672 TRANSCATHETER VS SURGICAL TREATMENT FOR PERCEVAL DEGENERATION: TAILORED STRATEGY FROM THE HEART TEAM

Transcatheter treatment of degenerated aortic bioprostheses is nowadays a well-established option (Valve-in-vale, ViV); however, some patients may pose some specific challenges.

Perceval® is a sutureless, stent-mounted, aortic valve bioprosthesis that can be placed with a less invasive surgical technique. Its nitinol self-expandable stent frame is a bulky structure that anchors to the aortic annulus without the need of continuous suture, thus reducing aortic cross-clamp and cardiopulmonary bypass time. Performing transcatheter aortic valve replacement (TAVR) in Perceval® may be associated with increased risk of coronary obstruction, impaired coronary access and increased post-procedural gradients.

Here we present the cases of two patients with Perceval® degeneration that have been treated with two different tailored approaches following a dedicated Heart Team evaluation.

R.M. is a 74-year-old, very low-weight, woman with a history of diabetes, severe COPD, 3b stage CKD, rheumatoid arthritis and previous carotid surgery. She underwent surgical aortic valve replacement (SAVR) with Perceval® “S” bioprosthesis for severe aortic stenosis in 2016. After five years she was diagnosed with severe symptomatic degeneration of the aortic prosthesis (mean gradient 45 mmHg, NYHA class III). The patient was therefore discussed by the Heart Team and scheduled for percutaneous treatment. A ViV with a self-expandable Medtronic 23 mm Evolut™ R bioprosthesis was successfully performed. Hospital stay was uneventful and the patient was discharged on 6th post-operative day in good clinical conditions and good functional class.

S.R. is a 70-year-old active smoker woman with a history of previous hemicolectomy for cancer that underwent SAVR in ministernotomy for severe aortic stenosis with Perceval® “L” in 2015. In 2016 she underwent PCI + DES implantation on OM of LCX for an acute coronary syndrome. In 2022 she was diagnosed with severe symptomatic degeneration of the bioprosthesis (mean gradient 40 mmHg, NYHA class II). The patient was referred to Heart Team discussion and scheduled for surgical reintervention. She underwent successful surgery with implantation of a Medtronic Avalus™ 23 mm bioprosthesis, followed by regular rehabilitation.

In the first case the severe comorbidities and frailty made the surgical risk almost prohibitive for reintervention (STS-M 9,23%, STS-MM 23,7%, Euroscore II 6,18%). Moreover, there was very little concern about the risk of impaired coronary access afterwards.

The second patient, instead, had an acceptable risk for surgery (STS-M 2,2%, STS-MM 10,6%, Euroscore II 4.45%); there was also a significant concern about the risk of impaired coronary access in case of ViV, since she already had a history of percutaneous coronary revascularization. Furthermore, from a lifetime management point of view it is possible to hypothesize easier future reintervention with a TAVR in SAVR instead of a complex TAVR in TAVR in SAVR.

Thus, although ViV was technically feasible in both cases with predictable good short-term outcomes, we decided for opposite treatments by looking at individualized long-term needs.

In Conclusion the choice between surgical and transcatheter intervention must be based not only on careful evaluation of clinical, anatomical and procedural characteristics but also on future perspectives, especially in patients with longer life expectancy.

Comparison Between Invasive and Noninvasive Methods to Estimate Subendocardial Oxygen Supply and Demand Imbalance

Background

Estimation of the balance between subendocardial oxygen supply and demand could be a useful parameter to assess the risk of myocardial ischemia. Evaluation of the subendocardial viability ratio (SEVR, also known as Buckberg index) by invasive recording of left ventricular and aortic pressure curves represents a valid method to estimate the degree of myocardial perfusion relative to left ventricular workload. However, routine clinical use of this parameter requires its noninvasive estimation and the demonstration of its reliability.

Methods and Results

Arterial applanation tonometry allows a noninvasive estimation of SEVR as the ratio of the areas directly beneath the central aortic pressure curves obtained during diastole (myocardial oxygen supply) and during systole (myocardial oxygen demand). However, this “traditional” method does not account for the intra‐ventricular diastolic pressure and proper allocation to systole and diastole of left ventricular isometric contraction and relaxation, respectively, resulting in an overestimation of the SEVR values. These issues are considered in the novel method for SEVR assessment tested in this study. SEVR values estimated with carotid tonometry by "traditional” and "new” method were compared with those evaluated invasively by cardiac catheterization. The “traditional” method provided significantly higher SEVR values than the reference invasive SEVR: average of differences±SD= 44±11% (limits of agreement: 23% – 65%). The noninvasive “new” method showed a much better agreement with the invasive determination of SEVR: average of differences±SD= 0±8% (limits of agreement: ‐15% to 16%).

Conclusions

Carotid applanation tonometry provides valid noninvasive SEVR values only when all the main factors determining myocardial supply and demand flow are considered.

Sheath Size Up and Down With Single Proglide - A Technique for Achieving Hemostasis With Use of Large Size Delivery System During Endovascular Graft Placement

BACKGROUND

A total percutaneous approach for management of aortic pathologies with endovascular grafts requires the use of large size delivery-systems. The diameter of these delivery systems usually exceeds the recommended sizes for most of the currently available percutaneous closure devices. A safe, effective and simple vascular access site closure device is desirable for success for percutaneous procedures for aortic pathologies. Hence, we aim to study safety and effectiveness of the use of a single suture based vascular access closure device (ProGlide) using a technique involving serial up and downsizing of the sheath size to achieve access site hemostasis in patients undergoing endovascular graft placement using femoral artery approach.

MATERIALS AND METHODS

We studied all consecutive patients who underwent endovascular grafting from January 2018 to December 2019. It is a retrospective observational study comparing procedural and short-term outcomes between single ProGlide use and surgical cut-down for femoral access site closure. We excluded patients with femoral artery minimal luminal diameter less than 5 mm, the presence of an aneurysm of the femoral artery, ≥180 degrees of calcium present at femoral/ external iliac artery and history of any vascular closure device use in the last six months.

RESULTS

We included 30 patients in single ProGlide group and 30 patients in the surgical cut-down group. One-third of the procedures were urgent procedures in the single Proglide group. Single ProGlide was successful in 93.34% patients and failure (6.66%) was seen due to hematoma and pseudoaneurysm in one patient each detected before discharge. The primary end-point defined by the success of procedure did not differ between the two groups. There were higher complications in the surgical group till 30 days as evidenced by infection, hematoma and neuronal injury. The secondary end-point, defined by the composite of complication events after discharge till 30 days was significantly higher in the surgical group (P-0.005) CONCLUSION: In patients with suitable femoral artery anatomy who undergo endovascular graft placement, effective hemostasis can be achieved safely using up and downsizing of the sheath with a single suture-based technique (Proglide). The results of the study could be considered hypothesis generating and needs to be confirmed in a randomized controlled trial before being adopted in clinical practice.

Closure of an unusual morphology patent ductus arteriosus with a covered stent in a dog

Patent ductus arteriosus (PDA) with unusual morphology was diagnosed in a 3-year-old German shepherd presented for exercise intolerance. Two interventional PDA closure procedures with various Amplatzer devices and one surgical ligation were attempted to close the PDA. However, PDA closure failed with both methods due to the unusual morphology and the severe enlarged ductus ampulla. Therefore, the patient underwent an aortic covered stent placement, and successful closure of the PDA was achieved. Eight months after the procedure, the dog was free of clinical signs and no residual flow was identified through the PDA on transthoracic echocardiography. Moreover, computed tomography angiography demonstrated correct stent positioning, with no evidence of thrombus formation, damage to the stent, nor any aortic wall abnormalities. Aortic covered stent placement is a viable option in dogs with unusual PDA morphology.

Noninvasive Estimation of Aortic Stiffness Through Different Approaches

Aortic pulse wave velocity is a worldwide accepted index to evaluate aortic stiffness and can be assessed noninvasively by several methods. This study sought to determine if commonly used noninvasive devices can all accurately estimate aortic pulse wave velocity. Pulse wave velocity was estimated in 102 patients (aged 65±13 years) undergoing diagnostic coronary angiography with 7 noninvasive devices and compared with invasive aortic pulse wave velocity. Devices evaluating carotid-femoral pulse wave velocity (Complior Analyse, PulsePen ET, PulsePen ETT, and SphygmoCor) showed a strong agreement between each other ( r>0.83) and with invasive aortic pulse wave velocity. The mean difference ±SD with the invasive pulse wave velocity was -0.73±2.83 m/s ( r=0.64) for Complior-Analyse: 0.20±2.54 m/s ( r=0.71) for PulsePen-ETT: -0.04±2.33 m/s ( r=0.78) for PulsePen ET; and -0.61±2.57 m/s ( r=0.70) for SphygmoCor. The finger-toe pulse wave velocity, evaluated by pOpmètre, showed only a weak relationship with invasive aortic recording (mean difference ±SD =-0.44±4.44 m/s; r=0.41), and with noninvasive carotid-femoral pulse wave velocity measurements ( r<0.33). Pulse wave velocity estimated through a proprietary algorithm by BPLab (v.5.03 and v.6.02) and Mobil-O-Graph showed a weaker agreement with invasive pulse wave velocity compared with carotid-femoral pulse wave velocity (mean difference ±SD =-0.71±3.55 m/s, r=0.23; 1.04±2.27 m/s, r=0.77; and -1.01±2.54 m/s, r=0.71, respectively), revealing a negative proportional bias at Bland-Altman plot. Aortic pulse wave velocity values provided by BPLab and Mobil-O-Graph were entirely dependent on age-squared and peripheral systolic blood pressure (cumulative r²=0.98 and 0.99, respectively). Thus, among the methods evaluated, only those assessing carotid-femoral pulse wave velocity (Complior Analyse, PulsePen ETT, PulsePen ET, and SphygmoCor) appear to be reliable approaches for estimation of aortic stiffness.

Short-Term Repeatability of Noninvasive Aortic Pulse Wave Velocity Assessment: Comparison Between Methods and Devices

BACKGROUND

Aortic pulse wave velocity (PWV) is an indirect index of arterial stiffness and an independent cardiovascular risk factor. Consistency of PWV assessment over time is thus an essential feature for its clinical application. However, studies providing a comparative estimate of the reproducibility of PWV across different noninvasive devices are lacking, especially in the elderly and in individuals at high cardiovascular risk.

METHODS

Aimed at filling this gap, short-term repeatability of PWV, estimated with 6 different devices (Complior Analyse, PulsePen-ETT, PulsePen-ET, SphygmoCor Px/Vx, BPLab, and Mobil-O-Graph), was evaluated in 102 high cardiovascular risk patients hospitalized for suspected coronary artery disease (72 males, 65 ± 13 years). PWV was measured in a single session twice, at 15-minute interval, and its reproducibility was assessed though coefficient of variation (CV), coefficient of repeatability, and intraclass correlation coefficient.

RESULTS

The CV of PWV, measured with any of these devices, was <10%. Repeatability was higher with cuff-based methods (BPLab: CV = 5.5% and Mobil-O-Graph: CV = 3.4%) than with devices measuring carotid-femoral PWV (Complior: CV = 8.2%; PulsePen-TT: CV = 8.0%; PulsePen-ETT: CV = 5.8%; and SphygmoCor: CV = 9.5%). In the latter group, PWV repeatability was lower in subjects with higher carotid-femoral PWV. The differences in PWV between repeated measurements, except for the Mobil-O-Graph, did not depend on short-term variations of mean blood pressure or heart rate.

CONCLUSIONS

Our study shows that the short-term repeatability of PWV measures is good but not homogenous across different devices and at different PWV values. These findings, obtained in patients at high cardiovascular risk, may be relevant when evaluating the prognostic importance of PWV.

Long-Term Contrast Echocardiography and Clinical Follow-Up after Percutaneous Closure of Patent Foramen Ovale Using Two Different Atrial Septal Occluder Devices

INTRODUCTION

Percutaneous patent foramen ovale (PFO) closure by means of a septal occluder device (SOD) is a well-known therapeutic strategy for the secondary prevention of paradoxical embolic neurological events. The aim of this study was to provide long-term echocardiographic and clinical follow-up data on patients who had undergone percutaneous PFO closure with 2 different SOD.

METHODS

We selected 2 groups of patients treated with 2 different SOD: Group A: 52 patients with an Amplatzer(®) PFO Occluder and Group B: 49 patients with a Figulla Flex(®) device. All patients underwent follow-up Bubble Test Transthoracic Echocardiography (BTTE) and clinical examination. The results were compared with those recently reported in a group of patients with similar characteristics, but that had been treated conservatively, which acted as a control group.

RESULTS

The mean follow-up after PFO closure was 53 months. The Amplatzer(®) PFO Occluder and the Figulla Flex were used in 52 (51.5%) and 49 (48.5%) of patients, respectively. We found no significant difference in the rate of effective PFO closure between the devices: Amplatzer 91.4%, Figulla 93.9% (P = 0.71). One patient (1.0%) suffered a recurrent neurologic event. BTTE was positive (BTTE+) in 8 patients (8%), 5 with an Amplatzer, and 3 with a Figulla device (P = 0.516). Only 1 patient with BTTE+ had a recurrent TIA (12.5%). No significant relationship was found between device dimensions and BTTE+ (P = 0.062). In the control group (163 patients), the recurrence of neurologic events was 9.2% (15 events), that was significantly higher in respect to the patients who had undergone percutaneous closure of the PFO.

CONCLUSIONS

Percutaneous PFO closure was associated with a remarkably low risk of recurrent embolic neurological events, and no long-term device-related major complications. No statistically significant difference emerged between the 2 different SODs regarding BTTE positivity. Long-term follow-up showed that the recurrence of neurological events has been significantly higher in the group treated in a conservative way.

How should I treat severe symptomatic aortic stenosis with transcatheter aortic valve implantation in a patient with right aortic arch?

BACKGROUND

An 84-year-old man suffering from dyspnoea on mild exertion and a 10-year history of mitral valve replacement with a mechanical prosthesis presented to our department. The patient had an isolated right aortic arch.

INVESTIGATION

Transthoracic echocardiography demonstrated severe LV systolic dysfunction (EF 25%), good function of the previously implanted mechanical prosthesis and severe aortic stenosis. Multislice computed tomography confirmed the presence of an isolated right aortic arch with mirror-image branching.

DIAGNOSIS

Severe symptomatic aortic stenosis in a patient with right aortic arch at high risk for surgical reintervention.

MANAGEMENT

Transcatheter aortic valve implantation using conventional delivery system.

Proximal endovascular occlusion for carotid artery stenting

Carotid artery stenting (CAS) is considered to be an acceptable alternative to carotid endarterectomy (CEA), particularly in patients at increased risk for CEA. The safety of CAS has improved significantly over the past decade. Adjunctive use of embolic protection devices (EPDs), is thought to be partially responsible for the improved outcomes. Among these, proximal EPDs are based on the surgical principle of stopping or reversing flow by clamping the carotid arteries, much in the same way carotid endarterectomy accomplishes neuroprotection. This is achieved through external and common carotid clamping. A recent meta-analysis demonstrates that the use of proximal EPDs for neuroprotection in patients undergoing CAS is associated with a very low incidence of any strokes and composite MACCE at 30 days. This study also demonstrates that the excellent outcomes achieved using proximal EPDs are independent of patient gender, symptomatic status, and other baseline clinical characteristics including the presence of a contralateral carotid occlusion.

[Transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis: position statement of the Italian Society of Interventional Cardiology (SICI-GISE) on minimum standards for hospitals and operators]

At present, transcatheter aortic valve implantation (TAVI) is a proven treatment option for patients with symptomatic degenerative aortic stenosis at high risk for conventional surgery. In countries where TAVI is currently performed, the number of procedures and centers involved has been continuously increasing. The present document from the Italian Society of Interventional Cardiology (SICI-GISE) aims to improve the available evidence and current consensus on this topic through the definition of training needs and knowledge base for both operators and centers.

Peri-procedural tight glycemic control during early percutaneous coronary intervention is associated with a lower rate of in-stent restenosis in patients with acute ST-elevation myocardial infarction

OBJECTIVE

We examined the effects of peri-procedural intensive glycemic control (IGC) during early percutaneous coronary intervention (PCI) on restenosis rate in hyperglycemic patients with ST-segment elevation myocardial infarction (STEMI).

RESEARCH DESIGN AND METHODS

A total of 165 hyperglycemic patients (glucose ≥ 140 mg/dl) with first STEMI undergoing PCI were studied. Patients were randomized to IGC for almost 24 h after PCI (n = 82; glucose, 80-140 mg/dl) followed by multidose sc insulin during the hospital stay or conventional glycemic control (CGC; n = 83; glucose, 180-200 mg/dl) followed by conventional therapy. Coronary angiography was performed at study entry and at 6-month follow-up. Blood samples for glycemia, hemoglobin A1c, inflammatory markers (C-reactive protein and TNF-α), monocyte chemoattractant-protein-1, and oxidative stress (nitrotyrosine) were collected immediately before and 24 h, 30 and 180 d after PCI.

RESULTS

After insulin infusion, mean plasma glucose during the peri-procedural period was greater in the CGC group than in the IGC group (CGC, 191 ± 15 mg/dl; IGC, 145 ± 35 mg/dl; P < 0.001). After the insulin infusion period, the levels of markers of oxidative stress (nitrotyrosine), inflammation (C-reactive protein, TNF-α), and monocyte chemoattractant-protein-1 were significantly higher in CGC patients compared with IGC patients. Moreover, ICG during PCI reduces restenosis by half (48 and 24%) at 6 months. During follow-up, there was no difference in mortality rates, glucose, inflammatory and oxidative stress markers among the groups. In-stent restenosis was positively associated with mean plasma glucose levels as well as oxidative stress and inflammatory markers during the insulin infusion period.

CONCLUSIONS

In hyperglycemic patients with STEMI, optimal peri-procedural glycemic control by reducing oxidative stress and inflammation may improve the outcome after PCI.

Combined treatment of heavy calcified femoro-popliteal lesions using directional atherectomy and a paclitaxel coated balloon: One-year single centre clinical results

BACKGROUND

The use of directional atherectomy (DA) for the treatment of calcified femoro-popliteal lesions seems to improve the acute procedural success, however without reducing the long term restenosis rate. Drug coated balloons (DCB) reduced restenosis rate in non heavy calcified lesions. Aim of this study was to demonstrate safety and efficacy of a combined endovascular approach using DA and DCB for the treatment of heavy calcified lesions of the femoro-popliteal tract.

METHODS

From January 2010 to November 2010, 240 patients underwent PTA of the femoro-popliteal tract in our institution. Within this cohort a total of 30 patients had life limiting claudication (LLC) (n=18) and 12 a critical limb ischemia (CLI) with baseline Rutherford class 4.2±1.2 underwent PTA of heavy calcified lesions with intravascular ultrasound guided DA and DCB. All procedures have been performed using a distal protection device. Stent implantation was allowed only in case of flow limiting dissections or suboptimal result (residual stenosis>50%) by visual estimation. After the intervention patients were followed up to 12 months.

RESULTS

Procedural and clinical success, was achieved in all cases. Bail-out stenting was necessary in only two (6.5%). At twelve month follow up median Rutherford class was 2.2±1.2, ABI was 0.8±0.1 and Limb salvage rate was 100%. Two minor, foot finger or forefoot amputations, were performed to reach complete wound healing and/or preserve deambulation. Duplex control was performed in all the cases (n=30). In three cases duplex scan showed a significant target lesion restenosis requiring a reintervention (TLR=10%) leading a total one-year secondary patency rate of 100%. All the three restenosed patients were insulin dependent diabetics and none of them were stented during the procedure.

CONCLUSION

The data suggest that combined use of DA and DCB may represent a potential alternative strategy for the treatment of femoro-popliteal severely calcified lesions. These very promising data and the considered hypothesis have to be confirmed in a multicentre randomised trial.

Carotid artery stenting in octogenarians using a proximal endovascular occlusion cerebral protection device: a multicenter registry

BACKGROUND

Carotid stenting (CAS) has been proposed as an alternative to carotid endoarterectomy also in elderly patients with discrepant results. However, the use of proximal neuroprotection devices have not been evaluated in octogenarians.

PURPOSE

The aim of this multicenter prospective registry was to demonstrate that CAS in octogenarians is safe and effective if performed in high-volume centers by experienced operators.

METHODS

From July 2005 to May 2009, a total of 198 octogenarians patients, in three different institutions, were included in this registry. All patients underwent CAS using proximal endovascular occlusion device (Mo.Ma. device Invatec, Roncadelle, Italy). An independent neurologist evaluated all patients. The primary endpoint was death and stroke rate at 30 days.

RESULTS

198 octogenarians (135 men; mean age: 83.2 years) were included in the registry. 39.4% of the patients were symptomatic. Procedural success was 100%. In-hospital complications: Two minor and two major strokes (2.02%) occurred. No device-related complications and no serious access site complication were noted. Between discharge and 30-day follow-up, one patient died due to a cardiac arrest. The overall 30-day combined stroke/death rate was 2.52%, resulting in 1.61% event incidence in asymptomatic and 3.9% in symptomatic patients (P = ns). Logistic regression did not identify independent predictor of neurological events, except in the female gender.

CONCLUSION

This multicenter prospective registry shows that CAS performed with proximal flow blockage is safe and feasible also in octogenarians. Thirty days death/stroke rates are similar to those of the overall population and within the International guidelines.

Proximal endovascular occlusion for carotid artery stenting: results from a prospective registry of 1,300 patients

OBJECTIVES

This single-center registry presents the results of proximal endovascular occlusion (PEO) use in an unselected patient population.

BACKGROUND

In published multicenter registries, the use of PEO for carotid artery stenting (CAS) has been demonstrated to be safe and efficient in patient populations selected for anatomical and/or clinical conditions.

METHODS

From July 2004 to May 2009, 1,300 patients underwent CAS using PEO. Patients received an independent neurological assessment before the procedure and 1 h, 24 h, and 30 days after the procedure.

RESULTS

Procedural success was achieved in 99.7% of patients. In hospital, major adverse cardiac or cerebrovascular events included 5 deaths (0.38%), 6 major strokes (0.46%), 5 minor strokes (0.38%), and no acute myocardial infarction. At 30 days of follow-up, 2 additional patients died (0.15%), and 1 patient had a minor stroke (0.07%). The 30-day stroke and death incidence was 1.38% (n = 19). Symptomatic patients presented a higher 30-day stroke and death incidence when compared with asymptomatic patients (3.04% vs. 0.82%; p < 0.05). No significant difference in 30-day stroke and death rate was observed between patients at high (1.88%; n = 12) and average surgical risk (1.07; n = 7) (p = NS). Operator experience, symptomatic status, and hypertension were found to be independent predictors of adverse events.

CONCLUSIONS

The use of PEO for CAS is safe and effective in an unselected patient population. Anatomical and/or clinical conditions of high surgical risk were not associated with an increased rate of adverse events.

Acute left main obstructions following TAVI

AIMS

Transcatheter aortic valve implantation (TAVI) is becoming a safe and effective technique for treating symptomatic aortic valvular stenosis (AVS) as an alternative to surgery in very high-risk patients. A possible consequence of valve implantation is the obstruction of coronary ostia.

METHODS AND RESULTS

Here we report five cases of angiographically confirmed left main (LM) obstruction, occurred immediately after balloon expandable aortic valve implantations at our institution. In four of these cases, LM obstruction was resolved with an emergency percutaneous coronary intervention (PCI). In the remaining case, obstruction transiently occurred only at the time of balloon valvuloplasty and did not required treatment. During this type of intervention, performing an aortography at the time of balloon valvuloplasty could help to identify patients at risk for coronary obstructions.

CONCLUSIONS

These cases illustrate that obstruction of the coronary ostia following TAVI is a possible complication. As the use of TAVI becomes widespread, the operators should be aware of this dangerous complication in their case preparation should it arise.

Radiation dose exposure during cardiac and peripheral arteries catheterisation

BACKGROUND

Ionising radiation carries an oncogenic risk which is linearly related to the dose. An estimation of the effective dose can be obtained from the measurements of the dose-area product (DAP), which is a measure of stochastic risk and a potential quality indicator.

AIM

To assess radiation exposure of patients in a large volume cardiac cath-lab.

METHODS

A retrospective analysis of adult cardiac and peripheral percutaneous procedures (April to December 2004) was carried out to determine the DAP and estimated risk of malignancy. We identified 6 groups: Group 1 (n=100, coronary angiography and ventriculography); Group 2 (n=50, carotid stenting); Group 3 (n=50, aortography+coronary angiography+ventriculography); Group 4 (n=100, inferior extremities angiography+predilatation and stenting); Group 5 (n=100, coronary angiography+ventriculography+direct coronary stenting); Group 6 (n=100, coronary angiography+ventriculography+coronary predilation and stenting). Dose-area product meter attached on the X-ray unit was used for the estimation of the radiation dose received by the patient during the procedures.

RESULTS

DAP values (mean+/-S.D.) ranged from 41+/-30 Gy cm2 in Group 1 (lowest) to 118+/-89 Gy cm2 in Group 6 (highest). Within each group, individual radiation exposure varies substantially: from 11 to 200 Gy cm2 in Group 1, and from 30 to 733 Gy cm2 in Group 6 patients. Average exposure in a Group 6 patient corresponds to a risk of mortality from a malignancy of about 1 in 1000.

CONCLUSION

The radiation dose varies substantially across different types of procedures and up to tenfold within the same procedure. The enhanced knowledge of radiation dose might help the cardiologist to implement radiation sparing procedures eventually minimizing patient and operator radiation hazards in invasive cardiology.

The adiponectin gene SNP+276G>T associates with early-onset coronary artery disease and with lower levels of adiponectin in younger coronary artery disease patients (age <or=50 years)

Adiponectin, an adipocyte-derived protein, is an essential modulator of insulin sensitivity and several studies suggest an important role of adiponectin in the processes leading to atherosclerosis, thus indicating the adiponectin gene as a potential candidate for coronary artery disease (CAD). In the present study we have studied the association between two single nucleotide polymorphisms (SNPs) (+45T>G and +276 G>T) of the adiponectin gene and CAD, looking also into the possible influence of these SNPs on adiponectin plasma levels. The SNPs were analysed in a first cohort of 595 subjects, 325 with CAD and 270 matched controls. We observed a significant association (p<0.001) between the SNP +276G>T in the adiponectin gene and CAD. In multivariate analysis, carriers of the +276G>T SNP had an odds ratio (OR) for CAD of 4.99 (p<0.0007). A strong interaction between the +276G>T SNP and age was also present (OR, 1.03; p<0.0001). The increase in CAD risk was most evident among individuals with early-onset CAD (age <or=50 years), whereas in older CAD subjects other factors, and not the adiponectin SNP, were the major determinants. Furthermore, in CAD subjects with early-onset disease this SNP was also a significant determinant of lower levels of serum adiponectin levels. This association resulted independent from the other variables known to be associated with CAD in our population, including sex, body mass index, high-density lipoprotein and Homeostasis Model Assessment for insulin resistance. To confirm the results the +276G>T SNP was analysed in a second cohort of CAD and controls. The difference between CAD and controls in the +276G>T SNP frequencies showed a similar trend as before, although not significant. The combination of the two cohorts (1,046 subjects: 580 CAD and 466 controls) showed a statistically significant association, particularly in CAD subjects with early-onset of disease. In addition, we confirmed that in younger CAD subjects the SNP was a significant determinant of lower levels of adiponectin. In view of these results, it could be speculated that the adiponectin gene variant, or a mutation in linkage with it, determines lower adiponectin gene expression, causing in turn an increased risk to develop insulin resistance, atherosclerosis and cardiovascular disease. The significant association of the adiponectin gene in subjects with early-onset CAD also suggests that that genetic factors for late-onset diseases may exert a greater influence in younger persons, when other risk factors are not as prevalent as in older age groups.

Genetic study of common variants at the Apo E, Apo AI, Apo CIII, Apo B, lipoprotein lipase (LPL) and hepatic lipase (LIPC) genes and coronary artery disease (CAD): variation in LIPC gene associates with clinical outcomes in patients with established CAD

BACKGROUND

Current evidence demonstrates that positive family history and several alterations in lipid metabolism are all important risk factors for coronary artery disease (CAD). All lipid abnormalities themselves have genetic determinants. Thus, objective of this study was to determine whether 6 genetic variants potentially related to altered lipid metabolism were associated with CAD and with lipid abnormalities in an Italian population. These genetic variables were: apolipoprotein E (Apo E), Apo AI, Apo CIII, Apo B, lipoprotein lipase (LPL) and the hepatic lipase (LIPC) genes. Furthermore, an 8 years prospective analysis of clinical cardiovascular events was related to the various genetic markers.

METHODS

102 subjects with established coronary artery disease and 104 unrelated normal subjects were studied. CAD Patients were followed up for 8 years, and clinical CAD outcomes (a second coronary angioplasty (PTCA), myocardial infarction, coronary artery by-pass graft (CABG), cardiovascular deaths), available from 60 subjects, were related to the genetic variants by multiple regression analysis. Results. Of the six lipid loci studied (for a total of 11 polymorphisms) only the apolipoprotein E, Apo B and LIPC polymorphisms distinguished between case and controls. However, multivariate analysis accounting for clinical and metabolic predictors of CAD showed that only the ApoB Xba1 and ApoE4 polymorphism associated with CAD in this Italian population. When lipid parameters were related to genotypes, the ApoE, ApoB, and LIPC gene polymorphisms were associated to various markers of dyslipidaemia in the CAD patients, confirming previous reports. When the occurrence of a second cardiovascular event was related to genotypes, an independent role was observed for the LIPC gene T202T variant.

CONCLUSIONS

variation in LIPC (hepatic lipase) gene associates with clinical outcomes in Italian patients with established CAD. Further studies on the LIPC gene in CAD patients are warranted, in particular looking at the possible influences on clinical outcomes.

Percutaneous femoral artery angioplasty with stent-in-stent technique and tirofiban administration

Despite the use of stent implantation along with percutaneous transluminal angioplasty, the rate of restenosis in high-risk patients is still high. Some studies have proven the ability of platelet glycoprotein IIb/IIIa receptor antagonists to reduce peri- and post-procedural thrombotic complications in endovascular procedures. We present the case of a 62-year-old female with in-stent restenosis who was successfully treated with femoral artery angioplasty with a stent-in-stent technique and tirofiban administration.