Three-Dimensional Electroanatomical Voltage Mapping and Histologic Evaluation of Myocardial Substrate in Right Ventricular Outflow Tract Tachycardia Domenico Corrado, Cristina Basso, Loira Leoni, ...Barbara Tokajuk, Pietro Turrini, Barbara Bauce, Federico Migliore, Andrea Pavei, Giuseppe Tarantini, Massimo Napodano, Angelo Ramondo, Gianfranco Buja, Sabino Iliceto, Gaetano Thiene Twenty-seven patients (15 men and 12 women, age 33.9 ± 8 years) with right ventricular outflow tract (RVOT) tachycardia and no right ventricular (RV) dilation/dysfunction were studied by electroanatomical voltage mapping (EVM) and endomyocardial biopsy (EMB) before catheter ablation. Right ventricular EVM was normal in 20 of 27 patients (74%, group A), whereas the other 7 patients (26%, group B) showed RVOT electroanatomical scars that correlated with fibrofatty myocardial replacement at EMB (p < 0.001). Three of 7 patients (43%) from group B received an implantable defibrillator during the follow-up, compared with no patients from group A (p = 0.012). Electroanatomical voltage mapping is able to identify RVOT tachycardia due to concealed arrhythmogenic RV cardiomyopathy/dysplasia.
Although transcatheter aortic valve implantation (TAVI) for severe aortic stenosis is becoming an established technique, the effect of gender-related differences is poorly described. We performed a ...gender-based comparison of high-risk patients undergoing TAVI with the self-expandable CoreValve Revalving System for severe aortic stenosis to evaluate early and mid-term clinical outcomes. From the Italian prospective CoreValve registry, 659 consecutive patients (55.8% women) who underwent TAVI were included in the present study. We analyzed the gender-based differences in terms of clinical, angiographic, and procedural features and the differences in the rate of early and mid-term major adverse cardiac and cerebrovascular events. The men were younger, presented more often with severe left ventricular dysfunction, and had a greater rate of previous myocardial infarction, coronary revascularization, peripheral artery disease, renal failure, and heart conduction disorders than the women. The logistic European System for Cardiac Operative Risk Evaluation score did not differ between the 2 groups. The overall unadjusted and adjusted analyses failed to show significant differences between genders in terms of major adverse cardiac and cerebrovascular events at a median follow-up of 13 months (range 8 to 18). At late follow-up (landmark analysis >12 months), a survival benefit was observed in women (hazard ratio 0.27, 95% confidence interval 0.09 to 0.84, p = 0.02). In conclusion, in this multicenter registry, the gender-based comparison of TAVI patients showed that men, despite the younger age, had more extensive atherosclerotic burden compared to women. Overall, the early and mid-term outcomes were similar between genders, although women might have a survival benefit with longer follow-up.
Transcatheter Valve-in-Valve Implantation Using CoreValve Revalving System for Failed Surgical Aortic Bioprostheses Francesco Bedogni, Maria Luisa Laudisa, Samuele Pizzocri, Corrado Tamburino, Gian ...Paolo Ussia, Anna Sonia Petronio, Massimo Napodano, Angelo Ramondo, Patrizia Presbitero, Federica Ettori, Gennaro Santoro, Silvio Klugman, Federico De Marco, Nedy Brambilla, Luca Testa CoreValve Revalving System (Medtronic, Minneapolis, Minnesota) implantation could be a valid option for patients with a failed aortic bioprosthesis deemed at prohibitive risk for surgical redo. In this multicenter consecutive cohort of 25 patients, the CoreValve Revalving System was feasible and effective regardless of the prevalent cause of failure (regurgitation or stenosis), with excellent procedural success and a considerable 6-month survival rate. These results can significantly affect the treatment of such a high-risk population.
The purposes of this study were to assess the ex vivo cardiovascular magnetic resonance (CMR) signals of pathologically proved hemorrhagic myocardial infarction (MI) and to correlate these with in ...vivo CMR findings. Late gadolinium hypoenhancement within a hyperenhanced area in reperfused acute MI is ascribed to severe microvascular obstruction. The hearts of 2 patients, who died from cardiogenic shock after acute MIs and who had undergone coronary recanalization and in vivo CMR, were examined by T2 and T1 late enhancement sequences as well as by gross and histologic investigation. Four corresponding short-axis slices of each cardiac specimen from the base to the left ventricular apex were selected to assess the extent of MI and hemorrhage and were compared with the in vivo T2 and late enhancement CMR scans. On pathologic examination, the extent of MI was 57 ± 30% and 44 ± 24%, and the extent of hemorrhage was 23 ± 13% and 19 ± 8% of the left ventricular area, respectively, showing progressive increases from the base to the apex. The low-signal intensity areas observed by ex vivo T2 CMR strongly correlated with the hemorrhage quantified on histology (R = 0.93, p = 0.0007). Using ex vivo late gadolinium sequences, bright areas surrounded by thin dark rims, consistent with magnetic susceptibility effects, were detected, corresponding with hemorrhage. On in vivo CMR images, low-signal intensity and hyperintense areas with peripheral susceptibility artifacts were observed within the MI core on T2 and late gadolinium sequences, respectively. In conclusion, in reperfused MI, CMR hypointense T2 signal and susceptibility effects within the late gadolinium hypoenhanced areas are consistent with interstitial hemorrhage due to irreversible vascular injury, as proved by pathologic study.
The aim of this study was to compare long term clinical outcome after left main stenting in a large real world population of patients treated with drug-eluting stents (DES) or bare-metal stents (BMS) ...in the setting of acute coronary syndromes. The advent of DES decreased the risk of unprotected left main coronary artery restenosis as compared with BMS, but safety concerns still exist, especially when high-risk patients presenting with acute coronary syndromes are considered. The Gruppo Italiano Studi Emodinamici-Societa' Italiana di Cardiologia Invasiva (GISE-SICI) registry is a retrospective, observational multicenter registry promoted by the Italian Society of Invasive Cardiology in which 19 high-volume participating centers enrolled 1,453 consecutive patients who underwent percutaneous coronary intervention on unprotected left main coronary artery between January 2002 and December 2006. From the registry, a total of 849 consecutive patients presenting with unstable angina or non–ST-segment elevation myocardial infarction who underwent DES (n = 611) or BMS (n = 238) implantation were analyzed with extensive multivariable and propensity-score adjustments. At 3-year follow-up, the adjusted hazard ratio for the risk of mortality after DES implantation relative to BMS implantation was 0.90 (95% confidence intervals CI 0.59 to 1.38, p = 0.617), and the adjusted hazard ratio for the risk of cardiac mortality was 0.75 (95% CI 0.45 to 1.27, p = 0.287). DES were associated with significant reduction of myocardial infarction (hazard ratio 0.37, 95% CI 0.17 to 0.81, p = 0.009) and target lesion revascularization rates (hazard ratio 0.38, 95% CI 0.21 to 0.69, p = 0.001). Younger age, low ejection fraction, an increase in the cardiac biomarkers, absence of diabetes, and bifurcations showed a significant interaction with assigned treatment regarding myocardial infarction. The treatment effects on target lesion revascularization were consistent across multiple subgroups, with the possible exception of patients with nonbifurcational lesions. In conclusion, in a large population of patients with acute coronary syndromes and unprotected left main coronary artery disease DES were more effective than BMS in reducing myocardial infarction and target lesion revascularization. There was no evidence of a significant reduction in mortality with DES versus BMS.
In this study we investigated the impact of acute coronary syndromes (ACSs) on clinical outcomes in patients with unprotected left main coronary artery (ULMCA) stenosis treated with drug-eluting ...stents (DESs). In this multicenter, retrospective, observational study we enrolled 1,101 patients with ULMCA stenosis treated with DESs. Six hundred eleven patients presented with ACS and 490 had stable coronary artery disease. ACS was defined as the presence of unstable angina or non–ST-segment elevation myocardial infarction (MI). During 2-year follow-up, the adjusted hazard ratio of cardiac mortality and MI of patients with ACS versus stable patients was 2.42 (95% confidence interval 1.37 to 4.28, p = 0.002). We observed a stepwise risk increase, namely patients with stable coronary disease had the lowest risk, patients with unstable angina an intermediate risk, and patients with non–ST-segment elevation MI the highest risk. The increased risk of cardiac mortality and MI of patients with ACS was concentrated in the first year after DES implantation. In conclusion, patients with ULMCA stenosis and ACS treated with DESs have an increased risk of cardiac mortality and MI during the first year after the intervention compared to stable patients.
Objectives The aim of this study was to investigate whether there is a temporal pattern of ischemic events in relation to dual antiplatelet therapy in patients with unprotected left main coronary ...artery (ULMCA) stenosis treated with percutaneous coronary intervention (PCI). Background Identifying which periods during follow-up of patients with ULMCA stenosis treated with PCI are associated with higher risk of clinical events might help to improve therapeutic strategies. Methods We analyzed data from 15 centers involved in an observational study conducted by the Italian Society of Invasive Cardiology on patients with ULMCA stenosis treated with PCI. Eight hundred ninety-four patients were enrolled. Results At 30-day follow-up, the rate of cardiac mortality and myocardial infarction (MI) was 5.4%. In patients still taking dual antiplatelet therapy, the adjusted incidence rate ratio/10,000 patient-days of the combination of cardiac mortality and MI in the 31- to 180-day interval compared with the 181- to 360-day interval after PCI was 3.64 (p = 0.035). This risk was particularly high in patients with acute coronary syndromes. After stopping clopidogrel, the adjusted incidence rate ratio of cardiac mortality and MI in the 0- to 90-day interval compared with the 91- to 180-day interval was 4.20 (p = 0.009). Conclusions In patients with ULMCA stenosis taking dual antiplatelet therapy there is an increased hazard of cardiac mortality and MI between 31 and 180 days compared with 181 to 360 days. Furthermore, there is an increased hazard of cardiac mortality and MI in the first 90 days after stopping clopidogrel.
Determination of coronary flow reserve (CFR) is increasingly being used in cardiac allograft vasculopathy (CAV). We aimed to identify determinants of CFR in heart transplantation (HT).
CFR was ...measured by transthoracic echocardiography in 119 HT recipients (97 men, 22 women; 50 +/- 12 years of age at HT and 8 +/- 5 years post-HT). CFR was expressed as the ratio of hyperemic (adenosine infusion at a rate of 0.14 mg/kg) to basal diastolic flow velocity. Rejection scores (RS) on endomyocardial biopsy were calculated. Angiographic CAV was analyzed using a qualitative grading system. The coronary tree was divided into 17 traits and a CAV severity/diffusion index (SDI) was calculated for each patient, summing the scores assigned to all lesions.
Upon multivariate analysis, CFR was related to CAV (p = 0.001), interventricular septum thickness (p = 0.01), ischemic heart disease pre-HT (p = 0.02) and SDI and SDI/segment number (p < 0.0001 and p = 0.003, respectively). In patients without CAV, CFR was related only to RS for severe grades (p = 0.01).
Left ventricular hypertrophy, CAV and its severity/diffusion independently contribute to reduced CFR. In patients without angiographic CAV, CFR was only independently related to RS. Because a high rejection burden is associated with increased risk of CAV, CFR reduction may be an early marker of CAV. Microvascular dysfunction may contribute to the late morbidity and mortality seen in HT.
Objectives We appraised the incidence and clinical outcomes of patients who were treated with the valve-in-valve (ViV) technique for hemodynamically destabilizing paraprosthetic leak (PPL). ...Background Device malpositioning causing severe PPL after transcatheter aortic valve implantation is not an uncommon finding. It occurs after release of the prosthesis, leading to hemodynamic compromise. It can be managed successfully in selected cases with implantation of a second device inside the malpositioned primary prosthesis (ViV technique). Methods Consecutive patients (n = 663) who underwent transcatheter aortic valve implantation with the 18-F CoreValve ReValving System (Medtronic, Inc., Minneapolis, Minnesota) at 14 centers across Italy were included in this prospective web-based registry. We identified patients treated with the ViV technique for severe PPL and analyzed their clinical and echocardiographic outcomes. Primary end points were major adverse cerebrovascular and cardiac events and prosthesis performance at the 30-day and midterm follow-up. Results Overall procedural success was obtained in 650 patients (98.0%). The ViV technique was used in 24 (3.6%) of 663 patients. The 30-day major adverse cerebrovascular and cardiac event rates were 7.0% and 0% in patients undergoing the standard procedure and ViV technique, respectively (p = 0.185); the mortality rates were 5.6% versus 0% in patients undergoing the standard procedure and ViV technique, respectively (p = 0.238). There was an improvement in the mean transaortic gradient in all patients without significant difference between the 2 groups (from 52.1 ± 17.1 mm Hg and 45.4 ± 14.8 mm Hg p = 0.060 to 10.1 ± 4.2 mm Hg and 10.5 ± 5.2 mm Hg, respectively p = 0.838). At 12 months, the major adverse cerebrovascular and cardiac event rates in the standard procedure and ViV technique groups were 4.5% and 14.1%, respectively (p = 0.158), and the mortality rates were 4.5% versus 13.7%, respectively (p = 0.230). Conclusions This large, multicenter registry provides important information about the feasibility, safety, and efficacy of the ViV technique with the third-generation CoreValve ReValving System. The clinical and echocardiographic end points compare favorably with those of patients undergoing the standard procedure. The ViV technique offers a viable therapeutic option in patients with acute significant PPL without recourse to emergent surgery.
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