BACKGROUND—Invasive physiological assessment of myocardial bridges (MBs) is largely unsettled. Unlike fractional flow reserve (FFR), instantaneous wave–free ratio (iFR) is a diastole-specific index. ...As such, its value might not be hampered by systolic pressure overshooting and negative systolic pressure gradient caused by the compression of the tunneled coronary artery.
METHODS AND RESULTS—We prospectively enrolled 20 patients with angina and/or positive noninvasive stress test, absence of significant coronary artery stenosis, and angiographic suspicion/evidence of MB in the left anterior descending artery. According to a prespecified protocol, all patients underwent functional intracoronary evaluation with FFR at rest and after dobutamine (up to 20 μg kg min) and atropine (1 mg) intravenous infusion. iFR at baseline and dobutamine-induced hyperemic wave–free period pressure ratio were also recorded. FFR values ≤0.80 and iFR values ≤0.89 were considered indicative of hemodynamic significance of MB. At baseline, no MB was hemodynamically significant according to FFR, whereas iFR was below the cutoff value in all but 7 patients. During inotropic challenge, median FFR did not change significantly (0.87–0.86, P=0.59).
CONCLUSIONS—Physiological evaluation of MBs with iFR seems to be more consistent with patients’ symptoms and noninvasive test results compared with FFR.
Background Transcatheter aortic valve replacement (TAVR)-in-TAVR is a possible treatment for transcatheter heart valve (THV) degeneration. However, the displaced leaflets of the first THV will create ...a risk plane (RP) under which the passage of a coronary catheter will be impossible. The aim of our study was to evaluate the potential risk of impaired coronary access (CA) after TAVR-in-TAVR. Methods and Results We prospectively performed coronary angiography after TAVR with different THVs in 137 consecutive patients, looking where the catheter crossed the valve frame. If coronary cannulation was achieved from below the RP, the distance between valve frame and aortic wall was measured by aortic angiography. CA after TAVR-in-TAVR was defined as feasible if the catheter passed above the RP, as theoretically feasible if passed under the RP with valve-to-aorta distance >2 mm, and as unfeasible if passed under the RP with valve-to-aorta distance ≤2 mm. Seventy-two patients (53%) received a Sapien 3 THV, 26 (19%) received an Evolut Pro/R THV, and 39 (28%) received an Acurate Neo THV. CA after TAVR-in-TAVR was considered feasible in 40.9% (68.1%, 19.2%, and 5.1%, respectively;
<0.001), theoretically feasible in 27.7% (8.3%, 42.3%, and 53.8%, respectively;
<0.001), and unfeasible in 31.4% (23.6%, 38.5%, and 41.1%, respectively;
=0.116). Independent predictors of impaired CA after TAVR-in-TAVR were female sex (odds ratio OR, 3.99; 95% CI, 1.07-14.86;
=0.040), sinotubular junction diameter (OR, 0.62; 95% CI, 0.48-0.80;
<0.001), and implantation of a supra-annular THV (OR, 6.61; 95% CI, 1.98-22.03;
=0.002). Conclusions CA after TAVR-in-TAVR might be unfeasible in >30% of patients currently treated with TAVR. Patients with a small sinotubular junction and those who received a supra-annular THV are at highest risk of potential CA impairment with TAVR-in-TAVR.
Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite ...prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI-CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.
The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well ...represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex‐based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex‐oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management.
The left ventricular remodeling (LVR) process has limited the effectiveness of therapies after myocardial infarction. The relationship between autoantibodies activating AT1R-AAs (angiotensin II ...receptor type 1-AAs) and ETAR-AAs (autoantibodies activating endothelin-1 receptor type A) with myocardial infarction has been described. Among patients with ST-segment-elevation myocardial infarction, we investigated the relationship between these autoantibodies with LVR and subsequent major adverse cardiac events.
In this prospective observational study, we included 131 patients with ST-segment-elevation myocardial infarction (61±11 years of age, 112 men) treated with primary percutaneous coronary intervention. Within 48 hours of admission, 2-dimensional transthoracic echocardiography was performed, and blood samples were obtained. The seropositive threshold for AT1R-AAs and ETAR-AAs was >10 U/mL. Patients were followed up at 6 months, when repeat transthoracic echocardiography was performed. The primary end points were LVR, defined as a 20% increase in left ventricular end-diastolic volume index, and major adverse cardiac event occurrence at follow-up, defined as cardiac death, nonfatal re-myocardial infarction, and hospitalization for heart failure. Forty-one (31%) patients experienced LVR. The prevalence of AT1R-AAs and ETAR-AAs seropositivity was higher in patients with versus without LVR (39% versus 11%,
<0.001 and 37% versus 12%,
=0.001, respectively). In multivariable analysis, AT1R-AAs seropositivity was significantly associated with LVR (odds ratio OR, 4.66;
=0.002) and represented a risk factor for subsequent major adverse cardiac events (OR, 19.6;
=0.002).
AT1R-AAs and ETAR-AAs are associated with LVR in patients with ST-segment-elevation myocardial infarction. AT1R-AAs are also significantly associated with recurrent major adverse cardiac events. These initial observations may set the stage for a better pathophysiological understanding of the mechanisms contributing to LVR and ST-segment-elevation myocardial infarction prognosis.
The use of percutaneous right ventricular assist devices (pRVADs) to support patients with right ventricular (RV)-predominant cardiogenic shock (CS) refractory to optimal medical therapy is ...increasing progressively, and the Impella RP is the first FDA-approved pRVAD in such a clinical scenario. The aim of the present study is to report the outcomes of patients treated with Impella RP in the IMP-IT (IMPella Mechanical Circulatory Support Device in Italy) registry, a multicenter registry that evaluated the trends in use and clinical outcomes of the Impella in the setting of CS and high-risk percutaneous coronary intervention in Italy. A total of 15 patients who received Impella RP were enrolled. In 40% of the patients, the main cause was ST-segment elevation myocardial infarction. A total of 40% of patients required biventricular support with a left Impella. Device-related complications were reported in 46.7% of patients. Overall, the in-hospital mortality was 46.7%, whereas the one-year mortality was 53.3%. The composite rate of all-cause death, heart failure (HF) hospitalization, left ventricular assist device (LVAD) and heart transplant at one year was 60%. The Impella RP has favorable survival outcomes in RV-predominant cardiogenic shock. However, the device-related complications are frequent and should be carefully weighed when considering escalation to Impella RP.
Background Women represent an increasing percentage of interventional cardiologists in Italy compared with other countries. However, gaps exist in understanding and adapting to the impact of these ...changing demographics. Methods and Results We performed a national survey to analyze demographics, gender-based professional difference, needs in terms of catheterization laboratory (Cath-Lab) abstention, and radiation safety issues in Italian Cath-Lab settings. A survey supported by the Italian Society of Interventional Cardiology (Società Italiana di Cardiologia Interventistica-Gruppo Italiano di Studi Emodinamici SICI-GISE) was mailed to all SICI-GISE members. Categorical data were compared using the χ
test.
<0.05 was considered significant. There were 326 respondents: 20.2% were <35 years old, and 64.4% had >10 years of Cath-Lab experience. Notably, 26.4% were women. Workload was not gender-influenced (women performed "on-call" duty 69.8% versus men 68.3%;
=0.97). Women were more frequently unmarried (22.1% women versus 8.7% men;
=0.002) and childless (43.9% versus 56.1%;
<0.001). Interestingly, 69.8% of women versus 44.6% of men (
<0.001) argued that pregnancy/breastfeeding negatively impacts professional skill development and career advancement. For Cath-Lab abstention, 38.9% and 69.6% of respondents considered it useful to perform percutaneous coronary intervention robotic simulations and "refresh-skill" sessions while they were absent or on return to work, respectively, without gender differences. Overall, 80% of respondents described current radioprotection counseling efforts as inadequate and not gender specific. Finally, 26.7% faced some type of job discrimination, a significantly higher proportion of whom were women. Conclusions Several gender-based differences exist or are perceived to exist among interventional cardiologists in Italian Cath-Labs. Joint strategies addressing Cath-Lab abstention and radiation exposure education should be developed to promote gender equity in interventional cardiologists.
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