Abstract: The morbidity and mortality burden of heart valve disease is increasing in the developing world, especially among the elderly. Whereas surgery remains the standard of care in fit patients with degenerative aortic stenosis, percutaneous aortic valve replacement could become an effective alternative to surgery in selected higher risk patients. The authors report on two women with aortic stenosis, both at high surgical risk (an 81-year-old female with coronary artery and cerebro-vascular disease, and a 70-year-old female with end-stage cirrhosis), in whom percutaneous valve replacement was effectively performed by means of transfemoral access and retrograde CoreValve Revalving System implantation. Two major postprocedural complications occurred, both effectively managed, in the second patient: a third degree atrio-ventricular block (requiring permanent pace-maker implantation) and bleeding from the right femoral artery access (requiring implantation of two covered stents and blood transfusion). Despite the increased baseline risk, both patients were discharged asymptomatic, the first twelve days and the other three weeks after admission. In the authors' experience percutaneous aortic valve replacement can be performed with reasonable safety in patient with severe aortic stenosis at high surgical risk.
Abstract: Objectives: We aimed to conduct a retrospective cohort study focusing on our 5-year experience in the percutaneous treatment of unprotected left main (ULM) trifurcation disease. Background: Percutaneous treatment of ULM trifurcation remains a challenging and rare procedure for most interventional cardiologists. Moreover, data on long-term outcomes are lacking. Methods: We retrieved all patients with ULM trifurcation disease treated percutaneously at our Institution since 2002, and adjudicated baseline, procedural, and outcome data. The primary end point was the long-term rate of major adverse cardiovascular events (MACE, i.e., cardiac death, myocardial infarction, bypass surgery, or target vessel revascularization). Results: A total of 27 patients underwent percutaneous coronary intervention with stent implantation for ULM trifurcation disease, with 14 (52%) cases of true trifurcations, i.e., with concomitant significant stenoses of the distal ULM/ostial left anterior descending plus ostial ramus intermedius and ostial circumflex. Bare-metal stents were implanted in 8 (29%) patients and drug-eluting stents (DES) in 26 (96%), with a main branch stent only strategy in 11 (40%), T stenting in 9 (33%), and V stenting in 6 (27%). Procedural and clinical success occurred in 26 (96%), with one postprocedural death. Angiographic follow-up was obtained in 22 patients (81%), and clinical follow-up was completed in all subjects after a median of 28 ± 17 months, showing overall MACE in 9 (33%), with cardiac death in 4 (15%), myocardial infarction in 1 (4%), coronary artery bypass grafting (CABG) in 4 (15%), and percutaneous target vessel revascularization in 5 (19%). Definite stent thrombosis was adjudicated in 1 (3%) patient. Treatment of a true trifurcation lesion and recurrence of angina during follow-up were significantly associated with an increased risk of MACE (P = 0.029 and P = 0.050, respectively). Conclusions: Percutaneous treatment of ULM trifurcation disease is feasible, associated with favorable mid-term results, and may be considered given its low invasiveness in patients at high surgical risk or with multiple comorbidities.
Abstract: Percutaneous aortic valve replacement is performed with increasing frequency in patients with severe aortic stenosis at prohibitive surgical risk. Currently available devices are however in their early development stage, and are thus quite bulky with a large profile, with ensuing difficulties in delivery of the device through a stenotic aortic valve. We report hereby a case in which we employed a buddy wire and balloon technique as a âshoehornâ to enable accurate delivery of a balloon-expandable aortic valve prosthesis from the transfemoral route.
Abstract: We report the case of a 55-year-old man who underwent coronary angiography in 2004 for early angina following anterior ST-elevation myocardial infarction. Angiography disclosed a critical stenosis in the proximal left anterior descending artery and significant stenoses in the right coronary artery and first obtuse marginal branch, treated with two paclitaxel-eluting stents and a sirolimus-eluting stent, respectively. After completion of a six-month thienopyridine course and while still being on lifelong aspirin, in 2007 he was readmitted for lateral ST-elevation myocardial infarction: angiography revealed stent thrombosis beginning at the proximal edge of the sirolimus-eluting stent implanted in the first obtuse marginal branch. Intravascular ultrasound was performed after thrombectomy but before balloon dilation showing suboptimal stent expansion and a thrombus partially adhering to the sirolimus-eluting stent. The procedure was then successfully completed with the implantation of another sirolimus-eluting stent. This clinical vignette suggests that suboptimal drug-eluting stent deployment may be associated with stent thrombosis well after the traditional time frame of subacute thrombosis.
Abstract: Percutaneous coronary revascularization has been a mainstay in the management of coronary artery disease since its introduction in the late 1970s. Bare-metal stents and, more recently, first-generation drug-eluting stents (DES), such as sirolimus-eluting (Cypher) and paclitaxel-eluting stents (Taxus), have further improved results of percutaneous coronary intervention (PCI) by improving early results and reducing the risk of restenosis. There is currently debate on the safety of these first-generation DES, given the potential for late stent thrombosis, especially after discontinuation of dual antiplatelet therapy. There are well known caveats on the performance of their respective metallic stent platforms, delivery, and dilation systems, and polymer coatings. Second-generation DES, such as zotarolimus-eluting (Endeavor) and everolimus-eluting stents (Xience V), have recently become available in the USA and/or Europe. The Xience V stent holds the promise of superior anti-restenotic efficacy as well as long-term safety. In addition, this stent is based on the Multi-link platform and delivery system. Recently available data already suggest the superiority of the Xience V stent in comparison to the Taxus stent in terms of prevention of restenosis, without significant untoward events. Nonetheless, the number of patients studied and the follow-up duration are still too limited to enable definitive conclusions. Only indirect meta-analyses can be used to date to compare the Xience V with the Cypher. This systematic review tries to provide a concise and critical appraisal of the data in support of the Xience V everolimus-eluting stent.
Abstract: BACKGROUND: Studies focusing on short- and mid-term follow up support the beneficial role of sirolimus-eluting stents (SES) in the treatment of in-stent restenosis (ISR), yet no long-term safety and/or efficacy data are available. METHODS: Patients with ISR following bare-metal stenting (BMS) and treated with SES were prospectively studied. Baseline, procedural, and in-hospital data were appraised. The primary endpoint was the rate of major cardiovascular events (MACE) at long-term follow up (>9 months). Secondary endpoints were the individual contributors to MACE. RESULTS: A total of 180 SES were implanted to treat 138 consecutive patients. Procedural success was achieved in all patients without in-hospital death, acute stent thrombosis, stroke, or urgent coronary artery bypass. During follow up, MACE occurred in 5.8% of patients at 6 months, 14.3% at 12 months, and 25% at 24 months. Specifically, all-cause mortality was 1.7% at 6 months, 3.5% at 12 months, and 4.8% at 24 months, for a total of 5 deaths. Target vessel revascularization occurred at 6, 12, and 24 months in 4.2%, 11.2%, and 15.9% of patients, respectively, while target lesion revascularization (TLR) alone accounted for 3.4% at 6 months, 9.6% at 12 months, and 11% at 24 months. Three case of myocardial infarction occurred during follow up (2.2%), without any surgical revascularization or stent thrombosis. CONCLUSIONS: Treatment of ISR with SES appears safe and effective, even if a 10% annual rate of MACE can be expected, with a sizable portion of these due to apparently nontarget lesion events.
Abstract: Background: Coronary chronic total occlusions (CTO) remain a challenging lesion subset for interventional cardiologists. The retrograde approach is a novel but still incompletely described technique. We report our 5-year-long experience in retrograde percutaneous coronary intervention (PCI) for CTOs. Methods: We abstracted patient and procedural data on all cases with attempted retrograde approach by means of a native septal or epicardial collateral pathway. End-points were wiring, angiographic and procedural success, plus long-term major adverse cardiovascular events (MACE). Results: The retrograde approach was used in 18 patients, including 11 CTOs of right coronary artery (RCA), 3 of left circumflex (LCX), and 4 of left anterior descending (LAD), with procedural success in 12 (67%). Conversely, two cases of wiring failures, three angiographic failures despite successful retrograde wiring, and one postprocedural myocardial infarction in an otherwise angiographically successful procedure were found. Causes of wiring failure were inability to retrogradely cross the distal (1) or the proximal stump (1) with the wire, while angiographic failures were due to interruption of the procedure due to rupture of a minor septal collateral branch during attempts at advancing the noninflated balloon (1) or persistent inability to deliver the balloon through the chosen collateral (2). Follow-up at a mean of 15 months showed MACE had occurred in five (28%) subjects. Conclusions: The retrograde approach appears feasible and safe in the percutaneous management of coronary occlusions, and its application can be envisioned as a promising alternative in selected patients in whom antegrade approaches fail or are unsafe.
Abstract: Given their suboptimal success rates, coronary chronic total occlusions (CTO) represent one of the last challenges of percutaneous coronary intervention (PCI). Among several novel techniques, the retrograde approach is one of the most promising, but it is still incompletely described. We report our 5-year experience in retrograde PCI for CTOs. We abstracted patient and procedural data on all cases with attempted retrograde approach. End-points were technical and procedural success, plus long-term major adverse cardiovascular events (MACE). The retrograde approach was used in 17 patients, with procedural success in 12 (71%), including 9 CTOs of right coronary, 2 of left circumflex, and 2 of left main arteries. Conversely, 4 cases of technical failure and 1 post-procedural myocardial infarction in an otherwise angiographically successful procedure were found. Causes of retrograde failure were: inability to deliver the balloon through the chosen collateral in 2 cases, inability to retrogradely cross the distal stump with the wire in 1 case, and interruption of the procedure due to rupture of a minor septal collateral branch during attempts at advancing the non-inflated balloon in 1 case. In all patients with retrograde failure, subsequent antegrade attempts could be carried out, with ultimate success in everybody. Follow-up at 24+/-21 months showed an overall MACE rate of 23%. In conclusion, the retrograde approach appears feasible and safe, and its application can be envisioned as a promising alternative strategy in selected patients in whom antegrade approaches fail or are deemed unsafe.
Abstract: BACKGROUND
Bifurcational coronary lesions treatment is still a relevant question. It isnât clear what is the better way: to implant a single stent or two stents, the first in the main branch and the second in the side branch. Our paper compare the long-term follow up results of treatment with one or two drug-eluting stents.
METHODS
We enrolled consecutive patients who underwent percutaneous coronary intervention of bifurcational lesions with drug-eluting stents between July 2002 and December 2005 in our Division. Patients are divided into two arm: stenting only the main branch plus only balloon angioplasty on side branch or stenting both branches. The primary end-point was the freedom from major adverse cerebral-cardiovascular events (myocardial infarction, repeated revascularization, cerebrovascular event, death, all these also known as MACCE).
RESULTS
We identified 216 patients, 121 (56%) stenting of only 1 branch and 95 (44%) stenting of both branches. Between two groups there arenât statistically significant differences about baseline characteristics, but the two stent group angiographic characteristics were unfavourable. There were no significant differences between the two groups regarding in-hospital adverse events (1.6% vs 3.15%, p=0.5). Neither at the long-term follow up (median 22 months [interq. range 15â34 months]) there were no significant differences regarding freedom from MACCE (82% vs 65%, p=0.09), overall death (89% vs 85%, p=0.87), myocardial infarction (1% vs 3%, p=0.6). However, the stenting one branch group freedom from repeated revascularization was significantly higher (86% vs 69%, p=0.02), included also target vessel revascularization, in most of cases PTCA.
CONCLUSIONS
Bifurcational coronary lesions treatment with two drug-eluting stents donât appear better at the brief and long-term. So, except in selected patients or with bailout to two stents, the main branch only treatment should be the preferred option.
Abstract: BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) with drug-eluting stent implantation is commonly used in patients with unprotected left main (ULM), but no detailed information is available on results of this procedure in patients with versus without left ventricular dysfunction.
METHODS: We identified all consecutive subjects treated with PTCA and stenting on ULM at our Center between 2002 and 2006. We then distinguished those with normal left ventricular systolic function (ejection fraction [EF] greater than 50%, group A), those with mild dysfunction (EF between 40 and 50%, group B), and those with moderate or severe dysfunction (EF less than 40%, group C). The primary end-point was major adverse cardiovascular events (MACE, ie death, myocardial infarction [MI], or target vessel revascularization [TVR]) at the longest available follow-up.
RESULTS: A total of 197 patients were included, 113 (57,4%) in group A, 63 (32%) in group B and 21 (10,6%) in the group C. In-hospital events rates were similar, except for death rate, which was significantly higher in group C (2 [10%], p<0.001), and always for cardiac cause. A total of 96% patients were followed for a median of 23 months, yielding the following MACE: 47 (42%) in group A, 26 (42%) in group B, and 13 (62%) in group C (p=0.4). Specifically, death occurred in 3 (3%) in group A, 5 (8%) in group B, and 6 (29%) in group C (p<0,001), cardiac death in 2 (2%) in group A, 3 (5%) in group B, and 5 (24%) in group C (p<0,001),
CONCLUSIONS: Left ventricular systolic dysfunction is a significant predictor of early and long-term mortality after PTCA with stenting for ULM, and it should be taken into account when planning revascularization strategy and ancillary medical treatment or cardiac support means.
Abstract: BACKGROUND: Drug-eluting stents (DES) are commonly used in patients with unprotected left main (ULM) and concomitant multivessel disease, yet no data are available on the impact of incomplete versus complete revascularization in this setting.
METHODS: We identified consecutive subjects treated with DES at our Center between 2002 and 2006 for disease of the ULM and at least another major epicardial vessel. We distinguished those achieving a functionally complete revascularization (ie with effective treatment of every stenotic vessel of at least 2.25 mm diameter and providing flow to viable myocardium, group A), versus those with a functionally incomplete revascularization (group B). The primary end-point was major adverse cardiovascular events (MACEs, ie death, myocardial infarction [MI], or target vessel revascularization [TVR]) at the longest available follow-up.
RESULTS: A total of 141 patients were included, 89 (63%) in group A and 52 (27%) in group B. No major differences were identified in baseline characteristics. In-hospital events were similarly favourable (cardiac death 3 [2.8%] and 0, respectively, p=0.3, myocardial infarction 5 [5.6%] vs 0, p=0.2). A total of 99% patients were followed (for a mean of 24 months), yielding MACEs in 35 (40%) and 37 (71%) patients (P=0.07, hazard ratio [HR] 95% confidence interval from 0.473 to 1.304). Specifically, death occurred in 7 (8.3%) and 5 (9.3%) (p=0.85, HR from 0.251 to 3.425), cardiac death in 5 (5.5%) and 3 (6.2%) (p=0.35, HR from 0.304 to 19.417), MI in 3 (3.7%) and 2 (3.2%) (p=0,26, HR from 0.393 to 23.970), TVR in 31 (34.9%) and 15 (29%) (p=0.76, HR from 0.451 to 2.419). Documented recurrent angina was detected in 20 (22.9%) vs 15 (29.0%) (p=0.6) and was significantly associated with MACE occurrence (39 [43.4%] vs 40 [77.2%], p=0.001). Mortality predictors resulted, regardless of group assignment, diabetes (p=0.01), current smoking status (p=0.03), prior myocardial infarction (p=0.03) and presence at the index procedure of mitral regurgitation (p=0.05). Significant results at bivariate analysis were maintained at multivariable analyses.
CONCLUSIONS: Multivessel stenting on top of DES implantation for ULM disease can be performed with relatively favourable clinical results. Whereas functionally complete revascularization tends to be associated with fewer adverse events, the most important clinical goal would be prevent or early treatment of documented recurrent angina pectoris.
