiently and quite rapidly retrieved with this simple and highly reproducible technique.

Key clinical message

Broken guidewires that were lost in the coronary vasculature can be safely retrieved with this novel and simple technique requiring no special safety equipment.

Mechanical valve thrombosis: current management and differences between guidelines

All foreign bodies inserted in the circulatory system are thrombogenic and require temporary or lifelong antithrombotic therapies to prevent thrombosis. The adequate level of anticoagulation during the first few months determines the long-term durability, particularly for mechanical prostheses;2 however also for biological valves. Suboptimal anticoagulation is the most frequent source of mechanical valve thrombosis (MVT). The patient's clinical presentation decides how mechanical prosthetic valve obstruction is managed. If the mechanical valve thrombosis is obstructive and the patient is in a critical condition with hemodynamic instability, an immediate surgical intervention should be performed. The thrombolytic treatment is an option for left mechanical valve thrombosis in patients who have high surgical risk and no contraindications and also for right heart valve thrombosis. In non-obstructive thrombosis on the mechanical valve, patients can be asymptomatic, requiring optimization of the anticoagulant treatment. Both obstructive and non-obstructive thrombus generated on the mechanical prosthesis can result in embolic events. After anticoagulant treatment, if the thrombus persists the indication is for thrombolytic treatment or redo surgery. Pannus can also cause obstruction of the prosthesis for which surgical treatment is the only option. All these clinical scenarios seem to have a simple solution in terms of surgery vs thrombolysis vs effective anticoagulation, but the real-world clinical experience could be different. For example, the same patient with some common comorbidities, non-obstructive mechanical valve thrombosis, and symptomatic only by repeated systemic embolizations, can go through all these 3 therapeutic options, due to MVT's unpredictable nature. Therefore, treatment indications can intersect both on the time axis and depending on the patient's clinical status and the expertise of the center where he is hospitalized. Moreover, the European and American guidelines show subtle but important differences. The aim of this review was to compare these differences, comment on recent studies and evidence gaps, propose a more pragmatic algorithm combining all current indications, and highlight important research directions for this disease that has dominated already the cardiovascular landscape for more than five decades, but for which there have been no significant recent changes in management.

Combination of Laser Atherectomy and Super High-pressure Non-compliant Balloon to Treat Stent Under-expansion in Cases of Failed Interventional Options

Patients with calcified, fibrotic native coronary vessels with prior suboptimal stenting outcomes are at major risk of stent thrombosis and could face serious consequences if untreated. In cases of multiple layers of under-expanded stents, the risk is multiplied. If conventional balloon post-dilatation is unsuccessful after stent implantation without proper lesion preparation, few interventional options remain. The authors report on a patient with prior numerous right coronary unsuccessful coronary interventions resulting in partially crushed multiple layers of stent material with critical lumen narrowing caused by stent under-expansion. Balloon angioplasty and stent rotational atherectomy (ROTA) had been attempted to overcome stent under-expansion but were unsuccessful. The authors investigated a new combination therapy of laser atherectomy (ELCA) and super high-pressure balloon (OPN non-compliant balloon) to treat single or multiple layers of stent with severe under-expansion due to fibrotic, calcified tissue surrounding the under-expanded stent structure.

TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion

Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.

Three-Dimensional Speckle-Tracking Echocardiography-Derived Tricuspid Annular Dimensions and Right Atrial Strains in Healthy Adults-Is There a Relationship? (Insights from the MAGYAR-Healthy Study)

INTRODUCTION

The tricuspid valve and its annulus (TA) are thought to be integrally related to right atrial (RA) size and function. The present study aimed to assess associations between TA dimensions and RA strains, and quantitative features of its contractility were determined by 3DSTE in healthy adults.

METHODS

The study comprised 145 healthy volunteers with a mean age of 34.4 ± 12.5 years (73 males). Electrocardiographic, two-dimensional Doppler echocardiographic and 3DSTE parameters were in normal reference ranges in all subjects.

RESULTS

Enlarged TA areas, regardless of which phase of the cardiac cycle were measured, were not associated with the deterioration of peak RA strains in longitudinal (LS) and circumferential (CS) directions. Increased end-diastolic TA area was associated with reduced RA strain in the radial direction (RS). Dilation of end-diastolic and end-systolic TA areas was related to increased RA volumes. End-diastolic TA area was the smallest in case of increased peak global RA-RS, and other associations between increasing TA areas and peak global strains could not be detected. Peak global RA-CS and RA-LS were not related to TA areas. Increasing peak global RA-RS was not associated with peak global RA-LS and RA-CS, while increasing peak global RA-LS and RA-CS were not associated with peak global RA-RS. Increasing peak global RS did not show associations with RA volumes, V_min was the smallest in the case of highest peak global RA-CS and RA-LS. V_max increased with increasing peak global RA-LS.

CONCLUSIONS

3DSTE is suitable for simultaneous non-invasive determination of TA dimensions and RA volumes and strains using the same acquired 3D dataset, allowing physiologic studies. RA volumes are associated with end-diastolic and end-systolic TA areas. RA strains in radial direction (RS) show associations with end-diastolic TA area.

Simultaneously Assessed Three-Dimensional Speckle-Tracking Echocardiography-Derived Left Ventricular and Left Atrial Volumes Are Associated in Healthy Adults-Findings from the MAGYAR-Healthy Study

INTRODUCTION

The left atrium (LA) has a significant role in regulating blood flow from veins to the left ventricle (LV). LV performance is affected by several factors including preload, which is partly, but highly, dependent on LA volumes. The aim of the present study is to perform simultaneous assessment of LA and LV volume changes during the cardiac cycle in healthy circumstances. Therefore, LA and LV volumes and volume-based functional properties were determined in healthy adults, and the associations of these parameters were examined.

METHODS

The present study consists of 164 healthy adults (age: 33.0 ± 12.3 years, 82 males) being in sinus rhythm. All subjects have undergone complete two-dimensional Doppler echocardiography with three-dimensional speckle-tracking echocardiography (3DSTE).

RESULTS

Increased end-systolic maximum LA volume was associated with higher LV volumes and reduced LV ejection fraction. Very high early pre-atrial contraction and late diastolic LA volumes were associated with increased LV volumes, reduced LV ejection fraction and increased LV mass. Increased LA volumes were associated with increased LV mass. Higher LV volumes were associated with tendentiously higher LA volumes. Higher LV end-diastolic volume was associated with tendentiously higher all LA stroke volumes (SVs) and total and active LA emptying fractions (EFs). Higher LV end-systolic volume was associated with tendentiously higher all LA SVs but preserved all LA EFs.

CONCLUSIONS

3DSTE is capable of simultaneous assessment of LA and LV volumes and volume-based functional properties for (patho)physiologic studies. Moreover, 3DSTE-derived LV and LA volumes and functional properties show strong associations.

Diagnosis of Left-Sided Mechanical Prosthetic Valve Thrombosis: A Pictorial Review

Although transcatheter valve therapy is rapidly evolving, surgical valve replacement is still required in many patients with severe left-side valve stenosis or regurgitation, the mechanical bi-leaflet heart valve being the standard prosthesis type in younger patients. Moreover, the prevalence of valvular heart disease is steadily increasing, especially in industrialized countries, and the problem of lifelong efficient anticoagulation of these patients remains fundamental, especially in the context where vitamin K antagonists continue to be the current standard of anticoagulation despite a level of oscillating anticoagulation. In this setting, avoiding prosthetic valve thrombosis after surgery is the number one objective for both the patient and the responsible physicians. Although rare, this complication is life threatening, with the sudden onset of acute cardiac failure such as acute pulmonary edema, cardiogenic shock, or sudden cardiac death and inadequate anticoagulation remaining the leading cause of prosthesis thrombosis, along with other risk factors. The availability of multimodal imaging techniques enables and encompasses to a full extent the diagnosis of mechanical valve thrombosis. The gold-standard diagnostic methods are transthoracic and transesophageal echocardiography. Moreover, 3D ultrasound has undoubted value in giving a more accurate description of the thrombus's extension. When transthoracic and transesophageal echocardiography are uncertain, the multidetector computer tomography examination is an important complementary imaging method. Fluoroscopy is also an excellent tool for evaluating the mobility of prosthetic discs. Each method complements the other to differentiate an acute mechanical valve thrombosis from other prosthetic valve pathologies such as pannus formation or infective endocarditis and aids the physician in accurately establishing the treatment method (surgical or pharmaceutical) and its optimal timing. The aim of this pictorial review was to discuss from an imagistic perspective the mechanical prosthetic aortic and mitral valve thrombosis and to provide an overview of the essential role of non-invasive exploration in the treatment of this severe complication.

Transesophageal echocardiography-guided versus fluoroscopy-guided patent foramen ovale closure: A single center registry

BACKGROUND

Percutaneous closure of patent foramen ovale (PFO) is conventionally performed under continuous transesophageal echocardiographic (TEE) guidance. We aimed to evaluate whether a simplified procedural approach, including pure fluoroscopy-guidance and final TEE control, as well as an aimed 'next-day-discharge' is comparable with the conventional TEE-guided procedure in terms of periprocedural and intermediate-term outcomes.

METHODS

All patients who underwent a PFO closure at our center between 2010 and 2022 were retrospectively included. Prior to June 2019 cases were performed with continuous TEE guidance (TEE-guided group). Since June 2019, only pure fluoroscopy-guided PFO closures have been performed with TEE insertion and control just prior to device release (fluoroscopy-guided group). We analyzed procedural aspects, as well as long term clinical and echocardiographic outcomes.

RESULTS

In total 291 patients were included in the analysis: 197 in the TEE-guided group and 94 in the fluoroscopy-guided group. Fluoroscopy-guided procedures were markedly shorter (48 ± 20 min vs. 25 ± 9 min; p < .01). There was no difference in procedural complications, including death, major bleeding, device dislodgement, stroke or clinically relevant peripheral embolization between the two groups (.5% vs. 0%; p = .99). Hospital stay was also shorter with the simplified approach (2.5 ± 1.6 vs. 3.5 ± 1.2 days; p < .01), allowing 85% same-day discharges during the last 12 months of observation period. At 6 ± 3 months echocardiographic follow-up a residual leakage was described in 8% of the TEE-guided cases and 2% of the fluoroscopy-guided cases (p = .08).

CONCLUSION

While a complete TEE-free PFO closure might have potential procedural risks, our approach of pure fluoroscopy-guided with a brisk final TEE check seems to be advantageous in terms of procedural aspects with no sign of any acute or intermediate-term hazard and it could offer an equitable compromise between the two worlds: a complete TEE procedure and a procedure without any TEE.

The Role of Multimodality Imaging in the Diagnosis and Follow-Up of Malignant Primary Cardiac Tumors: Myxofibrosarcoma-A Case Report and Literature Review

Cardiac tumors are a very rare but heterogenous group of diseases that may reveal themselves through a variety of nonspecific cardiac symptoms that may pose a challenge to the diagnostic process. Myxofibrosarcoma is a particularly rare type of cardiac tumor that carries a poor prognosis, thus making accurate and timely diagnosis essential. A 61-year-old woman presented with fatigue and shortness of breath during mild exercise, symptoms that have progressively worsened during the previous year. Multimodality imaging consisting of transthoracic and transesophageal echocardiography (TTE and TEE), cardiac magnetic resonance (CMR), cardiac computer tomography (CCT), and fluorodeoxyglucose positron emission computer tomography (18F-FDG PET-CT) was used for the diagnosis and postoperative follow-up of a myxofibrosarcoma.

Correlation between Coronary Artery Disease with Other Arterial Systems: Similar, Albeit Separate, Underlying Pathophysiologic Mechanisms

Atherosclerosis is a multifactorial systemic disease that affects the entire arterial tree, although some areas are more prone to lipid deposits than others. Moreover, the histopathological composition of the plaques differs, and the clinical manifestations are also different, depending on the location and structure of the atherosclerotic plaque. Some arterial systems are correlated with each other more than in that they simply share a common atherosclerotic risk. The aim of this perspective review is to discuss this heterogeneity of atherosclerotic impairment in different arterial districts and to investigate the current evidence that resulted from studies of the topographical interrelations of atherosclerosis.

Oral Health of Patients Undergoing Percutaneous Coronary Intervention-A Possible Link between Periodontal Disease and In-Stent Restenosis

Introduction: There is a well-documented association between coronary artery disease (CHD) and periodontal disease (PD) mediated by common inflammatory pathways. This association, however, has not been investigated extensively in the special context of in-stent restenosis. This study aimed to investigate the periodontal status of patients undergoing percutaneous coronary intervention (PCI) for restenotic lesions. Methods and Results: We enrolled 90 patients undergoing percutaneous coronary intervention and 90 age- and gender-matched healthy controls in the present study. All subjects received a full-mouth examination by a periodontist. Plaque index, periodontal status, and tooth loss were determined. The periodontal state was significantly worse (p < 0.0001) in the PCI group, and each periodontal stage increased the odds of belonging to the PCI group. This effect of PD was independent of diabetes mellitus, another strong risk factor for CAD. The PCI group was further divided into two subgroups: PCI for restenotic lesions (n = 39) and PCI for de novo lesions (n = 51). Baseline clinical and procedural characteristics were comparable between the two PCI subgroups. A significant (p < 0.001) association was found between the PCI subgroup and the severity of periodontal disease, with the incidence of severe PD reaching 64.1%. Conclusions: Patients undergoing PCI for in-stent restenosis exhibit more severe forms of periodontal disease not only as compared to healthy controls but also as compared to patients stented for de novo lesions. The potential causality between PD and restenosis must be studied in larger prospective studies.

Clinical Characteristics and Outcomes following Percutaneous Coronary Intervention in Unprotected Left Main Disease: A Single-Center Study

Background: Hemodynamically significant unprotected left main (LM) coronary artery disease is a high-risk clinical condition because of the large area of myocardium at risk, and it requires prompt revascularization. Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected LM disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG after adequate counseling by the heart team. Methods: We retrospectively evaluated 201 patients receiving left main (LM) provisional one-stent or two-stent procedures, and we assessed the clinical characteristics and outcomes of patients undergoing unprotected LM PCI. Results: The mean age was 66.5 ± 9.9 years, and 72% were male. The majority of the subjects presented several cardiovascular risk factors, among which arterial hypertension (179 patients, 89.5%) and dyslipidemia (173 patients, 86.5%) were the most frequent. Out of all patients, 162 (81.8%) underwent revascularization by using the one-stent technique, while the two-stent technique was used in 36 patients (18.2%). The median value of fractional flow reserve (FFR) of the side branch was 0.9 [0.85–0.95], and 135 patients (67.1%) showed a value of FFR > 0.8. One hundred nine patients (54.2%) had a stent enhancement side branch length (SESBL) > 2, with median values of 2.5 mm2 [2.1–3]. Regarding angiographic parameters, the LM area as assessed by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and the grade of stenosis as assessed by quantitative coronary angiography (QCA) were similar between groups. However, patients who required revascularization by using the two-stent technique presented more frequently with intermediate rather than low SYNTAX scores (69.4% vs. 28.4%, p < 0.0001). Also, the same group required kissing balloon inflation (KBI) more frequently (69.4% vs. 30%, p < 0.001). There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique. FFR was able to predict a SESBL > 2 mm. The cut-off value for FFR to afford the highest degree of sensitivity (74.5%) and specificity (47%) for a SESBL > 2 was >0.86, indicating a moderate accuracy (AUC = 0.61, 95% CI 0.525–0.690, p = 0.036). Conclusions: Unprotected left main PCI is a safe and effective revascularization option amongst a complex and morbid population. There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique, and there was no significant impact of KBI on side branch FFR measurements but lower side branch FFR values were correlated with angiographic side branch compromise.

Dependence of Left Ventricular Rotational Mechanics on Left Atrial Volumes in Non-Smoker Healthy Adults: Analysis Based on the Three-Dimensional Speckle-Tracking Echocardiographic MAGYAR-Healthy Study

Introduction: As has been established, the left ventricle (LV) and the left atrium (LA) form an organic unit of the left heart; however, little is known about the dependence of LV rotational parameters on LA volumes, even in healthy circumstances. Therefore, the present study aimed to assess the associations between basal and apical LV rotations and LA volumes and volume-based functional properties throughout the cardiac cycle in healthy adults by three-dimensional speckle-tracking echocardiography. Methods: The present study comprised 167 healthy adults (age: 33.4 ± 12.6 years, 77 males) with normally directed LV rotational mechanics. All subjects underwent complete two-dimensional Doppler echocardiography with three-dimensional speckle-tracking echocardiography (3DSTE)-derived data acquisition. The 3DSTE-derived LA volumes and LV rotational parameters were determined at a later date. Results: An increasing end-systolic maximum LA volume (Vmax) was associated with increasing pre-atrial-contraction early (VpreA) and minimum end-diastolic (Vmin) LA volumes, and all stroke volumes were increased as well. Systolic basal left ventricular rotation (LVrot) was highest in the case of the highest systolic Vmax and early-diastolic VpreA. Apical LVrot did not show obvious associations with any increasing LA volumes. The highest systolic basal LVrot was associated with significantly increased diastolic VpreA and Vmin. Reduced diastolic LA volumes (VpreA, Vmin) were seen in the case of increased apical LVrot. An increasing basal LVrot was associated with the tendentious lowering of the apical LVrot and the significant elevation of LV twist. Similarly, an increasing apical LVrot was associated with the tendentious lowering of basal LVrot and the significant elevation of LV twist. Conclusions: Strong associations and adaptations between 3DSTE-derived LA volumes throughout the cardiac cycle and LV rotational mechanics were evidenced, even in healthy circumstances.

Clinical application of results of the ISCHEMIA trial

More than a decade after the Clinical Outcomes Utilising Revascularization and Aggressive Drug Evaluation (COURAGE) trial, International Study of Comparative Health Effectiveness With Medical And Invasive Approaches (ISCHEMIA) is the second large clinical trial to challenge the concept of revascularization in chronic coronary syndromes whilst addressing some of the shortfalls of its predecessor.

Alcohol septal ablation in hypertrophic cardiomyopathy: For which patients?

Percutaneous and surgical therapies for septal reduction for hypertrophic cardiomyopathy have been going head-to-head for the past 20 years with similar outcomes and mortality rates, although contemporary myectomy seems to materialize its superiority. However, on closer analysis, the external validity of studies advocating myectomy does not translate to all centres. The aim of this review was to examine the most recent data on septal reduction therapy and to attempt to phenotype the appropriate patient for each of the two treatments. The key to similar low mortality rates between ventricular septal myectomy and alcohol septal ablation appears to be proper patient selection performed in high volume clinical environments. Furthermore, we analyse the role of mavacampten (the recently approved cardiac myosin inhibitor) in replacing or complementing the two septal reduction therapies.

Unrecoverable stent deformation in the left main: Crush it or remove it?

Serial ostial and distal left main lesions continue to be one of the most difficult tasks for the interventional cardiologist, with many potential complications occurring. We present such a high-risk percutaneous coronary intervention where immediate stent explantation was deemed necessary because the metal deformation and high radial strength of the particular stent platform would prevent an acceptable procedural result if it had been crushed to the vessel wall. The aim of this paper was to discuss left main stent deformation, debate the risks and benefits of stent explantation and finally test in-vitro our theory on "insufficient" crush with stents with high radial strength and compare it with conventional stents. Bench-testing supports our ad-hoc explantation decision showing stent underexpansion, recoil, and malapposition, obtaining an inadequate minimal stent area.

Distal Radial Artery Access for Recanalization of Radial Artery Occlusion and Repeat Intervention: A Single Center Experience

Background: Once occluded, the radial artery becomes unsuitable for repeat interventions and obligates the need for alternative vascular access, such as the femoral approach, which is not encouraged by current guidelines. With the dissemination of distal radial access (DRA), which allows the cannulation of the artery in its distal segment and which remains patent even in the case of radial artery occlusion (RAO), the option to perform angioplasty at this level becomes feasible. Methods: Thirty patients with RAO were enrolled in this pilot study. Recanalization was performed through DRA using hydrophilic guidewires. The feasibility endpoint was procedural success, namely the successful RAO recanalization, the efficacy endpoint was patency of the artery at 30 days, and the safety endpoint was the absence of periprocedural vascular major complications or major adverse cardiac and cerebrovascular events. Results: The mean age of the patients was 63 ± 11 years, and 15 patients (50%) were men. Most patients had asymptomatic RAO (n = 28, 93.3%), and only two (6.6%) reported numbness in their hands. The most common indication for the procedure was PCI (19, 63.2%). Total procedural time was 41 ± 22 min, while the amount of contrast used was 140 ± 28 mL. Procedural success was 100% (n = 30). Moreover, there were no major vascular complications (0%); only two small hematomas were described (10%) and one had an angiographically visible perforation (3%). One case of periprocedural stroke was reported (3%), with onset immediately after the procedure and recovering 24 h later. Twenty-seven radial arteries (90%) remained patent at the one-month follow-up. Conclusions: RAO recanalization is feasible and safe, and by using dedicated hydrophilic guidewires, the success rate is high without significantly increasing procedural time or the amount of used contrast.

Roadsaver versus Wallstent for carotid artery stenting: a retrospective cohort study

Introduction

Carotid artery stenting (CAS) is an established alternative option to surgical treatment for carotid artery stenosis, 3 main contemporary types of stent design being used for this purpose (open-, closed-cell, mesh-covered stents). So far, no definite conclusions have been reached on the superiority of any of those devices for CAS. With its new double-mesh design, the Roadsaver stent has emerged as an attractive option for use in CAS, aiming to further reduce neurological events. However, its efficacy as compared to other stents, such as Wallstent, has not been thoroughly explored. We thus aimed to compare the clinical outcomes of Roadsaver and Wallstent for use in CAS.

Methods

This retrospective cohort study included patients who underwent CAS and received either Wallstent or Roadsaver stent at a tertiary centre (centre A) in a Central European country during 2009–2021, and another tertiary centre (centre B) in the same country during 2016–2019. Patients with incomplete baseline clinical records were excluded. Patients were followed up for one year at centre A, and for 30 days at centre B. The primary outcomes were 30-day and 1-year major adverse cardiac or cerebrovascular events (MACCE), defined as a composite of myocardial infarction, stroke, and cardiovascular mortality. The secondary outcome was 30-day bradycardia. Baseline covariates were balanced between groups using inverse probability treatment weighting. Thirty-day outcomes were compared using logistic regression with odds ratio (OR) as the summary statistic, and 1-year MACCE was compared using Cox regression with hazard ratio (HR) as the summary statistic.

Results

In total, 982 patients were identified. After applying the exclusion criterion, 770 patients were included in the analysis (482 patients from centre A and 288 patients from centre B; 287 (37.3%) females, mean age 68±8 years old), of which 589 (76.5%) received Wallstent and 181 (23.5%) received Roadsaver. There was no loss to follow-up. Twenty-three (3%) patients had MACCE by 30 days, and 16 (3.3%) of those who completed one-year follow-up had MACCE by one year. No significant differences in MACCE were observed between the two stents at 30 days (OR 0.697 [0.374, 1.300], p=0.256) and one year (HR 0.512 [0.126, 2.073], p=0.348). Roadsaver was associated with significantly higher odds of 30-day bradycardia (OR 5.391 [4.089, 7.108], p&lt;0.0001), which remained significant after adjusting for the number of post-dilatations performed (p&lt;0.0001). Additionally, Roadsaver was associated with significantly lower risk of one-year MACCE among symptomatic patients (N=184; HR 0.131 [0.024, 0.723], p=0.020; Figure 1), but not among asymptomatic patients (N=298; HR 1.774 [0.332, 9.490], p=0.503).

Conclusion

There was no short- and long-term hazard difference between the 2 types of stent designs, however Roadsaver may be superior to Wallstent among symptomatic patients.

Funding Acknowledgement

Type of funding sources: None.

Radial artery calcification in predicting coronary calcification and atherosclerosis burden

Background

Atherosclerosis is a systemic arterial disease with heterogeneous involvement in all vascular beds, however studies examining the relationship between coronary and radial artery calcification are lacking.

The purpose of this study was to assess the relationship between the two sites and the prognostic value of radial artery calcification (RC) for coronary artery disease.

Methods and results

This is a single-center, retrospective cross-sectional study based on doppler ultrasound of radial artery (RUS) and coronary artery angiography (CAG). We included a total of 202 patients undergoing RUS during distal radial access and CAG at the same procedure, between December 2020 and May 2021, from which 103 were found having RC during RUS (RC-group) and 99 without (NRC-group). Coronary calcifications were evaluated either by angiography examination (moderate and severe), positive CT (&gt;100 Agatson units) or intracoronary imaging (IVUS, OCT). A significant correlation was observed between radial calcification and coronary calcification variables (67.3%, vs 32.7% – p=0.001). The correlation between risk factors such as age, smoking, chronic kidney disease and diabetes mellitus was higher while sex did not play a role. The need of PCI and/or CABG was higher in the RC-group (60% vs 44%, p=0.02). RC therefore predicts the extent and severity of coronary artery disease.

Conclusion

RC may be frequently associated with calcific coronary plaques. These findings highlight the potential beneficial examination of radial arteries whenever CAD is suspected.

Funding Acknowledgement

Type of funding sources: None.

Simultaneous Dual Distal Radial Balloon Aortic Valvuloplasty for Larger Aortic Annuli

Dual distal mini-balloon aortic valvuloplasty stabilized an 85-year-old patient with severe aortic stenosis. Puncturing both radial arteries solves the issue of large diameters at the aortic ring, introducing a feasible strategy in selected cases of fragile octogenarian patients with a high hemorrhagic risk. Moving at the anatomical snuffbox offers better postprocedural occlusion rates and better workspace ergonomics during the procedure.

Approaches to Peripheral Artery Disease in Diabetes: Are There Any Differences?

Peripheral artery disease (PAD) increases the risk of diabetes, while diabetes increases the risk of PAD, and certain symptoms in each disease increase the risk of contracting the other. This review aims to shed light on this harmful interplay between the two disorders, with an emphasis on the phenotype of a patient with both diabetes and PAD, and whether treatment should be individualized in this high-risk population. In addition, current guideline recommendations for the treatment of PAD were analyzed, in an attempt to establish the differences and evidence gaps across a population suffering from these two interconnected disorders.

Percutaneous drainage of a localized biatrial haematoma causing regional tamponade in a patient with prior coronary artery bypass graft surgery: a case report

Background

Regional cardiac tamponade presented as posterior extrapericardial haematomas compressing both atria, with cardiogenic obstructive shock due to inflow abolition is a rare cause of post-percutaneous coronary intervention vascular collapse.

Case summary

We present such a case where computed tomography-guided anterior pericardiocentesis decompressed the atria and restored cardiac output.

Discussion

Prior coronary artery bypass grafting should not be considered protective from cardiac tamponade in patients in whom perforation occurs, because loculated effusions can develop beneath adhesions of the pericardium and compress various cardiac structures (such as the left atrium or the right ventricle); they appear several hours after the intervention and cause atypical haemodynamic manifestations.

Commentary on the Enigma of Small Vessel Disease in Hypertrophic Cardiomyopathy: Is Invasive Assessment of Microvascular Resistance a Novel Independent Predictor of Prognosis?

The key pathophysiological features in hypertrophic cardiomyopathy are ventricular hypertrophy, diastolic dysfunction and abnormalities in the mitral valve apparatus, but coronary microvascular dysfunction and ischemia have also been described. The small vessel disease changes could be reflected in the invasive measurement of the index of microvascular resistance, with prognostic potential.

Bench test and in vivo evaluation of longitudinal stent deformation during proximal optimisation

BACKGROUND

While radial stent deformation has been thoroughly investigated, data on longitudinal deformation are scarce.

AIMS

The aim of the study was to describe longitudinal stent deformation associated with the proximal optimisation technique (POT).

METHODS

Longitudinal stent deformation was assessed by bench testing and by clinical evaluation. Bench testing was performed in silicone models using 3.00 (n=15) and 3.50 mm (n=14) stent platforms. After deployment, stents were sequentially post-dilated in the proximal main branch up to 5.50 mm, in increments of 0.50 mm, in order to simulate a spectrum of overexpansion. Stent length was redefined by optical coherence tomography (OCT) after each step. Clinical data were collected retrospectively from OCT-guided bifurcation percutaneous coronary intervention cases.

RESULTS

In bench tests, POT has led to significant stent elongation in all cases. The magnitude of elongation was comparable between the 3.00 and the 3.50 mm stent platforms, with 0.86±0.74 mm vs 0.86±0.73 mm, respectively (p=0.71), per 0.5 mm overexpansion. For 3.00 mm stent platforms, maximal elongation was 4.31±1.47 mm after up to 5.5 mm overexpansion. For 3.50 mm platforms, maximal elongation was 2.87±0.94 mm after up to 5.5 mm overexpansion. Thirty-six clinical cases were analysed, of which 22 (61%) were performed in the distal left main. Post-dilation was performed with 0.98±0.36 mm absolute overexpansion, resulting in 2.22±1.35 mm elongation, as compared to nominal stent length.

CONCLUSIONS

Overexpansion by POT results in proximal stent elongation. This has to be considered once the stent length is selected and the stent is positioned, especially in the left main stem, where proximal overexpansion is marked and accurate ostial landing is critical.

Switching From Proximal to Distal Radial Artery Access for Coronary Chronic Total Occlusion Recanalization

Background

Distal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures.

Methods

From 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time).

Results

A total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, p = 0.045) and dose area product (median 928 mGy×cm² vs. 1,300 mGy×cm², p < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, p = 0.450; large hematoma: 0.72% vs. 0%, p = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, p = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA (p = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, p = 0.35).

Conclusion

Using DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.

Surgical Turned-Downed CHIP Cases—Can PCI Save the Day?

Current guidelines, rarely if at all, address decision-making for revascularization when bypass surgery is not a possibility for high-risk cases. Patients who are surgically turned down are routinely excluded from clinical trials, even though they remain symptomatic. Furthermore, the reasons for surgical ineligibility are often times not captured in standardized risk models. There is no data regarding health status outcomes following PCI procedures in these patients and the ultimate question remains whether the benefits of PCI outweigh its risks in this controversial subpopulation. When CHIP (Complex High risk Indicated Percutaneous coronary interventions) is selected for these very complex individuals, there is no unanimity regarding the goals for interventional revascularization (for instance, the ambition to achieve completeness of revascularization vs. more targeted or selective PCI). The recognition that, worldwide, these patients are becoming increasingly prevalent and increasingly commonplace in the cardiac catheterization labs, along with the momentum for more complex interventional procedures and expanding skillsets, gives us a timely opportunity to better examine the outcomes for these patients and inform clinical decision-making.

A case report of COVID-19-associated acute hand ischaemia in a young professional volleyball player

Background

Several coronavirus disease-19 (COVID-19)-associated complications are being increasingly reported, including arterial and venous thrombo-embolic events that may lead to amputation of the affected limbs. So far, acute upper limb ischaemia (ULI) has been reported only in critically ill patients.

Case summary

Herein, we aimed to present a case of a 29-year-old, otherwise healthy male volleyball player, with acute ischaemic signs in the upper extremity who was diagnosed with COVID-19 1 month before the ischaemic event. It has been shown that volleyball players experience repetitive stress that involves their hands and, in particular, their fingers. Repetitive trauma can lead to local vascular abnormalities, such as reduced capillarization and lower resting blood flow that can lead to pain and cold digits, but never acute ULI.

Discussion

To our knowledge, this is the first case of such a hypercoagulable synergistic mechanism that leads to a high thrombus burden. Intra-arterial local thrombolysis and percutaneous transluminal angioplasty failed to succeed, and percutaneous large-bore embolectomy with the Indigo Aspiration System (Penumbra Inc., CA, USA) was deemed necessary.

A case report of recurrent acute myocardial infarction and cardiac arrest due to aortic dissection secondary to IgG4-related aortitis

Occlusion of the right coronary artery is a relatively rare complication of type A aortic dissection and an example of type 2 myocardial infarction (MI) as well but when it occurs, it may have a fatal result for the patient. Aortic pseudoaneurysms are local type A dissections with a restricted extent in which the majority of the aortic wall has been breached and luminal blood is held in only by a thin rim of the remaining wall, mainly purely the adventitia. They typically occur from iatrogenic trauma by interventional procedures or previous cardiac surgery. We present a case of a 56-years-old patient who suffered an acute functional MI due to such pseudoaneurysm formed in the context of an undiagnosed aortitis. The etiology remained unclear until the surgical aortic prosthesis was deemed necessary, finding chronic IgG4 infiltrates in the aortic tissue. To our knowledge, this is the first case of IgG4-related aortitis causing functional MI and cardiogenic shock.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting

BACKGROUND

Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS.

METHODS

A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up.

RESULTS

There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04).

CONCLUSION

The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.

Distal radial secondary access for transcatheter aortic valve implantation: The minimalistic approach

BACKGROUND

Although not yet recommended by the guidelines, distal radial access, a new site for cardiovascular interventions, has been rapidly acknowledged and adopted by many centers due to its high rate of success, safety and fewer complications. We present our experience using secondary distal radial access during transcatheter aortic valve implantation (TAVI), proposing a new, even more minimal approach.

METHODS

As of November 2020, a systematic distal radial approach as secondary access site for TAVI was adopted in our center. Primary endpoints were technical success and major adverse events (MAEs). Secondary endpoints: the access site complication rate, hemodynamic and clinical results of the intervention, procedural related factors, crossover rate to the femoral access site, and hospitalization duration (in days).

RESULTS

From November 2020, 41 patients underwent TAVI using this strategy. Patients had a mean age of 76 ± 11.2 years, 41% were male. Six (14.63%) patients received a balloon-expandable valve and 35 (85.37%) received a self-expandable valve. TAVI was successful in all cases. No complications occurred due to transradial access. Puncture success, defined as completed sheath placement was maximum (N = 41/41,100%) and emergent transfemoral secondary access was not required in any case. Primary transfemoral vascular access site complications occurred in 7 cases (17%) of which 4 (13.63%) were resolved through distal radial access: one occlusion, two flow-limiting stenoses and four perforations of the common femoral artery. There were no additional major vascular complications at 30 days. Overall MACE rate was 2.4%.

CONCLUSION

The use of the distal radial approach for secondary access in TAVI is safe, feasible and has several advantages over old access sites.