Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve intervention

Background

The role of right-ventricular (RV) function in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI) is poorly understood. Although cardiac computed tomography (CCT) provides elaborate three-dimensional (3D) visualization of the entire anatomy of the RV and theoretically allows to assess the global RV systolic function. Nevertheless, the utility of the functional assessments of the RV using CCT remains unclear in patients undergoing TTVI.

Purpose

This study investigated the association of right-ventricular ejection fraction (RVEF) assessed by CCT with clinical outcome in patients undergoing TTVI.

Methods

We retrospectively assessed 3D-RVEF by using pre-procedural CCT images in patients undergoing TTVI with either edge-to-edge repair or annuloplasty device. RV dysfunction (RVD) was defined as a CT-RVEF <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within one year after TTVI.

Results

Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Patients with CT-RVEF <45% were more likely to be male, to have a previous history of coronary artery disease, and had higher EuroSCORE II and a lower LVEF compared to those with CT-RVEF ≥45%, while the severity of TR was comparable between the groups.

Among the patients with CT-RVEF <45%, acute procedural success was achieved in 93.1%, and in-hospital mortality was 1.7%, which were comparable to those with CT-RVEF ≥45%.

Patients with CT-RVEF <45% had an improvement in New York Heart Association functional class at follow-up compared to baseline; however, CT-RVEF <45% was associated with a higher risk of the composite outcome (adjusted hazard ratio: 3.23; 95% confidence interval: 1.52–6.88; p=0.002) (Figure 1). Furthermore, CT-RVEF had an additional value to stratify the risk of the composite outcome beyond two-dimensional transthoracic echocardiographic (TTE) assessments (Figure 2).

In addition, patients with CT-RVEF <45% exhibited an attenuated association between a reduction in TR to <3+ and a lower incidence of the composite outcome after TTVI compared to those with CT-RVEF ≥45%.

Conclusions

TTVI is safe and feasible regardless of baseline RV function, while RVD, defined as 3D-RVEF <45%, is associated with a higher risk of the composite outcomes within one year after TTVI. Furthermore, our findings suggest that the prognostic benefits of TR reduction might be attenuated in patients with RVD. Given the additional prognostic value of CT-RVEF to the conventional echocardiographic assessments, the assessments of 3D-RVEF with CCT may refine the patient selection for TTVI.

Funding Acknowledgement

Type of funding sources: None.

P918Tricuspid regurgitation in patients undergoing transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in elderly patients with severe aortic stenosis and increased surgical risk. A significant number of these elderly patients have concomitant tricuspid valve regurgitation. The impact on outcome, however, is still matter of debate.

Objectives

In this prospective observational study, we investigated the impact of concomitant tricuspid regurgitation (TR) on outcome in patients undergoing transcatheter aortic valve implantation.

Methods

Between February 2008 and May 2018, 1411 patients with severe symptomatic aortic stenosis and increased operative risk underwent TAVI at the Heart Center Bonn and participated in this study, after written informed consent was obtained.

Before TAVI procedure, all patients underwent a careful cardiac evaluation and interdisciplinary discussion within the local, institutional Heart Team.

The pre-interventional 3D echocardiography was used to determine the degree of tricuspid valve regurgitation. According to the severity of TR, patients were divided into two groups; patients with TR < II and patients with moderate to severe TR ≥ II andcompared regarding rates of mortality after 1 year of follow-up between the two groups.

Results

Out of 1411 TAVI patients, 802 (56.8%) had tricuspid regurgitation < II, 610 (43.2%) patients suffered from tricuspid regurgitation ≥ II.

The mean age of our study population was 81.1 (±6.5). The baseline characteristics did not differ significantly between the two groups, such as extracardiac arteriopathy (TR < II: 44% vs TR ≥ II: 41.6%; p=0.37), diabetes (TR < II: 27.5% vs TR ≥ II: 27.7%; p=0.92) or arterial hypertension (TR < II: 91% vs TR ≥ II: 93.2%; p=0.64). However, patients with concomitant TR ≥ II had significantly more often NYHA class IV (TR < II: 5.0% vs TR ≥ II: 15.4%; p<0.001) and a higher logistic EuroSCORE (TR < II: 12.9 (8.8/21.2) vs TR ≥ II: 20.6 (13.1/33.4); p<0.001). Additionally, patients with a TR ≥ II had significantly more often a concomitant mitral regurgitation ≥ II (TR < II: 43.3% vs TR ≥ II: 60.4%; p<0.001). Comparing rates of mortality, we found a significant association between the degree of tricuspid regurgitation and 1-year mortality in patients undergoing TAVI (TR < II: 85 (10.6%) vs. TR ≥ II: 136 (22.3%); p<0.001), as presented in Figure 1.

Figure 1

Conclusion

Moderate to severe tricuspid valve regurgitation is associated with higher rates of mortality in patients undergoing transcatheter aortic valve implantation. Our results are hypothesis-generating and it has to be elucidated whether the severity of TR is only a surrogate for more advanced stage of aortic stenosis or whether it is causative so that mortality could be reduced by its treatment.

Acknowledgement/Funding

None

P3594Transition from 4th to 5th generation cardiac troponin T: testing patterns, myocardial infarction incident rates, and resource utilization across a multicenter United States regional healthcare system

Background

Several high-sensitivity cardiac troponin (cTn) assays have been cleared by the United States (US) Food and Drug Administration (FDA) for clinical use. Although some of them have been used outside the US for some time, there is limited experience thus far across US sites. Following FDA clearance of the Roche 5th Gen cTnT assay in January 2017, a multicenter US regional healthcare system introduced this more sensitive cTnT assay into clinical practice in September 2018.

Purpose

To examine cTn testing patterns, incidence of acute myocardial infarction (MI), and resource utilization before and after implementation of the 5th Gen cTnT assay across a large US healthcare system.

Methods

Using electronic-health records reporting software (Cogito SlicerDicer, EPIC), administrative data was examined to evaluate the transition (4-months before and after implementation) from the 4th to 5th Gen cTnT assays across 16 hospitals but not the major hub hospital of the system that transitioned at a separate time. Adult patient visits (emergency and hospital encounters), cTnT testing, incidence of chest discomfort and acute MI, and resource utilization, including hospital admissions, were examined during the transition period.

Results

98,558 adult ED patient visits occurred during an 8-month period across 16 hospitals, including 50,485 and 48,073 patient visits before (5/12/18 – 9/11/18) and after (9/12/18 – 1/11/19) implementation of the 5th Gen cTnT assay respectively. cTnT testing occurred in 20% (range 8.9–34.8%) of all ED visits, with testing performed in the absence of chest pain in 54% (range 37–67%) of cases. Acute MI was diagnosed in 5.6% (n=561) of cases using the 4th Gen cTnT assay as compared to 6.6% (n=608) of cases using the 5th Gen cTnT assay (absolute difference 1.0%, 95% CI: 0.32–1.68, p=0.004). Much of the increase in MI diagnoses were in women (2.2% vs. 2.8%, p=0.008). The proportion of ED patients requiring hospital admission did not differ between pre- and post-implementation periods (24.1% vs. 23.6%, p=0.4); however, among the subset of patients with chest pain, fewer admissions occurred post-implementation (17.9% vs. 15.8%, p=0.006). There was no increase in echocardiography (9.3% vs. 8.4%), coronary angiography (2.9% vs. 3.1%), or cardiac consultations (7.3% vs. 7.3%) utilization post-implementation.

Conclusions

Cardiac troponin testing occurs in nearly 20% of ED visits in a large multicenter regional healthcare system. About half of all tests are ordered in the absence of chest pain, with a low MI rate observed among the patients undergoing testing. Following implementation of the 5th Gen cTnT assay, testing rates/patterns remained unchanged, with a small but significant increase in MI diagnoses, primarily due to more women being diagnosed with MI. Fewer ED patients with chest pain required admission. Despite using a more sensitive cTn assay, hospital admissions and resource utilization did not increase post-implementation.

P3723Impact of frailty status on 30-day mortality in patients with valvular heart disease undergoing percutaneous transcatheter valve interventions

Background

Transcatheter strategies to treat valvular heart disease (VHD) are an established therapeutic option in elderly patients, not suitable for open heart surgery. The current ESC guidelines recommend the STS score and EuroSCORE II as tools for risk stratification. However, these surgical risk score do not consider important risk factors such as frailty, cognitive and nutritional status of the patients.

Aims

The aim of this study was to assess the frailty status in patients with severe VHD evaluated for transcatheter treatment strategies and to investigate the impact on mortality of these patients.

Methods and results

Our study cohort consisted of 456 consecutive patients (mean age 79±7.9 years, median STS-score 3.15 and EuroSCORE II 3.65) who were evaluated for percutaneous treatment of severe aortic valve stenosis (n=311), mitral valve regurgitation (n=100), and tricuspid valve regurgitation (n=45) in 2018. The frailty status in these patients was assessed using the Katz Index of Independence in Activities of Daily Living, the Lawton Instrumental Activities of Daily Living Scale, the five times chair rise, and the Score for assessment of frailty phenotype. The Mini Nutritional Assessment (MNA) and the Controlling Nutritional Status score were used for the assessment of the nutritional status of the cohort.

Assessment by the score for frailty phenotype showed that 220 (48.2%) cases were considered frail, 200 (37.3%) cases as prefrail, and only 36 (6.7%) patients considered robust. Regarding the MNA, 212 (46.5%) patients were at normal nutritional status, whereas 207 (45.4%) patients were at risk for malnutrition, and 37 (8.1%) patients were already malnourished.

The overall 30-day mortality rate was 3.1% (n=14). Multivariate analysis showed a significant association of 30-day mortality with baseline serum creatinine (1.2 mg/dl [IQR: 0.9–1.5 mg/dl] for survivors vs 1.6 mg/dl [IQR: 1.4–2.2 mg/dl] for non-survivors, p=0.14), high-sensitive cardiac troponin T (24.3 ng/l [IQR: 16.0–42.6 ng/l] for survivors vs 55.6 ng/l [IQR: 40.4–84.7 ng/l] for non-survivors, p=0.002), and the five chair rise test (p=0.005). Interestingly, there was no significant correlation of nutrition scores and frailty tests with 30-day mortality except for the five chair rise test. Linear regression analysis showed serum creatinine (p=0.04; OR: 1.4, CI: 1.0–1.8) and the five chair rise test (p=0.03; OR: 0.7, CI: 0.5–1) as independent predictors of the mortality.

Frailty Kaplan Meier Analysis

Conclusion

A comprehensive assessment of the clinical patient condition including frailty status is thought to be crucial for risk stratification and the decision-making process which treatment option a specific patient should undergo. However, in our study only the five chair rise test was found to be an independent predictor of 30-day mortality in patients with VHD undergoing percutaneous therapeutic options and seems to be an easy-to-assess test to assess the mortality risk of a specific patient.

P973Intravascular lithotripsy for lesion preparation in calcified coronary lesions: a prospective, observational, two-center registry

Background

Intravascular coronary lithotripsy (IVL) is a novel alternative treatment for heavily calcified lesions. This study sought to determine the strategy success and safety of IVL on calcified lesions in an all-comers cohort of patients.

Methods

Patients with moderate and severely calcified coronary lesions were screened in two centers in Spain and Germany starting April 2018. Until February 2019, 61 patients with 67 lesions were eligible for IVL. Patients were assigned to the following groups: A) Primary IVL therapy for patients with circumferential calcified de-novo coronary lesions (n=32), B) Secondary IVL therapy for patients with moderate or severe calcified coronary lesions in which conventional non-compliant balloon dilatation failed (n=18) and C) Tertiary IVL therapy in patients with in-stent stenosis due to stent underexpansion after previous stenting (n=17). Primary endpoint was strategy success and safety outcome. Strategy success was defined as successful stent delivery and expansion with attainment of <20% in-stent residual stenosis of the target lesion. Safety outcome were procedural complication, defined as coronary dissection, slow or no-reflow phenomenon, new coronary thrombus formation during PCI, abrupt vessel closure and device failure (inability to place the balloon, malfunction, or burst) and in hospital MACE.

Results

61 patients with 67 calcified lesions were treated with IVL. Mean diameter of calcified stenosis on quantitative coronary angiography was 72.02±13.8% at baseline and decreased to 17.7±15.84% (p-value: <0.01) after IVL with an acute gain of 1.9±0.63 mm. Mean minimal lumen diameter was 1.0±0.5 mm at baseline and increased after IVL to 2.9±0.6 mm. The overall average of applied pulses was 63±22. The primary endpoint of strategy success was reached overall in 85.2% of patients. 4 type b dissections (3 in group A, 1 in group B) were observed without further sequelae. There were no in-hospital MACE. In one patient (1.6%) non-ischemia driven target lesion failure was observed in routine follow up coronary angiography and was in need for revascularization. According to the subgroups, strategy success in primary IVL treatment (group A) and secondary IVL treatment (group B) was reached in 81.3% and 83.3% of cases, respectively. In tertiary IVL therapy (group C), the primary study endpoint was reached in 64.7% of cases. Device delivery and IVL treatment of target lesion could be performed in all lesions without vessel complications. 7 IVL balloons ruptured during treatment without any sequelae. Rupture was observed in most cases after repositioning of the balloon within the calcified lesion.

Conclusions

IVL provides a valid strategy for lesion preparation in severely calcified coronary lesions, with high success rate, and low procedural complication and MACE rates. Longitudinal studies will confirm if these favourable initial results of IVL-supported PCI are followed by good long-term results.

Innovations and novel technologies in TAVI. Second generation transcatheter heart valves

Transcatheter aortic valve implantation (TAVI) is the new standard-of-care for inoperable patients with superior outcome compared to conservative management including balloon valvuloplasty. In high-risk patients, TAVI has shown non-inferiority compared with surgical aortic valve replacement. Although data from national multi-centre registries are very encouraging and use of TAVI in intermediate risk patients has been discussed, it is of note that the commercially available and currently used transcatheter heart valves (THV) have not yet been assessed by randomized clinical trials in those patients. New technology advances promise to simplify TAVI and to improve outcome by reducing the rate of TAVI-specific issues such as paravalvular aortic regurgitation (PAR), annular rupture, and conduction disturbances. A reduction in the incidence and severity of PAR represents an obvious target for technical improvements in the design of upcoming "next generation" THVs and of implantation techniques including repositioning/recapturing features, paravalvular sealing techniques, and precise peri-interventional imaging modalities.

Advances in percutaneous treatment for adult valvular heart disease

Valvular heart disease occurs in 2-3% of the general population with an increase in prevalence with advancing age. The aetiology of valvular heart disease has evolved in recent decades with degenerative aortic and mitral valve disease supplanting rheumatic heart disease as a primary cause. The common valve lesions to be discussed in this article are aortic stenosis and mitral regurgitation. The traditional approach to calcific aortic stenosis when either symptoms or left ventricular impairment develops is surgical aortic valve replacement and it remains a treatment with excellent outcomes. In recent years there has been interest in less invasive approaches, including percutaneous and transapical aortic valve implantation. With refinements in technology these approaches are becoming a potential treatment option, primarily for high-risk patients who may otherwise be unsuitable for traditional open surgical treatment. Catheter-based approaches for mitral valve disease are also evolving. Mitral regurgitation may often be the result of mitral annular dilatation seen in patients with an enlarged left ventricle or left atrium. Percutaneous implantation of a constricting device in the coronary sinus, which lies in close proximity to the mitral annulus, results in a change to the geometry of the mitral valve and reduced regurgitation. Another technique in patients with degenerative mitral regurgitation is the endovascular edge-to-edge repair in which coaptation of the mitral valve leaflets can be improved with a percutaneously deployed clip. Small patient series indicate that these new techniques are promising. As such, advances in percutaneous interventional and surgical approaches have the potential to further improve outcomes for selected patients with valvular heart disease.

Volume-outcome relation for contemporary percutaneous coronary interventions (PCI) in daily clinical practice: is it limited to high-risk patients? Results from the Registry of Percutaneous Coronary Interventions of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK)

OBJECTIVE

The formerly observed volume-outcome relation for percutaneous coronary interventions (PCIs) has recently been questioned.

DESIGN

We analysed data of the PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte.

PATIENTS

In 2003 a total of 27 965 patients at 67 hospitals were included.

RESULTS

The median PCI volume per hospital was 327. In-hospital mortality was 1.85% in hospitals belonging to the lowest PCI volume quartile and 1.21% in the highest quartile (p for trend <0.001). Two groups of patients were then compared according to their treatment at hospitals with either <325 PCIs (n = 5754) or >325 PCIs (n = 22 211) per year. Logistic regression analysis showed that a PCI performed at hospitals with a volume of >325 PCI/year was independently associated with a lower hospital mortality (OR = 0.67, 95% CI: 0.52 to 0.87; p = 0.002). If PCI was performed in patients with acute myocardial infarction there was a significant decline in mortality with increasing volume (p for trend = 0.004); however, there was no association in patients without a myocardial infarction.

CONCLUSIONS

This analysis of contemporary PCI in clinical practice shows a small but significant volume-outcome relation for in-hospital mortality. However, this relation was only apparent in high-risk subgroups, such as patients presenting with acute myocardial infarction.

First experience with the Impella Recover(R) LP 2.5 micro axial pump in patients with cardiogenic shock or undergoing high-risk revascularisation

AIM

To study the feasibility, safety and efficacy of the Recover(R) LP 2.5 assist device in patients scheduled for high risk off-pump coronary bypass surgery, percutaneous coronary intervention or patients in cardiogenic shock.

METHODS AND RESULTS

40 patients presenting with cardiogenic shock (n=13) or scheduled for a high risk revascularisation (n=27) were included.36 were selected for safety and feasibility analysis. In 3 patients the pump could not be placed in an adequate position. 5 patients had access related complications. In 9 patients free Hb rose above 80 mg/dl. 3 malfunctions and early device-removal occurred. After device modifications these problems did not recur. CO in the shock group increased significantly: 4.4 l/min+/-1.9 to 4.8 l/min+/-1.2 (p=0.0178).The left ventricular filling pressures decreased in both groups (22 mmHg+/-7.5 to 16 mmHg+/-6 in the shock group, [p=0.0008] and over 6 hours from 14.3 mmHg+/-5.8 to 10 mmHg+/-2.9 in the high-risk revascularisation group,[p=0.0327]).

CONCLUSIONS

The Recover(R) LP 2.5 micro axial pump allows, via percutaneous approach, partial unloading of the left ventricle. The technique is, after design modifications, feasible and safe and results in haemodynamic improvement.

First-In-Man application of a miniature self-contained intracoronary magnetic resonance probe. A multi-centre safety and feasibility trial

AIMS

To assess safety and feasibility of intracoronary Magnetic Resonance (MR) Spectroscopy in living patients, using a self-contained MR catheter.

METHODS AND RESULTS

Prospective, multi-centre study in patients with stable or unstable angina that were scheduled for percutaneous coronary diagnostic or therapeutic catheterization. We assessed the feasibility of an intravascular MR catheter, capable of analysing the arterial wall without external magnets or coils, by differentiating lipid rich, intermediate and fibrotic areas of the atherosclerotic plaque on the basis of differential water diffusion.Twenty-nine patients were included at 4 centres. The intracoronary MR-spectroscopy procedure was well tolerated; no MACE and no device related serious adverse event was observed. The MR catheter was successfully advanced into the lesion in 28 patients. Introduction of the MR catheter was not possible in one patient with a tortuous proximal right coronary artery. MR data were obtained in 22 patients. According to the predominant MR pattern, lesions were classified as fibrous plaque in 4 patients, as intermediate plaque in 4 patients and as lipid-rich plaque in 8 patients. Six patients were excluded from analysis because artifacts impeded the quality of the MR signal. Plaque type did not show a correlation with angina status (p=0.552; all groups) or angiographic parameters, such as minimal lumen diameter and diameter stenosis.

CONCLUSIONS

This prospective, multi-centre study demonstrates for the first time that coronary artery assessment of potentially vulnerable, non-flow limiting lesions using a dedicated intravascular MR catheter, free of external magnets or coils, is feasible in clinical practice. Assessment of the coronary wall may provide important data regarding the composition of the atherosclerotic lesion, which then could contribute to predicting the likelihood of eventual rupture and clinical instability.

Comparative endoluminal visualization of TAXUS crush-stenting at 9 months follow-up by intravascular ultrasound and optical coherence tomography

We report a case of crush-stenting with Paclitaxel-eluting TAXUS stents in a left anterior descending artery (LAD) bifurcation lesion. In order to obtain precise information on the mid-term neointimal response of the main vessel to this approach, we evaluated the patient angiographically 9 months later, including intravascular visualization with optical coherence tomography (OCT), a new high resolution imaging technique, and IVUS. The evaluation revealed that there was a homogeneous neointimal coverage of the main vessel stents without evidence of significant recurrent lumen renarrowing or malappositions. Compared to IVUS, OCT proved the coverage of the stent struts adjacent to the vessel wall with a superior imaging quality and, in addition, provided new insights into the stent performance at the open bifurcation site.

Incidental finding of a papillary fibroelastoma on the aortic valve in 16 slice multi-detector row computed tomography

Papillary fibroelastoma (PFE) is a benign, rare, gelatinous tumour derived from the endocardium, primarily the cardiac valves, which is usually diagnosed by high resolution echocardiography. Although rarely clinically symptomatic, PFEs have a potential for coronary ischaemia, systemic embolisation with neurologic symptoms, and sometimes valvar dysfunction. There are reports of coronary occlusion and even sudden cardiac death due to a ball valve phenomenon on the coronary ostia. This report describes the characteristics of a PFE with multidetector 16 slice computed tomography and 1.5 Tesla cardiac magnetic resonance imaging.

Long-term evaluation of paclitaxel-coated stents for treatment of native coronary lesions. First results of both the clinical and angiographic 18 month follow-up of TAXUS I

The development of restenoses due to tissue proliferation within the stented segment is a major limitation of conventional stent implantations. Recently published studies have shown that drug-eluting stents effectively decrease the incidence of stent restenosis at 6 month follow-up as compared to bare metal stents. However, a persistent efficacy of this stent design beyond the 6 month period still needs to be proven. Therefore, in this study, we are demonstrating the first 18 month follow-up results of a Paclitaxel-coated coronary stent, based on the patient population of the TAXUS I study, a multicenter randomized study to evaluate both safety and efficacy of the Paclitaxel-coated NIRx stent as compared to an uncoated, bare metal stent. In this study we evaluated the long-term outcome of NIRx patients of our center, in which 20 out of 31 patients of the TAXUS I study with NIRx stent implantation have been enrolled. A clinical follow-up was available in 20 out of 20 patients (100%) 535 +/- 82 days post stent implantation (17.8 months). An angiographic follow-up was available in 14 out of 20 patients (70%) 580 +/- 77 days post stent implantation (19.1 months). The MACE rate at 18 month follow-up was 0.0%. There was no stent restenosis in the study group up to 18 month post drug-eluting stent implantation. There was one non-clinically driven target vessel revascularization due to a stent edge lumen renarrowing, which was subsequently calculated as a 43% diameter stenosis. Accordingly, this event was not regarded as MACE. The IVUS analysis of the study population has shown a decrease of the mean minimum lumen area from 8.45 mm(2) postinterventional to 6.87 mm(2) at 6 month follow-up with a relative mean maximum plaque area of 16%. At 18 month follow-up, there were no additional significant changes with a mean minimum lumen area of 7.16 mm(2) and a relative mean maximum plaque area of 13.4%. The reported results of the 18 month follow-up of TAXUS I are the first experiences demonstrating a persistent benefit of the Paclitaxel-coated NIRx stent. Therefore, this stent design seems to be safe and effective, even in long-term follow-up.

Drug eluting stents: initial experiences

Local delivery of immunosuppressive or antiproliferative agents using a drug-eluting stent is a new technology meant to inhibit in-stent restenosis providing both a biological and mechanical solution and has recently emerged as a very promising approach. Up to now several agents have been in use: Paclitaxel, Rapamycin, Actinomycin D or Tacrolimus. Evaluating these drugs regarding their release kinetics, effective dosage, safety in clinical practice and benefit, several studies have been published or are still ongoing: SCORE (Paclitaxel-derivative), TAXUS I, II, III, IV (Paclitaxel), ELUTE, ASPECT (Paclitaxel), RAVEL, SIRIUS (Sirolimus), ACTION (Actinomycin), EVIDENT, PRESENT (Tacrolimus). Paclitaxel was the first stent-based antiproliferative agent under clinical investigation providing profound inhibition of neointimal thickening, depending on delivery duration and drug dosage. The randomized multicenter SCORE trail (Quanam stent, Paclitaxel coated) enrolled 266 patients at 17 sites. At 6 month follow-up, a drop of 83% in stent restenosis using the drug-eluting stent could be achieved (6.4% drug-eluting stent vs. 36.9% control group) attributable to a remarkable decrease in intimal proliferation. Unfortunately, due to both frequent stent thrombosis and side-branch occlusions the reported 30-day MACE rate was 10.2%. The randomized TAXUS I safety trail (NIRx, Paclitaxel coated) also demonstrated beneficial reduction of restenotic lesions at 6-month FU (0% vs. 11%) but, this time, associated with the absence of thrombotic events presumably due to the lower drug dosage. The ongoing TAXUS II, III and IV trails are aimed at providing additional insight regarding the efficacy of the TAXUS Paclitaxel-eluting stent. Both the RAVEL and the SIRIUS trial have been conducted to evaluate a Sirolimus-coated stent (Bx VELOCITY stent). From the results available, the beneficial findings regarding reduction of renarrowing using a drug-eluting stent have been confirmed without any adverse effects. Although parameters like drug toxicity, optimal drug dosage or delayed endothelial healing need to be further evaluated, summarizing the today's clinical experience the strategy of drug-coated stents promises a striking benefit in interventional treatment of coronary lesions.

Drug-eluting stents: clinical experiences and perspectives

Drug-eluting stents (DES) have entered the arena and are about to changed the landscape of Interventional Cardiology. Today, the number of agents under preclinical and clinical investigation has increased considerably, including drugs such as Paclitaxel, Sirolimus, Tacrolimus, Everolimus, Dexamethasone, etc. Several studies have recently been published or are still ongoing evaluating different stent designs with respect to their safety and efficacy in treatment of coronary lesions. The SCORE trial (Paclitaxel) revealed a significant reduction in restenosis at follow-up (FU) in the drug-eluting stent group (6.4% vs 36.9% control group), attributable to decreased intimal proliferation. However, stentthromboses and myocardial infarctions, due to both stent design and high drug dosages, were observed causing a MACE rate of 10.2% in the DES group. Confirming the beneficial reduction of stent renarrowing using a local drug-eluting device, the rate of restenosis in the TAXUS-I trial (Paclitaxel) was 0% at follow-up in patients with DES vs 10% in patients with bare stents. Differences in MACE were not observed, which underlined the potential impact of an optimal stent design. First clinical experiences with a Sirolimus-coated stent (FIM trial) demonstrated again a profound inhibition of neointimal ingrowth at 4-month follow-up. The RAVEL trial, the first multicenter trial evaluating the Sirolimus stent and the largest DES study published so far, confirmed the FIM findings with a rate of restenosis in the DES group of 0% at 6 month FU. At 12 month FU, the beneficial impact on neointimal growth inhibition was persistent. The pivotal study SIRIUS is addressed to evaluate this stent design more extensively. However, given all the results being available today, local application of anti-proliferative agents delivered by coronary stents is one of the most promising techniques in treatment of coronary lesions. Nevertheless, we need more trials and an agreement of definitions in order to evaluate this treatment concept and eliminate unwanted side-effects.

[Brugada syndrome or ARVD (arrhythmogenic right ventricular dysplasia) or both? Significance and value of right precordial ECG changes]

We report about a 20-year old patient suffering cardiopulmonary resuscitation due to ventricular fibrillation. We diagnosed Brugada syndrome after exclusion structural heart disease and a positive Ajmalin test and implanted an ICD. In that there is a 20-30% familiar disposition, it was necessary that all family members undergo a cardiac examination. It was found that one brother and one sister presented the beginning of a right ventricular dilatation and a fibrolipomatous area in the anterior wall segment of the right ventricle. This result is compatible with a "concealed" arrhythmogenic right ventricular dysplasia (ARVD). As a prognostic indication we decided to implant an ICD prophylactically. The case report demonstrates the value of familiar examination of patients with an unclear ventricular arrhythmogenic event.

Balloon-protected carotid artery stenting: relationship of periprocedural neurological complications with the size of particulate debris

BACKGROUND

Carotid artery stenting (CAS) has been advocated as an alternative to endarterectomy. To prevent cerebral atheroembolism during CAS, distal balloon occlusion of the target artery increasingly is employed during the procedure. A correlation of the size of captured particles with the incidence of periprocedural neurological complications (PNCs) has not been attempted.

METHODS AND RESULTS

In a 4-center, phase-1 trial, 54 patients (46 men; age, 69+/-8 years) underwent 58 CAS procedures using the PercuSurge GuardWire system for distal protection. Aspirated debris was sent for histological/cytological analysis. Stent placement was successful in all cases. Mean balloon occlusion time was 10.4+/-4.0 minutes (range, 3.0 to 22.0 minutes). Three patients (5.2%) experienced PNCs: 1 prolonged reversible ischemic neurological deficit that resolved in </=48 hours, 1 stroke, and 1 transient ischemic attack. Relevant particles (those with an area >/=10 000 micrometer(2)) were found in 48 aspirates (83%). The median number of particles, their maximum diameter, and their maximum area were all significantly higher in the aspirates obtained during procedures associated with PNCs than in aspirates obtained during procedures not associated with PNCs. However, pronounced overlap in the distributions (PNCs versus no PNCs) of the number and maximum diameter of particles precluded any predictive inferences. In contrast, a maximum particle area >800 000 micrometer(2) (>0.8 mm(2)) was associated with a 60% chance of having a PNC.

CONCLUSIONS

Despite balloon protection, PNCs occurred in 5.2% of patients who underwent CAS procedures. The maximum area of aspirated particles seems to be an indicator of increased risk for PNCs.

Prevention of distal embolization during coronary angioplasty in saphenous vein grafts and native vessels using porous filter protection

BACKGROUND

Although distal embolization and the "no-reflow" phenomenon are well described in saphenous vein graft (SVG) interventions, the frequency, magnitude, and characterization of embolized debris have not been evaluated in routine coronary interventions. A unique embolus protection device described herein provides a means of containing and retrieving plaque material dislodged during percutaneous coronary interventions. This report details the first clinical experience of the effectiveness and safety of an emboli protection system in 11 SVG lesions and 15 native coronary artery lesions.

METHODS AND RESULTS

The AngioGuard Emboli Capture Guidewire (Cordis) consists of a PTCA wire with an expandable filter at the distal tip. The porous membrane permits normal distal blood flow, while trapping potential emboli by filtration. After crossing the lesion, the filter is expanded, and routine angioplasty is performed over the same wire. Emboli retrieval is achieved by collapsing the filter and retracting the emboli capture wire (ECW). In 26 patients, standard angioplasty was performed over the ECW; 20 of these 26 patients received a stent. Collected debris was sent for histopathological analysis. Plaque debris was retrieved after native coronary and SVG interventions in all cases. The ECW was positioned and retrieved without complications. No major adverse events occurred. Myocardial infarctions and no-reflow were not observed.

CONCLUSIONS

The embolization of plaque fragments frequently occurs during coronary and SVG intervention. Distal embolization leading to microvascular obstruction and no-reflow could be successfully minimized by using the ECW.