Combined ultrasound and angiographic guidance to facilitate transradial access procedures

The introduction of transradial access for percutaneous coronary diagnostic and interventional procedures has led to a decrease in access site complications. The aim of this paper is to propose a combined stepwise technical approach where real time ultrasound ("echo-first" approach) can be used to select the best vascular access and, together with angiography, to manage the potential obstacles that may occur during transradial procedures. In each section, we summarize some tips and tricks based on both our experience and current literature that can be easily implemented in daily practice to increase the success of transradial procedures.

[Myocardial infarction with non-obstructive coronary artery disease: diagnostic work-up in the catheterization laboratory]

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is a heterogeneous clinical condition affecting 5% to 8% of patients presenting with acute myocardial infarction. Initially it was considered a favorable clinical diagnosis, nowadays it is known that MINOCA can significantly affect patient quality of life and portends a guarded prognosis. Therefore, it is of utmost importance to identify the specific pathophysiological mechanism underlying this clinical condition in order to set up a targeted pharmacological and non-pharmacological therapy. Coronary angiography is still a mandatory diagnostic test to rule out obstructive coronary artery disease but has limited capability to identify other potential functional and structural etiologies of MINOCA. The purpose of this review is to provide an overview of the invasive diagnostic work-up of patients with MINOCA, highlighting the diagnostic tools warranted beyond coronary angiography inside the cath lab (intracoronary provocation tests, intracoronary imaging and indexes for the assessment of coronary microvascular dysfunction), and the remaining essential knowledge gaps in this field.

Under-deployment of extra-large drug-eluting stent: an adapted provisional technique for selected patients with distal lesions in large left main

BACKGROUND

In provisional technique, main vessel (MV) drug-eluting stent (DES) diameter is usually selected according to distal MV to reduce carina shift. Proximal optimization technique (POT) is used to expand the DES in the proximal MV. Occasionally, the size discrepancy between left main (LM) and left anterior descending artery (LAD) may be huge and this may cause stent malapposition and poor vessel wall coverage in large-sized LM. Recently, some manufactures designed extra-large DES to treat large vessels.

METHODS

We developed an "adapted" provisional strategy based on under-deployment of extra-large DES in case of major size mismatch between LM and proximal LAD. Bench tests were realized in appropriately designed LM bifurcation model using an extra-large DES (Onyx XL, Medtronic, Santa Rosa, CA, USA). This technique was adopted when such "rare" anatomy was found in our clinical practice.

RESULTS

At bench test, Onyx XL 4.5 mm stent reaches 3.8 mm at 5-6 atmospheres, with favorable stent deformation achieved after POT, kissing balloon and re-POT. This technique was performed in 10 patients undergoing unprotected LM stenting with large LM and major mismatch toward LAD. Angiographic success was achieved in all cases and optical coherence tomography assessment was performed in 5 patients revealing optimal stent result. After a follow-up of 557 days (range: 90-1369 days), clinical course was uneventful in all treated patients.

CONCLUSIONS

Under-deployment of extra-large DES is a technical option that can be considered to optimize the provisional stenting technique in selected patients with major diameter mismatch between large-sized LM and LAD.

[e-Health, telemedicine and applications in cardiology: state of the art in Italy and experience of the cardiology unit of the G.B. Grassi Hospital of Rome]

e-Health (electronic health) refers to the use of information and communication technologies (ICT) to promote organizational change and facilitate new healthcare skills. In the last few years, several telemedicine services using ICT have been launched and the updating of related regulations has started, also for the increase in demand for services, their complexity and the need to offer adequate care to the patient. In cardiology, the experiences concern mainly patients suffering from heart failure or the carriers of cardiac implantable electronic devices (CIEDs), and few experiences are described in ischemic heart disease. In this article we present the design, the implementation and the results of the telemedicine service at the Cardiology Unit of the G.B. Grassi Hospital in Rome, concerning follow-up televisits for patients with heart failure, ischemic heart disease and for management of treatment plans, telemonitoring and telecontrol of CIEDs carriers and teleconsultation in ischemic heart disease. The considerations of this review, the experiences reported and the speed of digital evolution make the implementation of existing practices and the redesign of new pathways necessary.

Coronary microvascular dysfunction beyond microvascular obstruction in ST-elevation myocardial infarction: Functional and clinical correlates

OBJECTIVES

To retrospectively characterize clinical predictors and impact on left ventricular (LV) ejection fraction (EF) of microvascular dysfunction (MVD) beyond microvascular obstruction (MVO), in 49 consecutive patients (58 ± 11 years), with successfully treated ST-elevation myocardial infarction.

METHODS

By myocardial contrast echocardiography, MVD was considered as myocardial segments with delayed/patchy opacification, while MVO as areas without any opacification. Both MVD and MVO were planimetered and expressed as percentage of total LV wall area. Patients were divided into tertiles of MVO: I (MVO 0%), II (MVO 4-17%), and III (MVO 18-38%) groups. Cardiac troponin T (cTnT) values obtained at admission and at peak were considered for analysis.

RESULTS

MVD correlated inversely with EF in groups I and II (p = 0.025, p = 0.019, respectively), but not in group III. MVD was independently predicted by cTnT on admission (β = 1.85; 95%CI = 0.46-3.24, p = 0.011) and female sex (β for male sex = -14.46; 95% CI = -27.96-0.95), while MVO by anterior MI (β = 0.57; 95% CI = 0.26-0.88, p = 0.008) and peak cTnT (β = 0.97; 95%CI = 0.57-1.38, p < 0.001). Altogether, MVD plus MVO predicted EF (β = -0.18; 95%CI = -0.28--0.07, p = 0.002).

CONCLUSIONS

Even in patients with limited amount of MVO, EF may be impaired by MVD. MVO and MVD have different predictors, which probably reflect their different pathogenesis.

Correlation between frequency-domain optical coherence tomography and fractional flow reserve in angiographically-intermediate coronary lesions

BACKGROUND

The decision-making process of patients with angiographically-intermediate coronary lesions (ICL) is clinically challenging and may benefit from adjunctive invasive techniques. Fractional-flow-reserve (FFR) represents the gold standard to evaluate ICL but frequency-domain optical-coherence-tomography (OCT) is a novel, promising, high resolution coronary imaging technique, which allows physiopathologic assessment of coronary plaque. We investigated the possible relation between OCT and FFR in selected ICL patients.

METHODS

Stable or unstable patients with ICL who underwent both FFR and OCT assessment at two large tertiary centers were retrospectively enrolled. FFR was performed according to standard methodology. OCT images were (on blind to clinical and FFR results) analyzed to assess minimal lumen area (MLA), percentage area stenosis (AS), thrombus and plaque ulceration.

RESULTS

Forty patients were identified (62±10years, 93% symptomatic, 35% acute presentation, 93% left-anterior-descending artery ICL). Percentage diameter stenosis at quantitative coronary angiography was 40±12% and FFR was 0.85±0.07. MLA (p=0.009), AS (p<0.001) and plaque ulceration (p=0.02) were significantly associated with FFR values. An integrated assessment of AS (≥ or <70%), MLA (≥ or <2.5mm²) and presence or absence of thrombus and plaque ulceration was found to have the potential to accurately (sensitivity 91%, specificity 93%) predict FFR results.

CONCLUSION

In patients with ICL, a combination of different OCT parameters may help predict FFR results. These findings suggest that only a comprehensive assessment of lesion features by OCT can allow an accurate prediction of lesion severity assessed by FFR.

Hemodynamics and its predictors during Impella-protected PCI in high risk patients with reduced ejection fraction

BACKGROUND

Percutaneous ventricular-assistance by Impella (IMP) represents an emerging strategy to manage patients with reduced left-ventricular (LV) ejection-fraction (EF) undergoing percutaneous-coronary-intervention (PCI). The hemodynamic behave during IMP-protected PCI has been scarcely investigated.

METHODS

We reviewed the IMP console's function and hemodynamic data (which are continuously recorded during assistance) in a consecutive series of 37 patients who underwent elective IMP-protected PCI in two high-volume centers. All patients had multivessel disease and impaired LVEF. Coronary artery disease burden was graded using the British-Cardiovascular-Intervention-Society jeopardy-score (BCIS-JS) score. IMP motor speed and pressure signals (systolic blood pressure, SBP, and mean blood pressure, MBP) were analyzed. Primary hemodynamic end-points were "critical systolic blood pressure (SBP) drop" (SBP decrease ≥ 20 mm Hg reaching ≤90 mm Hg values) and "critical mean blood pressure (MBP) drop" (MBP decrease reaching ≤60 mm Hg).

RESULTS

Over mean assistance duration of 254 ± 549 min, no IMP motor drop occurred. During PCI, SBP and MBP significantly decreased but all patients had SBP values >78 mm Hg. Critical SBP and MBP drops occurred in 10.8% of patients. Among all baseline and procedural characteristics, BCIS-JS was the only significant predictor of SBP drop (p = 0.001) while BCIS-JS and LV end-diastolic volume significantly predicted MBP drop (p = 0.001 for both).

CONCLUSIONS

In patients with reduced EF undergoing IMP-protected PCI, a significant pressure decrease occurs during PCI but pressure is systematically maintained at levels warranting vital organ perfusion. Critical pressure drops during PCI occur in some patients with higher jeopardized myocardium and left ventricular diastolic volumes.

Data on optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions

The data presented in this article are related to the research article entitled “Optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions: early clinical experience” [1].

In this article we reports details about our clinical experience with frequency domain-optical coherence tomography (FD-OCT) guidance for the management of patients with left main (LM) bifurcation lesions of intermediate angiographic severity. LM patients were assessed by FD-OCT and, on the bases of the findings, managed by myocardial revascularization or conservative treatment (revascularization deferral). The observed outcomes support the feasibility of FD-OCT guidance for LM bifurcated lesions and call for further clinical evaluations in appropriately designed prospective studies.

Rapid-deployment or transcatheter aortic valves in intermediate-risk patients?

Background Transcatheter aortic valve implantation and rapid-deployment aortic valve replacement represent two emerging therapies for patients with intermediate surgical risk and severe aortic stenosis. However, head-to-head comparisons between such novel therapies are lacking. Methods Severe aortic stenosis patients with intermediate surgical risk treated with rapid-deployment valve replacement at our institution were identified and compared with a propensity-matched population of patients who underwent transcatheter aortic valve replacement. Postoperative echocardiographic findings, in-hospital and midterm clinical outcomes were compared. Results We identified 60 patients who received transcatheter ( n = 30) or rapid-deployment ( n = 30) valve replacement. On postoperative echocardiography, freedom from paravalvular regurgitation was higher in the rapid-deployment valve group ( p < 0.001), while postoperative mean transprosthetic gradient was lower in the transcatheter valve group ( p = 0.03). Permanent pacemaker implantation was required more frequently in transcatheter valve patients ( p = 0.01). Postoperative atrial fibrillation was more common in the rapid-deployment valve group ( p = 0.03). Hospital mortality was similarly low in both groups ( p = 0.33). At midterm follow-up, mortality was comparable ( p = 0.42) but the rapid-deployment valve group still had a lower degree of paravalvular regurgitation. Conclusions Transcatheter and rapid-deployment valve replacement are promising treatment options for patients with intermediate surgical risk. These two techniques are associated with specific patterns of prosthesis function and postoperative complications. Further evaluation of the clinical impact of these therapies in this patient population is needed.

An update on radial approach for percutaneous coronary intervention in patients with chronic total occlusion

Radial approach is the emerging arterial access for percutaneous coronary interventions (PCIs) in patients with coronary artery disease. Among the different subset of complex targets for PCI, chronic total occlusion (CTO) still represent a challenge for the interventional cardiologist. Is radial approach suitable for PCI on CTO? A series of data collected in selected centers with high volume of transradial procedures supported the change from elective transfemoral approach to systematic transradial approach. In this paper, we tried to provide an update on the technical aspects and the theoretical data which may be useful during the planning of CTO procedures. Overall, a full knowledge of upper limb vascular anatomy, arterial sheaths/guiding catheters selections, transradial PCI technique and CTO lesion management skill is pivotal to safely offer CTO patients the potential benefit of reduced bleeding risks through radial access adoption.

Combining balloon-assisted tracking and sheathless guiding catheter: unloosening the Gordian knot

In a patient with a small-calibre radial artery and a 360° radio-ulnar loop, we combined the balloon-assisted tracking (BAT) technique (used to track a catheter trough the loop) with the use of a 6.5FPB sheathless guiding catheter, in order to allow the extensive catheter manipulations needed for PCI despite the ongoing artery spasm.

Positron emission tomography in acute coronary syndromes

Several imaging techniques have been used to assess cardiac structure and function, to understand pathophysiology, and to guide clinical decision making in the setting of acute coronary syndromes (ACS). Over the last years, cardiac positron emission tomography (PET) has affirmed its role in this setting. Indeed, the combined quantitative assessment of myocardial metabolism and perfusion has allowed to better understand the functional status of infarcted and non-infarcted myocardium, thus improving our knowledge of myocardial response to necrosis. More recently, several studies, taking advantage of previous observations in patients with cancer, have shown that PET could also provide important information on the mechanisms of vascular instability through the early identification of activated inflammatory cells in the atherosclerotic plaque. These findings are opening the way to more effective forms of prevention of acute vascular syndromes in high-risk patients; furthermore, new more sensitive and specific tracers for the identification of vascular inflammation are under development. In this review, we describe the potential and limitations of PET in the assessment of ACS.

Determinants of microvascular damage recovery after acute myocardial infarction: results from the acute myocardial infarction contrast imaging (AMICI) multi-centre study

AIMS

Microvascular damage (MD) occurring soon after primary percutaneous coronary intervention (PPCI) may reverse or remain sustained within the first week after ST-elevation myocardial infarction (STEMI). We investigated the incidence, determinants, and long-term clinical relevance of MD reversal after PPCI.

METHODS AND RESULTS

Serial two-dimensional echocardiograms (2DE) and a myocardial contrast study were obtained within 24 h of PPCI (T1) and at pre-discharge (T2) in 110 successfully re-perfused STEMI patients. Six months 2DE and 2-year clinical follow-up were obtained. After PPCI myocardial re-perfusion was normal at T1 only in 40 patients (36%, 'normal reflow'), recovered at T2 in 33 (30%, 'reversible MD'), and remained abnormal in 37 (34%, 'sustained MD'). At follow-up, normal reflow and reversible MD were coupled with a significant reduction in the infarct area, decrease in cardiac volumes, and a slight non-significant improvement in systolic function. Conversely, in the sustained MD group, the infarct area did not change and cardiac volumes significantly increased with a parallel worsening in systolic function. By multivariate analysis, independent predictors of reversible MD were: absence of family history of coronary artery disease (CAD), younger age, shorter time to re-perfusion, and absence of diabetes. The 2-year combined events rate was significantly lower in reversible MD (log-rank test P= 0.03) compared with sustained MD patients.

CONCLUSIONS

In STEMI patients treated according to the current guidelines, MD frequently occurs soon after re-perfusion but it is reversible in ~50% of cases and it is associated with a favourable functional and clinical outcome. Family history of CAD, aging, time to re-perfusion, and diabetes are independent predictors of MD reversibility.

Predicting the no-reflow phenomenon following successful percutaneous coronary intervention

In the setting of acute myocardial infarction, early and adequate reopening of an infarct-related artery is not necessarily followed by a complete restoration of myocardial perfusion. This condition is usually defined as ‘no-reflow’. The pathophysiology of no-reflow is multifactorial since extravascular compression, microvascular vasoconstriction, embolization during percutaneous coronary intervention, and platelet and neutrophil aggregates are involved. In the clinical arena, angiographic findings and easily available clinical parameters can predict the risk of no-reflow. More recently, several studies have demonstrated that biomarkers, especially those related to the pathogenetic components of no-reflow, could also have a prognostic role in the prediction and in the full understanding of the multiple mechanisms of this phenomenon. Thus, in this article, we investigate the role of several biomarkers on admission in predicting the occurrence of no-reflow following successful percutaneous coronary intervention.

Reversible coronary microvascular dysfunction: a common pathogenetic mechanism in Apical Ballooning or Tako-Tsubo Syndrome

AIMS

To study coronary microvascular dysfunction as possible pathogenetic mechanism in Apical Ballooning Syndrome (ABS).

METHODS AND RESULTS

Fifteen ABS patients (all women, 68 +/- 14 years) underwent myocardial contrast echocardiography at baseline during adenosine infusion (140 microg/kg/min) and at 1-month follow-up and compared with a group of anterior ST-elevation myocardial infarction (STEMI) patients with similar clinical characteristics. Myocardial perfusion was assessed by contrast score index (CSI) and endocardial length of contrast defect (contrast defect length, CDL), whereas myocardial dysfunction by wall motion score index (WMSI), endocardial length of contractile dysfunction (wall motion defect length, WMDL), and LV ejection fraction (LVEF). At baseline, no difference in myocardial perfusion and dysfunction were present between the two groups. During adenosine challenge, while no changes were observed in STEMI group, in ABS patients CSI, CDL, WMSI, and WMDL significantly decreased compared with baseline (P < 0.001 vs. baseline for all parameters) and LVEF significantly increased (P = 0.01 vs. baseline). At 1-month follow-up, myocardial perfusion and dysfunction completely recovered in ABS patients (P < 0.001 vs. baseline for all parameters), whereas no significant changes were observed in STEMI group.

CONCLUSION

Our data strongly suggest that in ABS, irrespectively of its underlying aetiology, acute and reversible coronary microvascular vasoconstriction could represent a common pathophysiological mechanism.