To report clinical outcomes in patients treated with drug-eluting balloon (DEB) versus second-generation drug-eluting stent (DES) for in-stent restenosis (ISR) involving a bifurcation lesion.
Between ...February 2007 and November 2012, 167 bifurcation restenoses in 158 patients were treated with either DEB (n=73) or second-generation DES (n=85). The EuroSCORE was significantly higher in the DEB group (4.2±3.8 vs. 2.8±2.1, p=0.004). Regarding restenosed stent type, second-generation DES was more frequently seen in the DEB group (26.9% vs. 6.7%, p<0.001). In this group, there was also a trend towards more frequent stenting for a previous ISR (stent-in-stent) as compared with the DES group (25.6% vs. 15.6%, p=0.074). Over a median follow-up period of 701 days, there was no significant difference in major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction including periprocedural myocardial infarction, target vessel revascularisation, between the two groups (p=0.585). Independent predictors of MACE on multivariate Cox regression analysis included stent-in-stent (HR: 2.16; 95% CI: 1.11 to 4.20; p=0.023) and true bifurcation lesions (HR: 2.98; 95% CI: 1.45 to 6.14; p=0.001).
DEB for bifurcation restenosis may be an acceptable treatment option, especially in cases where repeat stenting has not already been performed for the treatment of a previous restenosis.
Bicuspid aortic valve (BAV) is a common congenital valvular malformation, which may lead to early aortic valve disease and bicuspid-associated aortopathy. A novel BAV classification system was ...recently proposed to coincide with transcatheter aortic valve replacement being increasingly considered in younger patients with symptomatic BAV, with good clinical results, yet without randomized trial evidence. Procedural technique, along with clinical outcomes, have considerably improved in BAV patients compared with tricuspid aortic stenosis patients undergoing transcatheter aortic valve replacement. The present review summarizes the novel BAV classification systems and examines contemporary surgical and transcatheter approaches.
•Indications for surgical intervention in patients with bicuspid aortic valve (BAV) mirror the same for transcatheter aortic valve (TAV).•The data for transcatheter aortic valve replacement (TAVR) in BAV patients using newer generation prostheses are encouraging.•Patients with BAV are younger with lower operative risk and longer life expectancy.•Newer BAV prostheses have improved sealing skirt designs reducing paravalvular leak rates.•Short-term survival rates for BAV TAVR are equivalent to TAVR for tricuspid valve AS.
Background. Cardiac allograft vasculopathy (CAV) remains the Achilles’ heel of long-term survival after heart transplantation (HTx). The severity and extent of CAV is graded with conventional ...coronary angiography (COR) which has several limitations. Recently, vessel fractional flow reserve (vFFR) derived from COR has emerged as a diagnostic computational tool to quantify the functional severity of coronary artery disease. Purpose. The present study assessed the usefulness of vFFR to detect CAV in HTx recipients. Methods. In HTx patients referred for annual check-up, undergoing surveillance COR, the extent of CAV was graded according to the criteria proposed by the international society of heart and lung transplantation (ISHLT). In addition, three-dimensional coronary geometries were constructed from COR to calculate pressure losses using vFFR. Results. In 65 HTx patients with a mean age of 53.7 ± 10.1 years, 8.5 years (IQR 1.90, 15.2) years after HTx, a total number of 173 vessels (59 LAD, 61 LCX, and 53 RCA) were analyzed. The mean vFFR was 0.84 ± 0.15 and median was 0.88 (IQR 0.79, 0.94). A vFFR ≤ 0.80 was present in 24 patients (48 vessels). HTx patients with a history of ischemic cardiomyopathy (ICMP) had numerically lower vFFR as compared to those with non-ICMP (0.70 ± 0.22 vs. 0.79 ± 0.13, p=0.06). The use of vFFR reclassified 31.9% of patients compared to the anatomical ISHLT criteria. Despite a CAV score of 0, a pathological vFFR ≤ 0.80 was detected in 8 patients (34.8%). Conclusion. The impairment in epicardial conductance assessed by vFFR in a subgroup of patients without CAV according to standard ISHLT criteria suggests the presence of a diffuse vasculopathy undetectable by conventional angiography. Therefore, we speculate that vFFR may be useful in risk stratification after HTx.
Abstract Background Randomized controlled trials have demonstrated that second-generation drug-eluting stents (DESs) for the treatment of obstructive coronary artery disease are associated with ...comparable, if not improved, clinical outcomes as compared to those of their first-generation counterparts. The aim of this study was to compare the long-term clinical outcomes associated with first- versus second-generation DESs for the treatment of coronary bifurcation lesions. Methods and Materials This was a retrospective study of consecutive de novo bifurcation lesions, excluding those at the left main, treated with either second-generation DES (everolimus-eluting or resolute zotarolimus-eluting stents) between October 2006 and October 2011 (199 bifurcation lesions in 192 patients) or first-generation DES (sirolimus-eluting or paclitaxel-eluting stents) between April 2002 and December 2005 (289 bifurcation lesions in 273 patients). Results Second-generation DES use in this setting was associated with less major adverse cardiac events (MACE) (23.1% vs. 14.4%, p = 0.02) as well as lower target vessel revascularization (TVR) rates (15.5% vs. 8.3%, p = 0.01) at 2-year follow-up. Target lesion revascularization, both per patient (12.6% vs. 7.4%, p = 0.02) and per bifurcation (11.8% vs. 7.0%, p = 0.03), was also improved with second-generation DES over the same follow-up period. Propensity-score adjusted analysis suggested that second-generation DES was associated with a lower incidence of MACE (HR, 0.53; 95% CI, 0.33–0.85; p = 0.01) and TVR (HR, 0.44; 95% CI, 0.24–0.83; p = 0.01). Conclusions Our results suggest that the use of second-generation DES for the treatment of bifurcation lesions is associated with better clinical outcomes as compared to first-generation DES, largely due to a lower need for repeat revascularization.
Angina Pectoris and the Importance of Coronary Microcirculation in Practice
Microvascular angina is a common manifestation of coronary microvascular dysfunction, particulary prevalent in ...post-menopausal women above the age of 50 and associated with impaired quality of life and poor clinical outcomes. However, microvascular angina remains largely undetected given the underuse of diagnostic tools for the assessment of coronary microvascular function. As a consequence, many of these patients suffering from coronary microvascular dysfunction fail to receive the appropriate medical treatment and remain in the long term symptomatic. Invasive coronary catheterization with measurement of coronary flow reserve and intracoronary acetylcholine provocation testing allows for the assessment of coronary microvascular dysfunction, and a therapy targeting specific physiological pathways can be implemented. A targeted therapy includes lifestyle modifications, secondary prevention measures, and anti-anginal medication. Ongoing clinical research in the field is expected to deliver novel diagnostic and therapeutic concepts for an improved management of patients with coronary microvascular disease.
Zusammenfassung. Die koronare Mikrozirkulationsstörung weist insbesondere bei Frauen ab dem fünfzigsten Lebensjahr eine hohe Prävalenz auf und führt sowohl zu pektanginösen Symptomen wie auch zu ...einer erhöhten Rate kardiovaskulärer Ereignisse. Durch die auch heutzutage noch bestehende Unterdiagnostizierung haben viele Patientinnen und Patienten einen langen Leidensweg hinter sich. Mit einer invasiven Koronarangiografie, die sowohl eine Messung der koronaren Flussreserve wie auch eine Acetylcholin-Provokationstestung beinhaltet, kann die Diagnose einer koronaren Mikrozirkulationsstörung gestellt werden. Dies ist einerseits für das Wohl der Patientinnen und Patienten wichtig, ermöglicht andererseits aber auch eine gezielte Therapie. Diese besteht aus Lebensstilveränderungen, einer optimalen Kontrolle kardiovaskulärer Risikofaktoren sowie spezifischen anti-anginösen Medikamenten. Die aktuelle Forschung versucht, pathophysiologische Mechanismen besser zu verstehen und verbesserte oder alternative diagnostische Verfahren und neue Therapiekonzepte zu entwickeln.
Prognosis of Takotsubo syndrome (TTS) remains controversial due to scarcity of available data. Additionally, the effect of the triggering factors remains elusive.
This study compared prognosis ...between TTS and acute coronary syndrome (ACS) patients and investigated short- and long-term outcomes in TTS based on different triggers.
Patients with TTS were enrolled from the International Takotsubo Registry. Long-term mortality of patients with TTS was compared to an age- and sex-matched cohort of patients with ACS. In addition, short- and long-term outcomes were compared between different groups according to triggering conditions.
Overall, TTS patients had a comparable long-term mortality risk with ACS patients. Of 1,613 TTS patients, an emotional trigger was detected in 485 patients (30%). Of 630 patients (39%) related to physical triggers, 98 patients (6%) had acute neurologic disorders, while in the other 532 patients (33%), physical activities, medical conditions, or procedures were the triggering conditions. The remaining 498 patients (31%) had no identifiable trigger. TTS patients related to physical stress showed higher mortality rates than ACS patients during long-term follow-up, whereas patients related to emotional stress had better outcomes compared with ACS patients.
Overall, TTS patients had long-term outcomes comparable to age- and sex-matched ACS patients. Also, we demonstrated that TTS can either be benign or a life-threating condition depending on the inciting stress factor. We propose a new classification based on triggers, which can serve as a clinical tool to predict short- and long-term outcomes of TTS. (International Takotsubo Registry InterTAK Registry; NCT01947621)
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The need for a quantitative and operator-independent assessment of coronary microvascular function is increasingly recognized. We propose the theoretical framework of microvascular resistance reserve ...(MRR) as an index specific for the microvasculature, independent of autoregulation and myocardial mass, and based on operator-independent measurements of absolute values of coronary flow and pressure. In its general form, MRR equals coronary flow reserve (CFR) divided by fractional flow reserve (FFR) corrected for driving pressures. In 30 arteries, pressure, temperature, and flow velocity measurements were obtained simultaneously at baseline (BL), during infusion of saline at 10 mL/min (rest) and 20 mL/min (hyperemia). A strong correlation was found between continuous thermodilution-derived MRR and Doppler MRR (r = 0.88; 95% confidence interval: 0.72-0.93; P < 0.001). MRR was independent from the epicardial resistance, the lower the FFR value, the greater the difference between MRR and CFR. Therefore, MRR is proposed as a specific, quantitative, and operator-independent metric to quantify coronary microvascular dysfunction.
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