Mode of delivery and peripartum outcome in women with heart disease according to the ESC guidelines: an Italian multicenter study

INTRODUCTION

The European Society of Cardiology (ESC) guidelines (GL) provide indications on the mode of delivery in women with heart disease. However available data suggests that the rate of Cesarean Delivery (CD) is high and widely variable among such patients. In this study, we aimed to investigate the degree of adherence to the ESC recommendations among women delivering in four tertiary maternity services in Italy and how this affects the maternal and neonatal outcomes.

MATERIAL AND METHODS

Retrospective multicenter cohort study including pregnant women with heart disease who gave birth between January 2014 and July 2020. Composite adverse maternal outcome (CAM) was defined by the occurrence of one or more of the following: major postpartum hemorrhage, thrombo-embolic or ischemic event, de novo arrhythmia, heart failure, endocarditis, aortic dissection, need for re-surgery, sepsis, maternal death. Composite Adverse Neonatal outcome (CAN) was defined as cord arterial pH <7.00, APGAR <7 at 5 min, admission to the intensive care unit, and neonatal death. We compared the incidence of CAM and CAN between the cases with planned delivery in accordance (group "ESC consistent") or in disagreement (group "ESC not consistent") with the ESC GL.

RESULTS

Overall, 175 women and 181 liveborn were included. A higher frequency of CAN was found when delivery was not planned accordingly to the ESC guidelines [("ESC consistent" 9/124 (7.2%) vs "ESC not consistent" 13/57 (22.8%) p = 0.002 OR 3.74 (CI 95% 1.49-9.74) , while the occurrence of CAM was comparable between the two groups. At logistic regression analysis, the gestational age at delivery was the only parameter independently associated with the occurrence of CAN (p = 0.006).

CONCLUSION

Among pregnant women with heart disease, deviating from the ESC guidelines scheduling cesarean delivery does not seem to improve maternal outcomes and it is associated with worse perinatal outcomes, mainly due to lower gestational age at birth.

P90 LEFT ATRIAL APPENDAGE OCCLUSION AND RIGHT CARDIAC CATHETERIZATION IN PATIENT WITH PORTO–PULMONARY HYPERTENSION AND PERSISTENT ATRIAL FIBRILLATION WITH GASTRO–INTESTINAL BLEEDING IN ORAL ANTICOAGULANT TREATMENT

62–year–old male with multiple cardiovascular risk factors.Known pre–capillary porto–pulmonary hypertension treated with Macitentan 10 mg per day, in the context of serum–negative liver disease complicated by portal hypertension and congestive gastropathy.Persistent atrial fibrillation in AVK due to high thromboembolic risk (CHA2DS2VAsc 3).At the last echocardium–TT evidence of worsening of right ventricular systolic function (TAPSE from 20 to 16 mm) and estimated pulmonary hypertension (PAPS from 45 to 65 mmHg). Subsequent hospitalization for severe anemia (Hb 6.5 g/dl), with diagnosis of bleeding angiodysplasias.In consideration of high bleeding risk (HAS–BLED 3), left atrial appendage occlusion has been indicated.The patient underwent right cardiac catheterization, via right femoral vein, with confirmation of severe pulmonary pre–capillary hypertension (mean PAP 45 mmHg, PCWP 14 mmHg); during the same session, left atrial appendage was occluded percutaneously using a Watchman device. At discharge, combination therapy with Riociguat plus Macitentan and single antiplatelet therapy with Clopidogrel 75 mg per day were undertaken. Shortly thereafter, recurrence of gastro–enteric bleeding occurred; after cardiac evaluation, Clopidogrel was discontinued and anticoagulant therapy with Edoxaban 30 mg od was started.The choice of shifting from Clopidogrel to low dose NOAC was guided by the unclear evidence of efficacy and safety of single or dual antiplatelet therapy in a population of patients with both high thrombotic and bleeding risk, such as in this case.Given that NOACs can be considered as an alternative to Warfarin after Watchman implantation (class IIB), after the second recurrence of bleeding, we opted for long–term antithrombotic strategy using a direct oral anticoagulant at reduced dose, making bleeding risk more acceptable instead of the administration of full dosage of NOAC, matter of major importance in candidates for left appendage closure, in whom long–term anticoagulant therapy itself is contraindicated; on the other hand, aiming for a better protection against thromboembolic events compared to standard antiplatelet therapy.

P127 PERI–VASCULAR ADIPOSE TISSUE ATTENUATION ON CHEST COMPUTED TOMOGRAPHY IN PATIENTS WITH MARFAN SYNDROME: A CASE SERIES

Background and aim of the work

Marfan Syndrome is a genetic disorder that determines histopathological alterations of the aortic vascular wall leading to increased inflammatory component. The peri–vascular adipose tissue attenuation is a method able to capture localized vascular inflammation by mapping spatial changes of perivascular tissue attenuation on computed tomography.

Methods

We measured peri–vascular adipose tissue attenuation around the ascending aorta in three consecutive subjects with confirmed genetic diagnosis of Marfan Syndrome. All subjects received the genetic diagnosis of fibrillin–1 gene mutation as part of the family screening of patients with known Marfan Syndrome. Chest computed tomography was performed in such asymptomatic subjects after genetic confirmation of Marfan Syndrome. None of these subjects showed aortic aneurysms or suffered from chronic inflammatory/infectious disease.

Results

In the three subjects identified with Marfan Syndrome the value of aortic peri–vascular adipose tissue attenuation measured at chest computed tomography was higher than normal and the volume of aortic peri–vascular adipose tissue was lower.

Conclusion

These preliminary observations suggest that peri–vascular adipose tissue attenuation is unexpectedly high in patients with Marfan Syndrome, notwithstanding the normal aortic diameter at the time of computed tomography. Whether this observation may find a clinical use in suspected Marfan Syndrome or in predicting aortic complications in Marfan Syndrome is worth to be assessed in prospective studies.

C69 EFFECTIVENESS AND SAFETY OF DISTINCT ANTIPLATELET REGIMENS AFTER TRANSCATHETER LEFT ATRIALE APPENDAGE OCCLUSION: A SINGLE CENTER REAL–WORLD EXPERIENCE

Transcatheter left atrial appendage occlusion (LAAO) has emerged as a reliable tool to prevent thromboembolic events, in particular ischemic stroke, in patients with atrial fibrillation (AF) in the absence of mitral stenosis/valve prosthesis and contraindication to oral anticoagulation (OAC). Antiplatelet therapy (APT) is required after device implantation to prevent device–related thrombus (DRT). Previous studies provided conflicting results on the optimal APT regimen after LAAO. Thus, herein we aimed at assessing the comparative effectiveness and safety of distinct APT regimens. We conducted a real–world single–center observational study including consecutive AF patients that underwent LAAO at the University Hospital of Parma between October 2010 and June 2021. Clinical follow–up included all successfully implanted patients. Primary endpoint was net efficacy outcome, a composite of any ischemic or hemorrhagic event. Secondary endpoints were ischemic (any of the following: ischemic stroke, transient ischemic attack [TIA], DRT, systemic embolism) and hemorrhagic (major [≥3] bleedings according to Bleeding Academic Research Consortium [BARC] classification) complications alone. We enrolled a total of 130 patients (median age 77.0 [72.7;81.0] years; 78 [60.0%] men). History of hemorrhagic stroke in OAC (74 [56.9%]) was the main indication for LAAO. Technical procedure success was achieved in 123 (94.6%) patients. According to multidisciplinary team evaluation, immediately after LAAO, 39 (31.7%) patients received short (≤ 1 month)–dual APT (DAPT) consisting of cardioaspirin and clopidogrel, 35 (28.5%) long (&gt;1, ≤12 months)–DAPT and 49 (39.8%) single APT (SAPT). At a median follow–up of 32 months, the incidence of primary endpoint was significantly lower in short–DAPT group (3 [7.7%] vs. 7 [20.0%] in long–DAPT vs. 14 [28.6%] in SAPT, p = 0.049], mainly driven by a lower occurrence of bleeding endpoint (0 [0.0] vs. 4 [11.4%] in long–DAPT vs. 9 [18.4%] in SAPT, p = 0.020) without differences in the incidence of ischemic endpoint (p = 0.916). Finally, comparison of the Kaplan–Meier curves showed that short–DAPT group had a higher primary endpoint–free survival (p = 0.015) compared to the others. In summary, our study highlighted that short (≤ 1 month)–DAPT regimen after LAAO is associated with better outcomes, mainly driven by reduction of major bleedings. Strong evidences arising from randomized trials are warranted to support these findings.

P56 SPONTANEOUS CORONARY ARTERY DISSECTIONS: ANALYSIS OF NON TRADITIONAL RISK FACTORS

 

The etiology of spontaneous coronary dissection (SCAD) is not well defined and Non traditional risk factors (NT–RF) have assumed increasing interest, but few data are available. NT–RF include three categories: Sex–related (SR–NT–FR), Sex–predominant (SP–NT–RF) and Gender–related (GR–NT–RF). (Table 1)

Aim of the Study

The objective of our analysis was to evaluate the incidence of NT–RF in Parma SCAD registry population.

Material and methods

We reviewed 62 patients with SCAD enrolled between January 2013 through November 2021

Results

Traditional risk factors were less common: hypertension was the most prevalent (39 pts, 62.9%). When considering NT–RF, 51 patients (82%) had at least one of all, with at least one SR–RF (66%) or GR–RF (64,5%). Patients with NT–RF were younger at time of SCAD (mean age 53 vs 66; p = 0.027) and they were predominantly females (48 vs 7 pts, p = 0.004) (Table 2). No differences were found among NT–RF SCAD and nNT–RF SCAD patients by fibromuscular dysplasia, peripheral arterial disease and chronic kidney disease. Patients with SCAD more often presented with non ST–segment elevation myocardial infarction (43 pts, 72.6%) vs ST–segment elevation (17 pts, 27.4%). No differences in clinical presentation and angiographic characteristics were found among NT–RF and nNT–RF patients group. MACE occurred in 17.7% of patients of the overall study population, at a median follow–up of 23 (interquartile range: 11;57) months. When comparing the incidence of cardiovascular events in the 2 study groups there was a trend toward a higher prevalence of MACE in NT–RF group without statistical significance (NT–RF SCAD 19.6% – nNT–RF SCAD 9.1%; p = 0.4). (Table 3)

Conclusion

SCAD is an emerging cause of myocardial infarction in young and middle–aged women without the traditional cardiovascular risk profile. Although overall survival seems good, SCAD is a potentially malignant disease which can present with ventricular arrhythmias and sudden cardiac death. Risk estimation is difficult in women, due to the scarce validity of prediction models, therefore a great effort must be made by the clinical community for the widespread diffusion and use of models incorporating NT–RF. Acknowledgement of peculiar features of this disease could help clinicians and researchers to establish targeted interventions for cardiovascular primary prevention, early diagnosis and secondary prevention in women, including rehabilitation and stress management programmes.

189 Long-term outcomes of early-onset myocardial infarction with non-obstructive coronary artery disease

Aims

Data regarding long-term prognosis of MINOCA are very limited and conflicting.

Methods and results

The Italian Genetic Study on early-onset MI enrolled 2000 patients who had a first MI before they were 45. The median follow-up was 19.9 years, the equivalent of 39 535 person-years. The composite primary endpoint was cardiovascular (CV) death, non-fatal MI, and non-fatal stroke (MACE); the secondary endpoint was rehospitalization for coronary revascularization. MINOCA was experienced by 317 patients (15.9%). The risk of MACE was not significantly different between MINOCA patients and those with obstructive coronary artery disease (MICAD, 27.8% vs. 37.5%; adj. HR: 0.79, 95% CI: 0.57–1.09; P = 0.15, Figure 1). There was no between-group difference in the rate of non-fatal MI (17.3% vs. 25.4%; adj. HR: 0.76, 95% CI: 0.52–1.13; P = 0.18), non-fatal ischaemic stroke (9.5% vs. 3.7%; adj. HR: 1.79, 95% CI: 0.87–3.70; P = 0.12), or all-cause mortality (14.1% vs. 20.7%; adj. HR: 0.73, 95% CI: 0.43–1.25; P = 0.26), but the rates of CV death (6.2% vs. 8.4%; adj. HR: 0.26, 95% CI: 0.08–0.86; P = 0.03) and coronary revascularization (6.7% vs. 27.7%; HR: 0.27, 95% CI: 0.15–0.47; P &lt; 0.001) were lower in the MINOCA group.

Conclusions

MINOCA is frequent in early-onset MI patients and is not benign with a long-term risk of MACE and overall mortality not significantly different from that of the MICAD patients.

Left ventricular end-diastolic pressure predicts in-hospital outcomes in Takotsubo syndrome

Background

Takotsubo syndrome (TTS) is an acute and reversible form of myocardial injury often preceded by an emotional or physical stressful event. Of importance, TTS may be associated to serious adverse in-hospital complications. Coronary angiography and left ventricle angiography remain a cornerstone for TTS diagnosis. However, the prognostic role of invasively assessed left ventricular end-diastolic pressure (LVEDP) at the time of cardiac catheterization has never been investigated.

Purpose

We evaluated the role of invasively assessed LVEDP for predicting in-hospital complications in TTS patients compared to the most widely used echocardiographic parameters of ventricular function.

Methods

We prospectively enrolled 130 patients (mean age 71.2±11.3 years, 114 [87.7%] female) with TTS. Invasive measurement of LVEDP was performed at the time of cardiac catheterization. The rate of in-hospital complications (composite of acute heart failure, cardiogenic shock, life-threatening arrhythmias and all-cause death) was examined.

Results

In-hospital complications occurred in 37 (28.5%) patients. Patients who experienced in-hospital complications had a higher prevalence of neurological trigger and lower prevalence of emotional trigger, higher LVEDP and mean E/e' ratio and lower LV ejection fraction (LVEF) values compared to those who did not experience in-hospital complications. At multivariable Cox regression, higher LVEDP (hazard ratio [HR] 1.12, 95% confidence interval [CI] [1.05–1.20], p&lt;0.001) and lower LVEF (HR 0.95, 95% CI [0.91–0.99], p=0.011) remained independently predictors of in-hospital complications, while emotional trigger was associated to a lower risk (HR 0.24, 95% CI [0.06–0.96], p=0.044). The area under the curve (AUC) for LEVDP in the prediction of in-hospital events was 0.776 (95% CI [0.69–0.86], p&lt;0.001, with a sensitivity and specificity of 95% and 58% using a LVEDP cut-off value of 22.5 mmHg). The AUC was significantly higher for LVEDP than for E/e' ratio (p=0.045).

Conclusions

LVEDP measured at the time of cardiac catheterization may help in identifying TTS patients at higher risk of cardiovascular events during the hospitalization with relevant therapeutic implications. Of note, in the prediction of in-hospital events the LEVDP performed better than non-invasive indexes commonly used for the assessment of diastolic function.

Funding Acknowledgement

Type of funding sources: None.

Incidence, predictors and prognostic role of complications occurring during provocative testing with acetylcholine in patients with myocardial ischemia and non-obstructive coronary arteries

Background

Coronary provocative test with acetylcholine (ACh) is of utmost importance and increasingly used in patients with myocardial ischemia and non-obstructive coronary arteries. However, data on safety, predictors and prognostic role of complications during intracoronary provocative testing are scarce.

Purpose

We assessed the safety of ACh provocative test in patients with myocardial ischemia and non-obstructive coronary arteries. Moreover, we evaluated the predictors and the prognostic implications of complications occurring during the provocative test.

Methods

We prospectively enrolled consecutive patients undergoing intracoronary ACh provocative test for suspected myocardial ischaemia with angiographic evidence of non-obstructive coronary arteries. Complications during the ACh test were collected. Occurrence of major adverse cardiac events (MACE), arrhythmic events at 24-hours ECG dynamic Holter monitoring and angina status were assessed at follow-up.

Results

We enrolled 310 patients (mean age 60.6±11.9; 169 [54.5%] chronic coronary syndromes [CCS] and 141 [45.5%] with myocardial infarction and non-obstructive coronary arteries [MINOCA]). The overall incidence of complications was low (9%) with a similar incidence in MINOCA and CCS (10 [7.1%] vs 18 [10.7%], p=0.276, respectively). At multivariate logistic regression analysis, a previous history of paroxysmal atrial fibrillation (Odds Ratio [OR] 12.324, Confidence Interval [CI] 95% [4.641; 32.722], p=0.015) and moderate/severe diastolic dysfunction (OR 3.827, CI95% [1.296; 11.304], p=0.015) were independent predictors for occurrence of complications. The occurrence of complications was not associated with a worse clinical outcome at follow-up (median follow-up 22 months) in terms of both MACE, arrhythmic events and angina burden.

Conclusion

Intracoronary provocative testing with ACh test is safe in patients with myocardial ischemia and non-obstructive coronary arteries, without differences between MINOCA and CCS. History of paroxysmal atrial fibrillation and moderate/severe diastolic dysfunction predicted the occurrence of complications during ACh test. Of importance, our data can reassure clinicians, as the occurrence of complications did not portend a worse prognosis at follow-up in terms of MACE, arrhythmic events and angina burden.

Funding Acknowledgement

Type of funding sources: None. Complications and clinical presentationClinical outcome at follow-up

Long-term exposure to ambient air pollution portends a higher risk of coronary plaque vulnerability and instability in patients with acute coronary syndrome: an optical coherence tomography study

Background

Air pollution is an emerging key player in determining the residual risk of coronary events. However, pathophysiological mechanisms linking air pollution and coronary events have been not adequately investigated.

Purpose

We assessed the relationship between exposure to air pollutants and mechanisms of coronary instability evaluated by optical coherence tomography (OCT) in patients with acute coronary syndrome (ACS).

Methods

ACS patients undergoing OCT imaging were retrospectively selected. Mechanism of culprit lesion instability was classified as plaque rupture (PR) or intact fibrous cap (IFC) by OCT, and the presence of macrophage infiltrates (MØI) and thin-cap fibroatheroma (TCFA) at the culprit site was also assessed. Based on each case's home address, exposure to several pollutants was evaluated, including particulate matter 2.5 (PM2.5), particulate matter 10 (PM10), and carbon monoxide (CO). Only patients with &gt;2 years of available data on air pollution exposure prior to ACS were enrolled.

Results

We included 136 patients [median age 67.0 years (56.2–76.0), 104 (76.5%) male]. Sixty-six patients (48.5%) had PR as mechanism of plaque instability. Patients with PR were exposed to significantly higher PM2.5 levels compared to IFC, and PM2.5 was an independent predictor for PR (OR=1.133, 95% CI [1.020–1.258], p=0.019). Moreover, exposure to higher levels of PM2.5, PM10 and CO was an independent predictor for the presence of TCFA, while PM2.5 and CO levels predicted the presence of MØI. Interestingly, PM2.5, PM10 and CO levels were positively and significantly correlated with serum levels of C-reactive protein. ROC curves were constructed to assess the ability of PM2.5 to predict the presence of plaque rupture, TCFA or MØI. The AUC for PM2.5 to predict plaque rupture was 0.62 (95% CI: 0.52–0.71, p=0.018), for TCFA was 0.71 (95% CI: 0.61–0.80, p&lt;0.001) and for MØI was 0.80 (95% CI: 0.71–0.88, p&lt;0.001). Using a PM2.5 cut-off value of 13.40 μg/m3, the sensitivity and specificity for MØI were 81% and 66%, respectively.

Conclusions

We provide novel insights into the missing link between air pollution and increased risk of coronary events. In particular, exposure to higher concentrations of air pollutants is a risk factor for vulnerable plaque features and for plaque rupture as mechanism of coronary instability mediated by systemic and local plaque inflammation. Of importance, the thresholds of air pollutants that predicted the presence of vulnerable plaque features are far lower than commonly accepted safety thresholds used to start preventive measures for public health, suggesting that further efforts are needed in order to reduce the adverse effects on the cardiovascular system.

Funding Acknowledgement

Type of funding sources: None. Air pollutants exposure and OCT featuresROC curve analysis

Predictors of fractional flow reserve/instantaneous wave-free ratio discordance documented during functional coronary stenosis assessment: impact of tailored diagnostic cut-offs on long-term outcomes

Background

Patient- and lesion-related factors may influence concordance between instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR), potentially affecting safety of revascularization deferral.

Methods

Consecutive patients with at least an intermediate coronary stenosis evaluated by both iFR and FFR were retrospectively enrolled. Revascularization was at physician's discretion. The agreement between IFR and FFR at their diagnostic cut-offs (FFR 0.80, iFR 0.89) according to patient- and lesion-level characteristics was assessed. Multivariate analyses were carried to identify the independent predictors of discordance. Tailored iFR cut-offs according to predictors of discordance best matching an FFR of 0.80 were identified by receiver-operating characteristic (ROC) curves. The impact of reclassification according to tailored iFR cut-offs on major cardiovascular events (MACE: cardiovascular death, myocardial infarction or target lesion revascularization) among deferred lesions was investigated.

Results

299 coronary stenosis (diameter stenosis 54±14%, FFR 0.84 [0.78–0.89], iFR 0.91 [0.87–0.95], left main/left anterior descending [LM/LAD] vessel 67.6%) of 260 patients were studied, and 46.5% were revascularized. Discordance rate was 23.4% (10.7% iFR-negative discordant, 12.7% iFR-positive discordant). Independent predictors of discordance were LM/LAD disease, multivessel disease, non-ST-elevation myocardial infarction presentation, smoking, reduced glomerular filtration rate and hypertension. Lesion reclassification with tailored iFR-cut-offs based on patient-level predictors carried no prognostic value among deferred lesions. Reclassification according to lesion location, which was entirely driven by LM/LAD lesions (iFR-cut-offs: 0.93 for LM/LAD, 0.89 for non-LM/LAD), identified increased MACE among lesions deferred based on a negative FFR, between patients with a positive as compared to a negative iFR (19.4% vs. 6.1%, p=0.044), while the same association was not observed with the conventional 0.89 iFR cut-off (15.0% vs 8.6%, p=0.303).

Conclusion

Tailored vessel-based iFR cut-offs carry prognostic value among FFR negative lesions, suggesting that iFR may more safely defer revascularization of LM/LAD lesions than FFR and that a single iFR cut-off might be clinically unsatisfactory.

Funding Acknowledgement

Type of funding source: None

Brain-derived neurotrophic factor is associated with coronary macrophage infiltrates in patients with acute coronary syndrome

Background

Brain-derived neurotrophic factor (BDNF) is a neurotrophine that plays a key role in the regulation of both central and peripheral nervous system. Moreover, BDNF is secreted in multiple tissues and exerts systemic, autocrine, and paracrine effects in the cardiovascular system. Of importance, BDNF expression was enhanced in macrophages and smooth muscle cells in atherosclerotic coronary arteries and may be involved in thrombus formation. Thus, BDNF has been suggested as an important link between inflammation and thrombosis, potentially involved in the pathogenesis of acute coronary syndrome (ACS).

Purpose

In our study we aimed at assessing serum levels of BDNF in patients with ACS, evaluating differences according to clinical presentation [ST-segment elevation myocardial infarction (STEMI) vs. Non-ST-segment elevation ACS (NSTE-ACS)]. Moreover, we assessed the presence of optical coherence (OCT)-defined macrophage infiltrates (MØI) in the culprit vessel of ACS patients and evaluated their relationship with BDNF levels.

Methods

ACS patients were prospectively selected. Blood samples were collected at admission and serum levels of BDNF were subsequently assessed. Presence of OCT-defined MØI along the culprit vessel was assessed.

Results

166 ACS patients were enrolled [mean age 65.3±11.9 years, 125 (75.3%) male, 109 STEMI, 57 NSTE-ACS]. Serum levels of BDNF were higher among STEMI patients compared with NSTE-ACS [median (IQR) 2.48 pg/mL (1.54–3.34) vs. 2.12 pg/mL (1.34–2.47), p=0.007], while C-reactive protein levels did not differ between the two groups. OCT assessment was performed in 53 patients and MØI were detected in 27 patients. Of importance, patients with MØI in the culprit vessel had higher levels of BDNF compared with patients without MØI [median (IQR) 2.23 pg/mL (1.38–2.53) vs. 1.41 pg/mL (0.93–2.07), p=0.023], while C-reactive protein levels did not differ between the two groups. Of note, at multivariate regression analysis BDNF levels were independent predictor of MØI [OR: 2.20; 95% CI (1.02–4.74), p=0.043].

Conclusions

Serum levels of BDNF may reliable identify the presence of local macrophage inflammatory infiltrates in patients with ACS. Moreover, BDNF levels are higher in patients with STEMI compared with NSTE-ACS. Taken together, these data suggest that BDNF may represent an interesting link between local inflammatory activation and enhanced thrombosis in ACS.

BDNF serum levels

Funding Acknowledgement

Type of funding source: None

Perilipin-2 is associated with a higher risk of microvascular obstruction in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background

Coronary microvascular obstruction (MVO) is a noxious condition frequently occurring in patients with ST-elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI). However, multiple mechanisms are involved in the pathogenesis of MVO and not yet fully understood. Recent studies suggested that perilipin 2 (PLIN2) may play an important role in lipid metabolism of macrophages resident in atherosclerotic plaques along with a role in enhancing oxidative stress.

Purpose

To study the association between PLIN2 and MVO in STEMI patients undergoing primary PCI. We also assessed the role of PLIN2 to predict future major cardiovascular events (MACEs).

Methods

STEMI patients undergoing primary PCI were enrolled. PLIN2 was dosed within 24 hours from admission in peripheral blood monocytes. MVO was assessed using TIMI flow grade and myocardial blush grade on coronary angiogram after PCI, and patients were stratified accordingly (MVO or noMVO). Major adverse cardiac events (defined as a composite of cardiac death, non-fatal myocardial infarction, re-admission for heart failure and target vessel revascularization) were assessed at clinical follow-up.

Results

Among 100 STEMI patients (mean age, 65.2±12.0 years, 81 males), 33 (33.0%) had MVO. Patients with MVO were older, had higher troponin I peak, C-reactive protein and lower left ventricular ejection fraction on admission. Patients with MVO had significantly higher levels of PLIN2 (1.03±0.28 vs. 0.90±0.16, p=0.019) compared to noMVO patients. Age [OR (95% CI) per year, 1.045 (1.005–1.087), p=0.026] and PLIN2 [OR (95% CI) per unit, 16.606 (2.027–136.030), p=0.009] were associated with MVO at univariate logistic regression analysis. However, only PLIN2 levels [OR (95% CI) per unit, 12.325 (1.446–105.039), p=0.033] were independently associated with MVO at multivariate analysis. Follow up data were available for 76 patients (76%). After a mean follow up of 182.2±126.6 days, 13 MACEs occurred. Patients with MVO had more MACEs [9 (37.5%) vs. 4 (7.7%), p&lt;0.001] compared to noMVO patients. At univariate Cox regression analysis, MVO [HR (95% CI), 6.792 (2.053–22.460), p=0.002], hypercholesterolemia [HR (95% CI), 3.563 (1.094–11.599), p=0.035] and PLIN2 [HR (95% CI) per unit, 82.991 (9.857–698.746), p&lt;0.001] were predictors for MACEs at follow up. At multivariate analysis only PLIN2 [HR (95% CI) per unit, 26.904 (2.461–294.100), p=0.007] was an independent predictor of MACEs.

Conclusions

In STEMI patients undergoing primary PCI, PLIN2 was independently associated with MVO. PLIN2 was an independent predictor of MACEs at clinical follow-up. These findings suggest that PLIN2 may represent a promising therapeutic target, opening the avenue towards novel therapeutic approaches for MVO.

Funding Acknowledgement

Type of funding source: None

Meta-inflammation in monocytes of patients with Acute Coronary Syndrome

Background

Several studies suggest that an alteration of monocyte metabolism might be implicated in inflammatory diseases. Enhanced glycolysis might be a hallmark of pro-inflammatory monocyte subsets. Improved glycolysis enables the immune cells to generate sufficient ATP and biosynthetic intermediates to carry out its particular effector functions. For macrophages this includes phagocytosis and inflammatory cytokine production. Pyruvate Kinase isozyme M2 (PKM-2) catalyzes the final step of glycolysis producing pyruvate and ATP. Latest studies have shown that a member of Jumonji family (JMJD8) acts as a positive regulator in TNF-induced NF-kB signaling leading to pro-inflammatory pathways in macrophages and is involved in angiogenesis and cellular metabolism through interacting with PKM-2 in endothelial cells.

Purpose

The aims of the study are to assess the expression of the glycolytic key enzyme PKM-2 in CD14+ monocytes obtained from patients with non-ST-elevation myocardial infarction (NSTEMI) or with stable angina (SA). Furthermore, the expression of JMJD8 was evaluated.

Methods

30 patients with NSTEMI and 30 patients with SA were enrolled. Peripheral blood mononuclear cells were obtained from whole blood samples. For cytoplasmatic protein identification, cells were fixed and permeabilized and then incubated with fluorochrome-conjugated mAbs anti-CD14, anti-PKM-2 and anti-JMJD8. For analysis we used Two-tailed Mann-Whitney non parametric Comparison test.

Results

CD14+ monocytes from NSTEMI patients showed reduced expression of the key glycolytic enzyme PKM-2 as compared to CD14+ monocytes from SA patients (p=0.02) (Figure 1). JMJD8 expression in NSTEMI patients is increased compared with SA patients (p=0.02) (Figure 2).

Conclusion

This study introduces a role for immune-metabolism in the immunity dysregulation described in ACS patients and provides novel insights into the mechanisms responsible for coronary instability. Taking their potential interaction into account, our data suggest that in acute setting glycolysis key enzyme PKM2 expression is downregulated. Besides, JMJD8 protein levels increase in NSTEMI patients acting as potential limiting factor of PKM2 function. Moreover, our data propose the potential roles of immune-metabolism to detect novel therapeutic targets, associated with an accurate patient stratification based on immune-metabolic profiles, for prevention and treatment of atherosclerosis, in the perspective of a personalized medicine approach.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Fondazione Policlinico A. Gemelli

Macrophage infiltrates in coronary plaque erosion portend a worse cardiovascular outcome in patients with acute coronary syndrome

Background

Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS). Inflammatory activation is considered a key mechanism of plaque instability in patients with plaque rupture through the release of metalloproteinases and the inhibition of collagen synthesis that in turns lead to fibrous cap degradation. However, the clinical relevance of macrophage infiltration has never been investigated in patients with PE.

Purpose

In our study, we aimed at assessing the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value.

Methods

ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site and in non-culprit segments along the culprit vessel was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03–2.58) years].

Results

We included 153 patients [median age (IQR) 64 (53–75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. In particular, culprit lesion analysis demonstrated that patients with PE with MØI had a significantly thinner fibrous cap [median (IQR) 100 (60–120) μm vs. 160 (95–190) μm, p&lt;0.001], higher prevalence of thrombus [41 (80.4%) vs. 64 (62.7%), p=0.028], lipid plaque [39 (76.5%) vs. 50 (49.0%), p&lt;0.001], TCFA [20 (39.2%) vs. 14 (13.7%), p=0.001], and a higher maximum lipid arc [median [IQR] 250.0° (177.5°-290.0°) vs. 190.0° (150.0°-260.0°), p=0.018) at the culprit lesion compared with PE without MØI. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p=0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression model, PE with MØI [HR=2.95, 95% CI (1.09–8.02), p=0.034] was an independent predictor of MACEs.

Conclusion

Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with a more aggressive phenotype of coronary atherosclerosis with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up. These findings are of the utmost importance in the era of precision medicine because clearly show that macrophage infiltrates may identify patients with a higher cardiovascular risk requiring more aggressive secondary prevention therapies and a closer clinical follow-up.

Prognosis

Funding Acknowledgement

Type of funding source: None

Ticagrelor and preconditioning in patients with stable coronary artery disease (TAPER-S): a randomized pilot clinical trial

Background

Ticagrelor is a reversibly binding, direct-acting, oral, P₂Y₁₂ antagonist used for the prevention of atherothrombotic events in patients with coronary artery disease (CAD). Ticagrelor blocks adenosine reuptake through the inhibition of equilibrative nucleoside transporter 1 (ENT-1) on erythrocytes and platelets, thereby facilitating adenosine-induced physiological responses such as an increase in coronary blood flow velocity. Meanwhile, adenosine plays an important role in triggering ischemic preconditioning through the activation of the A1 receptor. Therefore, an increase in ticagrelor-enhanced adenosine bioavailability may confer beneficial effects through mechanisms related to preconditioning activation and improvement of coronary microvascular dysfunction.

Methods

To determine whether ticagrelor can trigger ischemic preconditioning and influence microvascular function, we designed this prospective, open-label, pilot study that enrolled patients with stable multivessel CAD requiring staged, fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI). Participants will be randomized in 1:1 ratios either to ticagrelor (loading dose (LD) 180 mg, maintenance dose (MD) 90 mg bid) or to clopidogrel (LD 600 mg, MD 75 mg) from 3 to 1 days before the scheduled PCI. The PCI operators will be blinded to the randomization arm. The primary endpoint is the delta (difference) between ST segment elevations (in millimeters, mm) as assessed by intracoronary electrocardiogram (ECG) during the two-step sequential coronary balloon inflation in the culprit vessel. Secondary endpoints are 1) changes in coronary flow reserve (CFR), index of microvascular resistance (IMR), and FFR measured in the culprit vessel and reference vessel at the end of PCI, and 2) angina score during inflations. This study started in 2018 with the aim of enrolling 100 patients. Based on the rate of negative FFR up to 30% and a drop-out rate up to 10%, we expect to detect an absolute difference of 4 mm among the study arms in the mean change of ST elevation following repeated balloon inflations. All study procedures were reviewed and approved by the Ethical Committee of the Catholic University of Sacred Heart.

Discussion

Ticagrelor might improve ischemia tolerance and microvascular function compared to clopidogrel, and these effects might translate to better long-term clinical outcomes.

Trial registration

EudraCT No. 2016–004746-28. No. NCT02701140. 

Trial status

Information provided in this manuscript refers to the definitive version (n. 3.0) of the study protocol, dated 31 October 2017, and includes all protocol amendments. Recruitment started on 18 September 2018 and is currently ongoing. The enrollment is expected to be completed by the end of 2019.

Trial sponsor

Fondazione Policlinico Universitario A. Gemelli – Roma, Polo di Scienze Cardiovascolari e Toraciche, Largo Agostino Gemelli 8, 00168 Rome, Italy.

100Culprit plaque morphology in patients with and without preinfarction angina: an optical coherence tomography imaging study

Background

The relation between culprit plaque morphology and the clinical presentation of an acute myocardial infarction (AMI) has not been examined in detail.

Purpose

To study the culprit plaque morphology in patients with AMI with or without preinfarction angina using optical coherence tomography (OCT) imaging.

Methods

A total of 102 patients with AMI (32 STEMI, 70 NSTEMI) who underwent OCT imaging before percutaneous coronary intervention were enrolled. Patients were classified as: i) having either intermittent chest pain in the six hours preceding the final episode of pain, or unstable angina (or both) in the week preceding AMI (preinfarction angina group); or ii) having a single episode of chest pain without unstable symptoms in the preceding week (no preinfarction angina group). Culprit plaque was classified as plaque rupture (PR) or intact fibrous cap (IFC), as previously described. Prati thrombus score was calculated, and the prevalence of calcification, neovascularization, and OCT-defined macrophage accumulation was assessed.

Results

Patients with preinfarction angina showed a significantly higher prevalence of IFC than PR, while those without preinfarction angina showed a significantly higher prevalence of PR than IFC (Figure). PR in patients with preinfarction angina were more frequently associated with macrophage accumulation, while those in patients without preinfarction angina were not (Figure). White thrombus tended to be more frequent in patients with preinfarction angina than in those without (85.7% vs. 63.6%, p=0.097), and Prati thrombus score tended to be lower [22.0 (15.8–30.3) vs. 38.5 (12.8–67.5), p=0.145]. Calcifications were significantly less frequent in patients with preinfarction angina than in those without (22.0% vs. 40.4%, p=0.045), while neovascularization tended to be more frequent (58.0% vs. 42.3%, p=0.113).

Conclusions

Patients with preinfarction angina have a distinct culprit plaque phenotype, frequently characterized by IFC and a relatively lower thrombotic burden, probably reflecting a prevalence of reparative mechanisms and spontaneous thrombolytic activity in these patients.

Drug eluting stent and coronary chronic total occlusions

Chronic total occlusion (CTO) is a common finding on diagnostic coronary angiography and represents one of the most challenging lesion subset in interventional cardiology. The introduction of dedicated guidewires and the development of new techniques have led to improve the success rate in the crossing of CTO lesion while the use of bare metal stent first, and, then, the use of drug eluting stent (DES) have significantly reduced the occurrence of restenosis and the need for target lesion revascularization in short and mid-term follow-up after CTO recanalization. However, new unsolved issues about the use of DES in CTO, that might impact long-term outcome, are emerging. The aim of this article is to review the current stage of knowledge on the application of stents in the treatment of CTO, with a particular attention to DES use and to DES-related challenges.

Sirolimus, Tacrolimus and Zotarolimus eluting stents to treat bifurcated lesions: a 7-month clinical outcome comparison

AIM

Drug eluting stents (DES) have been shown to reduce restenosis compared with bare metal stents in bifurcated lesions. The aim of this study was to evaluate the long-term clinical outcomes of patients with bifurcated lesions treated by 3 different DES.

METHODS

Consecutive patients with symptomatic coronary artery disease on one bifurcated lesion with SB>2.25 mm (on visual estimation) undergoing at the Department of Cardiology of the Catholic University of Rome, Italy were screened. Patients treated with Sirolimus-eluting stent (Cypher Select; SES Group), Tacrolimus-eluting stent (Taxus-Libertè; TA Group) and Zotarolimus-eluting stent (Endeavor Driver; ZOT Group) were enrolled in the study. Clinical and angiographic characteristics of all patients were prospectively recorded. Major adverse clinical events (MACE), including death, acute myocardial infarction (MI) or target lesion revascularization (TVR) by either percutaneous coronary intervention (PCI) or coronary surgery were recorded during the follow-up. Incidence of definite or probable stent thrombosis was calculated according to the ARC criteria.

RESULTS

Two hundred and forty-one consecutive patients were enrolled (89 Group CY, 98 Group TA and 54 Group EN). Length of follow-up was 235+/-60 days. Baseline clinical and angiographic characteristic were similar across the groups. The adopted technique for stent implantation was provisional stenting (73.4%), T-stenting technique (7%), crush (7%) and V-stenting (2.6%). The rate of patients finally treated with two stents was similar among groups. The cumulative rate of MACE (9% SES, 12% TA, 11% ZOT: P=0.7) and of TVR (2% SES, 9% TA, 7% ZOT) was similar among groups. No definite stent thrombosis was observed during follow-up, while 1 probable stent thrombosis was observed in TA group.

CONCLUSION

The clinical outcome of bifurcated lesions using DES and mainly a technique of single stent implantation is good. In the present observational study, clinical adverse events did not differ in patients with bifurcated lesions treated by Cypher, Taxus or Endeavor stent implantation.

Acute myocardial infarction interventional procedures: primary percutaneous coronary intervention versus facilitated percutaneous coronary intervention, rescue angioplasty, rescue excimer laser

ST-elevation myocardial infarction is due to the occlusion of a coronary artery, mainly due to a rupture of an atherosclerotic plaque with superimposed thrombosis. The main therapeutic goal is to restore the blood flow within the culprit artery as quickly as possible. In this review we discussed the several approaches which have been employed to reach this target. Primary percutaneous coronary intervention (PCI) is considered the best treatment option, as it is associated to lower in-hospital mortality, reduced risk of reinfarction and stroke, lower rate of intracranial bleeding and ventricular rupture from myocardial hemorrhage compared with fibrinolytic therapy. Also, it is superior to facilitated PCI, i.e. immediate planned PCI after i.v. thrombolytic therapy administration, because of lower mortality, reinfarction rate, strokes and bleedings. Rescue PCI after failed thrombolysis was associated with a reduction of early severe heart failure and improved survival at 1 year, in patients with moderate to large infarctions, compared to conservative medical therapy, in a pooled analysis of 9 randomized trials, carried out in the balloon era. Also in the stent era, a meta-analysis of 5 randomized trials found a significant 36% reduction in the risk of 30-day mortality, a trend to lower risk of heart failure, although a marginally increased risk of thromboembolic stroke, in the rescue PCI arm. However, rescue PCI is not associated with a better long-term clinical outcome. Laser thrombectomy before PCI could be a useful additional strategy which might be compared to standard stenting in future randomized studies.

Filter no reflow during percutaneous coronary interventions using the Filterwire distal protection device

BACKGROUND

Distal protection devices are increasingly used to prevent embolization during percutaneous coronary interventions (PCI) in saphenous vein grafts (SVG) and native coronary arteries (NV). During interventions with the Filterwire device we have observed reduced flow that is reversible following removal of the filter (filter no reflow, FNR), which might be erroneously interpreted as true no reflow and might be associated with reduced capture efficiency of the basket.

METHODS

We analyzed the incidence of FNR in 58 patients (60 lesions) at high risk of embolization undergoing PCI of either a SVG or a NV using the Filterwire (Boston Scientific, Natick, MA). Qualitative and quantitative angiographic analysis was performed, and the volume of collected debris was estimated using a photographic technique.

RESULTS

In our population, about 1/3 of the cases showed FNR, which was associated with angiographically visible filling defects within the basket, indicating macroembolism. However some patients (especially those undergoing vein graft interventions) showed filling defects without FNR, and some others FNR without filling defects. Thus we tried to understand the predictors of FNR: FNR was associated with higher amount of collected debris (36.97 +/- 42.98 mm(3) vs. 11.31 +/- 18.47 mm(3), p = 0.005), was neither prevented by abciximab, nor predicted by high thrombotic burden, increasing stent volume or need for predilatation. When patient with and without angiographically evident macroembolisation were separately analyzed, a linear correlation of FNR with the quantity of debris was only apparent in the macroembolization group.

CONCLUSIONS

Interventionalists should be aware of the "Filter No Reflow", a common but reversible angiographic complication when the Filterwire device is used. Reduced flow seen during these procedures should be treated conservatively. Mechanical obstruction of the filter, but also other mechanisms (pharmacologically active debris? platelet aggregates?) play a role in this phenomenon.

Heparin dose during percutaneous coronary intervention: how low dare we go?

Despite dramatic advances in percutaneous coronary intervention, including coronary stents and potent antiplatelet agents, unfractionated heparin remains the standard procedural anticoagulant. Tradition and habit may have considerable influence over dose selection. A review of the role and dosage of heparin during PCI appears to be overdue