A minority of patients with severe acute respiratory syndrome coronavirus 2 (COVID-19) develop cardiovascular complications, such as acute cardiac lesions with elevated troponins, de novo systolic ...heart failure, pericardial effusion and, rarely, acute myocarditis. The prevalence of COVID-19-related myocarditis ranges from 10 to 105 cases per 100,000 COVID-19-infected individuals, with a male predominance (58%) and a median age of 50 years. The etiopathogenetic mechanism is currently unclear, but may involve direct virus-mediated damage or an exaggerated immune response to the virus. Mortality is high, as fulminant myocarditis (FM) develops very often in the form of cardiogenic shock and ventricular arrhythmias. Hence, medical therapy with ACE inhibitors and beta-blockers may not always be sufficient, in which case inotropic and immunosuppressive drugs, most commonly corticosteroids, may be necessary. In this review we analyze the current data on COVID-19 myocarditis, management strategies and therapy, with a brief description of COVID-19 vaccine-associated myocarditis to help clinicians dealing with this peculiar form of myocarditis.
Coronary-Artery Bypass Grafting Alexander, John H; Smith, Peter K
The New England journal of medicine,
09/2016, Letnik:
375, Številka:
10
Journal Article
Background Deferring revascularization in patients with nonsignificant stenoses based on fractional flow reserve (FFR) is associated with favorable clinical outcomes up to 15 years. Whether this ...holds true in patients with reduced left ventricular ejection fraction is unclear. We aimed to investigate whether FFR provides adjunctive clinical benefit compared with coronary angiography in deferring revascularization of patients with intermediate coronary stenoses and reduced left ventricular ejection fraction. Methods and Results Consecutive patients with reduced left ventricular ejection fraction (≤50%) undergoing coronary angiography between 2002 and 2010 were screened. We included patients with at least 1 intermediate coronary stenosis (diameter stenosis ≥40%) in whom revascularization was deferred based either on angiography plus FFR (FFR guided) or angiography alone (angiography guided). The primary end point was the cumulative incidence of all‐cause death at 10 years. The secondary end point (incidence of major adverse cardiovascular and cerebrovascular events) was a composite of all‐cause death, myocardial infarction, any revascularization, and stroke. A total of 840 patients were included (206 in the FFR‐guided group and 634 in the angiography‐guided group). Median follow‐up was 7 years (interquartile range, 3.22–11.08 years). After 1:1 propensity‐score matching, baseline characteristics between the 2 groups were similar. All‐cause death was significantly lower in the FFR‐guided group compared with the angiography‐guided group (94 45.6% versus 119 57.8%; hazard ratio HR, 0.65 95% CI, 0.49–0.85; P <0.01). The rate of major adverse cardiovascular and cerebrovascular events was lower in the FFR‐guided group (123 59.7% versus 139 67.5%; HR, 0.75 95% CI, 0.59–0.95; P =0.02). Conclusions In patients with reduced left ventricular ejection fraction, deferring revascularization of intermediate coronary stenoses based on FFR is associated with a lower incidence of death and major adverse cardiovascular and cerebrovascular events at 10 years.
Abstract We aimed to assess the correlation between angiographic and physiologic evaluation of coronary lesions in aortic stenosis (AS) patients presenting with intermediate coronary stenoses at the ...angiography. From 2002 to 2010, we included 163 patients from 2 centers with both AS and coronary artery disease, matched by age and gender with 163 contemporary patients with CAD alone. With both quantitative coronary angiography (QCA) and fractional flow reserve (FFR), we assessed 259 coronary stenoses in the AS + CAD group, and 256 in the CAD alone group. A significant correlation was found between diameter stenosis (DS) and FFR in both groups, though this was significantly stronger in the AS + CAD than in the CAD alone group (R=-0.63 vs. R=-0.44; p<0.01). Likewise, the correlation between minimum lumen diameter and FFR was stronger in the AS + CAD than in the CAD alone group (R=-0.54 vs. R=-0.41; p=0.05). ROC curves analysis showed that DS was a better predictor of hemodynamically significant coronary stenoses (FFR≤0.8) in the AS + CAD rather than in the CAD alone group (AUC = 0.83 vs. 0.67; p<0.01). With 50% DS cut-off value, the sensitivity, specificity and accuracy was 77%, 66% and 70% in AS + CAD group versus 59%, 63% and 61% in CAD alone group. In both groups, the diagnostic accuracy of DS in predicting FFR was higher in the right and circumflex coronary artery (Right/LC) as compared to the left anterior descending artery (LAD), although this was only statistically significant in the AS + CAD group (AUC 0.88 in Right/LC vs. 0.76 in LAD; p=0.03). In conclusion, the correlation between the angiographic and hemodynamic significance of coronary stenoses is modest in AS patients. The assessment of CAD severity solely based on angiography poorly predicts the hemodynamic significance of the coronary stenosis especially when these are located in the LAD.
Background Coronary artery disease (CAD) patterns play an essential role in the decision-making process about revascularization. The pullback pressure gradient (PPG) quantifies CAD patterns as either ...focal or diffuse based on fractional flow reserve (FFR) pullbacks. The objective of this study was to evaluate the impact of CAD patterns on acute percutaneous coronary intervention (PCI) results considered surrogates of clinical outcomes. Methods and Results This was a prospective, multicenter study of patients with hemodynamically significant CAD undergoing PCI. Motorized FFR pullbacks and optical coherence tomography (OCT) were performed before and after PCI. Post-PCI FFR >0.90 was considered an optimal result. Focal disease was defined as PPG >0.73 (highest PPG tertile). Overall, 113 patients (116 vessels) were included. Patients with focal disease were younger than those with diffuse CAD (61.4±9.9 versus 65.1±8.7 years,
=0.042). PCI in vessels with high PPG (focal CAD) resulted in higher post-PCI FFR (0.91±0.07 in the focal group versus 0.86±0.05 in the diffuse group,
<0.001) and larger minimal stent area (6.3±2.3 mm
in focal versus 5.3±1.8 mm
in diffuse CAD,
=0.015) compared withvessels with low PPG (diffuse CAD). The PPG was associated with the change in FFR after PCI (
=0.51,
<0.001). The PPG significantly improved the capacity to predict optimal PCI results compared with an angiographic assessment of CAD patterns (area under the curve
0.81 95% CI, 0.73-0.88 versus area under the curve
0.51 95% CI, 0.42-0.60;
<0.001). Conclusions PCI in vessels with focal disease defined by the PPG resulted in greater improvement in epicardial conductance and larger minimal stent area compared with diffuse disease. PPG, but not angiographically defined CAD patterns, distinguished patients attaining superior procedural outcomes. Registration URL: https://clinicaltrials.gov/ct2/show/NCT03782688.
Fractional flow reserve (FFR) has never been investigated in patients with aortic stenosis (AS). From 2002 to 2010, we identified 106 patients with AS and coronary artery disease with at least one ...intermediate lesion treated according to FFR guidance. We matched 212 contemporary control patients with AS in which revascularization was decided on angiography only. More patients in the FFR-guided group underwent percutaneous coronary intervention (24% vs 13%; p = 0.019), whereas there was a trend toward less coronary artery bypass grafting (CABG) performed. After FFR, the number of diseased vessels was downgraded within the FFR-guided group (from 1.85 ± 0.97 to 1.48 ± 1; p <0.01) and compared with the angio-guided group (1.48 ± 1 vs 1.8 ± 0.97; p <0.01). Less aortic valve replacement was reported in the FFR-guided group (46% vs 57%; p = 0.056). In patients who underwent CABG, less venous conduits (0.5 ± 0.69 vs 0.73 ± 0.76; p = 0.05) and anastomoses (0.61 ± 0.85 vs 0.94 ± 1; p = 0.032) were necessary in the FFR-guided group. Up to 5 years, we found no difference in major adverse cardiac events (38% vs 39%; p = 0.98), overall death (32% vs 31%; p = 0.68), nonfatal myocardial infarction (2% vs 2%; p = 0.79), and revascularization (8% vs 7%; p = 0.76) between the 2 groups. In conclusion, FFR guidance impacts the management of selected patients with moderate or severe AS and coronary artery disease by resulting into deferral of aortic valve replacement, more patients treated with percutaneous coronary intervention, and in patients treated with CABG, into less venous grafts and anastomoses without increasing adverse event rates up to 5 years.
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