Objectives The aim of this study was to assess the safety and effectiveness of carotid artery stenting (CAS) with proximal cerebral protection in patients showing string sign at carotid angiography. ...Background Presence of string sign is a well-known factor for adverse events in patients with severe carotid artery disease undergoing CAS. Methods We used retrospective analysis of a cohort of patients who underwent carotid angiography with the intention to undergo carotid stenting and had angiographically documented string sign in the target lesion. Results From October 2006 to August 2007, 25 patients (21 men and 4 women, mean age 70.9 ± 8.7 years) presented with string sign during carotid angiography. This was 6.0% of a total of 416 patients studied during the time of the study. Twenty patients (80.0%) were symptomatic, and 5 (20.0%) were asymptomatic. Carotid artery stenting was performed successively in all patients. Proximal cerebral protection was applied in all but 1 patient. The 30-day death/stroke rate was 0%. At 12-month follow-up neurological events did not occur; 1 patient developed a nonfatal myocardial infarction, and another patient died from noncardiac cause. The 12-month death/stroke rate was 4.0%. Conclusions Carotid stenting under proximal cerebral protection seems to be a feasible and safe procedure to manage patients with severe carotid stenosis in presence of angiographic string sign. Further prospective trials are required to prove efficacy of CAS in larger study populations.
Although oral P2Y12 inhibitors are key in the management of patients with non–ST-segment elevation acute coronary syndrome, the optimal timing of their administration is not well defined.
The purpose ...of this study was to compare downstream and upstream oral P2Y12 inhibitors administration strategies in patients with non–ST-segment elevation acute coronary syndrome undergoing invasive treatment.
We performed a randomized, adaptive, open-label, multicenter clinical trial. Patients were randomly assigned to receive pre-treatment with ticagrelor before angiography (upstream group) or no pre-treatment (downstream group). Patients in the downstream group undergoing percutaneous coronary intervention were further randomized to receive ticagrelor or prasugrel. The primary hypothesis was the superiority of the downstream versus the upstream strategy on the combination of efficacy and safety events (net clinical benefit).
We randomized 1,449 patients to downstream or upstream oral P2Y12 inhibitor administration. A pre-specified stopping rule for futility at interim analysis led the trial to be stopped. The rate of the primary endpoint, a composite of death due to vascular causes; nonfatal myocardial infarction or nonfatal stroke; and Bleeding Academic Research Consortium type 3, 4, and 5 bleeding through day 30, did not differ significantly between the downstream and upstream groups (percent absolute risk reduction: –0.46; 95% repeated confidence interval: –2.90 to 1.90). These results were confirmed among patients undergoing percutaneous coronary intervention (72% of population) and regardless of the timing of coronary angiography (within or after 24 h from enrollment).
Downstream and upstream oral P2Y12 inhibitor administration strategies were associated with low incidence of ischemic and bleeding events and minimal numeric difference of event rates between treatment groups. These findings led to premature interruption of the trial and suggest the unlikelihood of enhanced efficacy of 1 strategy over the other. (Downstream Versus Upstream Strategy for the Administration of P2Y12 Receptor Blockers In Non-ST Elevated Acute Coronary Syndromes With Initial Invasive Indication DUBIUS; NCT02618837)
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Coronary artery aneurysms and coronary ectasia are defined as focal or diffuse dilation of the coronary arteries, respectively. Although frequently silent and detected as incidental findings at ...coronary angiography or computed tomography, coronary aneurysms have been associated with different clinical conditions, including silent ischemia and acute coronary syndromes, and with poor clinical outcomes. The optimal management still remains unsettled, as randomized data are lacking and treatment with either surgical or percutaneous procedures faces significant challenges. This review aims to provide an update on the classification, etiopathogenesis, diagnostic workup, and treatment of aneurysmal coronary disease.
Head-to-Head Comparison of Sirolimus- and Paclitaxel-Eluting Stent in the Same Diabetic Patient With Multiple Coronary Artery
Lesions
A prospective, randomized, multicenter study
Fabrizio Tomai , MD ...1 ,
Bernhard Reimers , MD 2 ,
Leonardo De Luca , MD 1 ,
Alfredo R. Galassi , MD 3 ,
Achille Gaspardone , MD 4 ,
Anna S. Ghini , MD 1 ,
Valeria Ferrero , MD 5 ,
Luca Favero , MD 2 ,
Gaetano Gioffrè , MD 4 ,
Francesco Prati , MD 6 ,
Corrado Tamburino , MD 3 and
Flavio Ribichini , MD 5
1 Division of Cardiology, Department of Cardiovascular Sciences, European Hospital, Rome, Italy
2 Cardiology Department, Mirano Hospital, Mirano, Italy
3 Division of Cardiology, Department of Internal Medicine and Systemic Disease, Ferrarotto Hospital, University of Catania,
Catania, Italy
4 Division of Cardiology, S. Eugenio Hospital, Rome, Italy
5 Institute of Cardiology, University of Verona, Verona, Italy
6 Catheterization Laboratory, S. Giovanni Hospital, Rome, Italy
Address correspondence and reprint requests to Fabrizio Tomai, MD, Division of Cardiology, Department of Cardiovascular Sciences,
European Hospital, Via Portuense 700, 00149 Rome, Italy. E-mail: f.tomai{at}tiscali.it
Abstract
OBJECTIVE —It is still controversial whether sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) are equally effective
in patients with diabetes. In these patients, multiple individual variables may be responsible for neointimal hyperplasia,
thus making difficult the comparison of the two drug-eluting stents (DES).
RESEARCH DESIGN AND METHODS —We designed a prospective, randomized study to compare the efficacy in prevention of restenosis of SES and PES, both implanted
in the same diabetic patient with multiple de novo coronary artery lesions undergoing elective percutaneous coronary intervention.
We enrolled 60 patients with diabetes with at least two significant de novo angiographic stenoses in different coronary segments.
The primary end point was in-stent late luminal loss (LLL) at 8-month angiographic follow-up.
RESULTS —A total of 120 lesions were successfully treated with the randomly assigned DES (SES, n = 60; PES, n = 60). In-stent LLL was lower in the SES than in the PES group (0.26 ± 0.4 vs. 0.50 ± 0.6 mm; P = 0.01). Coronary lesions treated with SES presented a reduced in-stent LLL in 40 (68%) patients, while PES resulted in a
lower in-stent LLL in 19 (32%) patients ( P = 0.0002). At multivariable analysis, the type of DES implanted was the only independent predictor of in-stent LLL (odds
ratio 2.3 95% CI 1.1–5.0; P = 0.03).
CONCLUSIONS —SES directly compared with PES in the same diabetic patient is associated with a decrease in the extent of in-stent LLL at
8 months, suggesting a reduced risk of restenosis.
DES, drug-eluting stents
LLL, late luminal loss
MLD, minimal luminal diameter
PCI, percutaneous coronary intervention
PES, paclitaxel-eluting stent
SES, sirolumus-eluting stent
Footnotes
Published ahead of print at http://care.diabetesjournals.org on 27 September 2007. DOI: 10.2337/dc07-1377.
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore
be hereby marked “advertisement” in accordance with 18 U.S.C Section 1734 solely to indicate this fact.
Accepted September 23, 2007.
Received July 17, 2007.
DIABETES CARE
Background
Redo surgical mitral valve replacement (SMVR) is the current standard of care for patients with failed bioprosthetic mitral valve (MV). Transcatheter mitral valve‐in‐valve replacement ...(TMViV) is arising as an alternative to SMVR in high risk patients. We sought to evaluate procedural safety, early and mid‐term outcomes of patients who underwent transseptal TMViV (TS‐TMViV), transapical TMViV (TA‐TMViV), or redo‐SMVR.
Methods
We identified patients with failed bioprosthetic MV who underwent TS‐TMViV, TA‐TMViV, or SMVR at four Italian Centers. Clinical and echocardiographic data were codified according to Mitral Valve Academic Research Consortium definition (MVARC), except for significant valve stenosis.
Results
Between December 2012 and September 27, 2019 patients underwent TS‐TMViV, 22 TA‐TMViV, and 29 redo‐SMVR. TS‐TMViV and TA‐TMViV patients presented higher mean age and surgical risk scores compared with SMVR group (77.8 ± 12 years, 77.3 ± 7.3 years, 67.8 ± 9.4 years, p < .001; STS PROM 8.5 ± 7.2; 8.9 ± 4.7; 3.6 ± 2.6, p < .001). TS‐TMViV procedure was associated with shorter intensive care unit time and total length of stay (LOS) compared with TA‐TMViV and SMVR group. There were no differences in MVARC procedural success at 30‐days (74.1, 72.7, and 51.7%, p = .15) and one‐year all‐cause mortality between groups (14.8, 18.2, and 17.2%, p = 1.0). MV mean gradient was similar between TS‐TMViV, TA‐TMViV, and SMVR groups at 30 days and 12 months.
Conclusions
For the selected patients, TS‐TMViV and TA‐TMViV are to be considered a valid alternative to redo‐SMVR with comparable 1‐year survival. TS‐TMViV is the less invasive strategy and has the advantage of shortening the LOS compared with TA‐TMViV.
Abstract
Background
The optimal treatment of aneurysmal or ectatic culprit vessels in the setting of acute myocardial infarction is still matter of debate, as revascularization with either ...percutaneous intervention or surgery is associated with low procedural success and poor outcomes.
Case summary
We report the case of a 55-year-old male patient, admitted for inferior ST-elevation myocardial infarction, who underwent successful percutaneous implantation of a micro-mesh self-expanding nitinol carotid stent in a right coronary aneurysm with intravascular ultrasonography measured diameter of 9 mm and massive thrombus apposition.
Discussion
The technical characteristics of the micro-mesh self-expanding nitinol carotid stent allow for adequate plaque coverage and good apposition even in large vessels, making this device particularly suitable for the treatment of coronary lesions with high thrombus burden, when severe coronary ectasia or aneurysms are present.
In 2020, the coronavirus disease 2019 (COVID-19) pandemic has led to a decrease in interventional treatment for structural heart disease worldwide. In this context, the management of patients with ...symptomatic severe aortic stenosis (AS) or bioprosthetic valve dysfunction (BVD) represents a clinical challenge, as a delay in aortic valve replacement procedures may increase short-term morbidity and mortality. We report four cases of TAVR performed in patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. All of them were discharged in good clinical conditions and no adverse events were reported at 30 days follow-up. Our experience suggests that in selected patients with mild SARS-CoV-2 infection and symptomatic native AS or BVD, TAVR has a favorable short-term outcome.
•In 2020, Covid-19 pandemic had led to a 70% reduction of TAVR procedures in Italy•Patients with severe aortic stenosis or bioprosthetic aortic valve disfunction are at high risk of severe adverse events•Heart failure could worsen respiratory symptoms of pulmonary SARS-CoV-2 infection.•Successful TAVR could promote pulmonary exchanges and reduce the risk of respiratory failure and need for intubation
•Structural prosthetic degeneration must be considered when planning TAVR in younger patients.•ViV TAVR is becoming a common procedure which requires specific planning and diagnostic work-up.•One of ...the most troubling issues of ViV TAVR is coronary re-access.•Bioprosthetic tissue failure is modulated by multiple, non-predictable, factors.
Transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve (BAV) stenosis is technically challenging and is burdened by an increased risk of paravalvular regurgitation ...(PVR).
The aim of this study was to identify the incidence, predictors, and clinical outcomes of PVR after TAVR in Sievers type 1 BAV stenosis.
Consecutive patients with severe Sievers type 1 BAV stenosis undergoing TAVR with current-generation transcatheter heart valves (THVs) in 24 international centers were enrolled. PVR was graded as none/trace, mild, moderate, and severe according to echocardiographic criteria. The endpoint of major adverse events (MAEs), defined as a composite of all-cause death, stroke, or hospitalization for heart failure, was assessed at the last available follow-up.
A total of 946 patients were enrolled. PVR occurred in 423 patients (44.7%)—mild, moderate, and severe in 387 (40.9%), 32 (3.4%), and 4 (0.4%) patients, respectively. Independent predictors of moderate or severe PVR were a larger virtual raphe ring perimeter (adjusted OR: 1.07; 95% CI: 1.02-1.13), severe annular or left ventricular outflow tract calcification (adjusted OR: 5.21; 95% CI: 1.45-18.77), a self-expanding valve (adjusted OR: 9.01; 95% CI: 2.09-38.86), and intentional supra-annular THV positioning (adjusted OR: 3.31; 95% CI: 1.04-10.54). At a median follow-up of 1.3 years (Q1-Q3: 0.5-2.4 years), moderate or severe PVR was associated with an increased risk of MAEs (adjusted HR: 2.52; 95% CI: 1.24-5.09).
After TAVR with current-generation THVs in Sievers type 1 BAV stenosis, moderate or severe PVR occurred in about 4% of cases and was associated with an increased risk of MAEs during follow-up.
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