Our aim was to compare three-dimensional (3D) and 2D and 3D speckle-tracking (2D-STE, 3D-STE) echocardiographic parameters with conventional right ventricular (RV) indexes in patients with chronic ...pulmonary hypertension (PH), and investigate whether these techniques could result in better correlation with hemodynamic variables indicative of heart failure.
Seventy-three adult patients (mean age, 53±13 years; 44% male) with chronic PH of different etiologies were studied by echocardiography and cardiac catheterization (25 precapillary PH from pulmonary arterial hypertension, 23 obstructive pulmonary heart disease, and 23 postcapillary PH from mitral regurgitation). Thirty healthy subjects (mean age, 54±15 years; 43% male) served as controls. Standard 2D measurements (RV-fractional area change-tricuspid annular plane systolic excursion) and mitral and tricuspid tissue Doppler annular velocities were obtained. RV 3D volumes and global and regional ejection fraction (3D-RVEF) were determined. RV strains were calculated by 2D-STE and 3D-STE. RV 3D global-free-wall longitudinal strain (3DGFW-RVLS), 2D global-free-wall longitudinal strain (GFW-RVLS), apical-free-wall longitudinal strain, basal-free-wall longitudinal strain, and 3D-RVEF were lower in patients with precapillary PH (P<0.0001) and postcapillary PH (P<0.01) compared to controls. 3DGFW-RVLS (hazard ratio 4.6, 95% CI 2.79 to 8.38, P=0.004) and 3D-RVEF (hazard ratio 5.3, 95% CI 2.85 to 9.89, P=0.002) were independent predictors of mortality. Receiver operating characteristic curves showed that the thresholds offering an adequate compromise between sensitivity and specificity for detecting hemodynamic signs of RV failure were 39% for 3D-RVEF (AUC 0.89), -17% for 3DGFW-RVLS (AUC 0.88), -18% for GFW-RVLS (AUC 0.88), -16% for apical-free-wall longitudinal strain (AUC 0.85), 16 mm for tricuspid annular plane systolic excursion (AUC 0.67), and 38% for RV-FAC (AUC 0.62).
In chronic PH, 3D, 2D-STE and 3D-STE parameters indicate global and regional RV dysfunction that is associated with RV failure hemodynamics better than conventional echo indices.
Refractory angina is still a major public health problem. The coronary sinus Reducer (CSR) has recently been introduced as an alternative treatment to reduce symptoms in these patients. The aim of ...this study was to investigate objective improvements in effort tolerance and oxygen kinetics as assessed by cardiopulmonary exercise testing (CPET) in patients suffering from refractory angina undergoing CSR implantation.
In this multicentre prospective study, patients with chronic refractory angina undergoing CSR implantation were scheduled for CPET before the index procedure and at six-month follow-up. The main endpoints of this analysis were improvements in VO2 max and in VO2 at the anaerobic threshold (AT). Clinical events and improvements in symptoms were also recorded. A total of 37 patients formed the study population. The CSR implantation procedure was successful and without complications in all. At follow-up CPET, significant improvement in VO2 max (+0.97 ml/kg/min +11.3%; 12.2±3.6 ml/kg/min at baseline vs 13.2±3.7 ml/kg/min, p=0.026), and workload (+12.9 +34%; 68±28 W vs 81±49 W, p=0.05) were observed, with non-significant differences in VO2 at the AT (9.84±3.4 ml/kg/min vs 10.74±3.05 ml/kg/min, p=0.06). Canadian Cardiovascular Society (CCS) grade improved from a mean of 3.2±0.5 to 1.6±0.8 (p<0.01), and significant benefits in all Seattle Angina Questionnaire variables were shown.
In patients with obstructive coronary artery disease suffering from refractory angina, the implantation of a CSR was associated with objective improvement in exercise capacity and oxygen kinetics at CPET, suggesting a possible reduction of myocardial ischaemia.
Objectives
In this retrospective observational study, we investigate outcome of patients treated with or without covered stent (CS) implantation in the management of coronary artery perforation (CAP) ...during coronary intervention.
Background
CSs have shown to be effective devices to achieve acute hemostasis in large CAP. However, doubts have been raised regarding their long‐term outcome.
Methods
Data of 19 061 PCI procedures during a 10‐year period were reviewed. Fifty‐five cases of large CAP were withheld (Ellis type 2, 3 or cavity spilling). All medical and procedural records of these cases were retrospectively reviewed.
Results
Twenty‐four (43.6%) patients were treated with CS implantation (15 polytetrafluoroethylene and 9 pericardium CSs). Twenty‐six (47.3%) patients were managed without CS implantation, of whom five had unsuccessful delivery of a CS (stent delivery failure 17.2%). Although significantly more Ellis type‐3 perforations were present in the CS group compared to the Non‐CS group (75.0% vs 45.2%; P = 0.03), in‐hospital mortality was not significantly different (8.3% vs 6.4%; P = 0.79). We observed a high rate of CS restenosis (29.2%) but a lower rate of CS thrombosis (4.2%). Despite these observations, 5‐year MACE and all‐cause mortality were not significantly different between CS and Non‐CS group (respectively, 58.8% vs 50.0% (P = 0.26) and 26.7% vs 13.3% (P = 0.36)).
Conclusion
Although deliverability of CSs was not flawless and a high rate of CS restenosis appeared, short‐ and long‐term outcome were comparable between patients treated with or without CS. Therefore, CSs are justifiable in the treatment of CAP.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Carotid artery angioplasty and stenting (CAS) is an established procedure to treat carotid artery stenosis for either primary or secondary prevention of stroke. Randomized clinical trials have shown ...an increased risk of periprocedural cerebrovascular events with CAS compared with carotid endarterectomy (CEA). Several strategies have been proposed to mitigate this risk, including alternative vascular access site, proximal/distal embolic protection devices, and dual-layer stents, among others.
This review provides a general overview of current embolic protection strategies for CAS. The phases of the procedure which can affect the early risk of stroke and how to reduce it with novel techniques and devices have been discussed.
Innovations in device technologies have dramatically improved the safety and efficacy of CAS. To minimize the gap with surgery, a thorough, patient-oriented approach should be pursued. Endovascular technologies and techniques should be selected on an individual basis to address unique lesion characteristics and vascular anatomies. Meticulous pre-procedural planning, both clinical and anatomical, is needed to assess the embolic risk of each procedure. Only by having an in-depth understanding of the wide range of available endovascular devices and techniques, the operator will choose the most appropriate strategy to optimize CAS results.
Abstract
Background
Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative to long-term oral anticoagulation with vitamin K antagonists (VKA) or direct ...oral anticoagulants (DOAC) for stroke prevention in patients with non-valvular atrial fibrillation.
Methods
We searched PubMed and Embase for randomized controlled trials (RCT) comparing 3 different strategies (DOAC vs VKA, LAAC vs VKA, LAAC vs DOAC). Treatment effects were calculated from a network meta-analysis using random-effect model with inverse-variance weighting. The ranking probability of each treatment was based on SUCRA. The primary endpoint was a composite of stroke or systemic embolism.
Results
A total of 7 RCTs and 73,106 patients were included. The risk of the primary endpoint was comparable between LAAC and oral anticoagulation (LAAC vs VKA: OR 0.87, 95% CI 0.55-1.39; LAAC vs DOAC: OR 1.00, 95% CI 0.62-1.61) while it was reduced with DOAC vs VKA (OR 0.87, 95% CI 0.77-0.98). Major bleeding was numerically lower with LAAC vs VKA (OR 0.74, 95% CI 0.48-1.16) and similar between LAAC and DOAC (OR 0.93, 95% CI 0.61-1.42). LAAC significantly reduced the risk of mortality compared with both VKA (OR 0.52, 95% CI 0.37-0.73) and DOAC (OR 0.58, 95% CI 0.42-0.82). The probability of being the best treatment for stroke or systemic embolism prevention was similar for DOAC (51%) and LAAC (48%) whereas LAAC ranked as best treatment for reducing major bleeding (64%) and mortality (100%).
Conclusions
LAAC is a safe and effective alternative to DOAC and VKA for the secondary prevention of patients with non-valvular atrial fibrillation.
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