01 febrero 2013

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS. Coil-occlusion of the left ventricle as emergency treatment in failing stage I palliation for hypoplastic left heart syndrome with sinusoids†

Johanna Hummel MD, Brigitte Stiller MD, Jochen Grohmann MD

We report on a patient with hypoplastic left heart syndrome (HLHS), ventricular septal defects, and coronary sinusoids who suffered recurrent myocardial ischemic events that required cardiopulmonary resuscitation after stage I palliation. We identified the main reason to be a steal phenomenon of blood from the left coronary artery via the sinusoids into the rudimentary left ventricle and across the septal defects into the right ventricle. To limit this coronary steal phenomenon, we successfully performed transcatheter closure of the left ventricle with implantation of three Microplex Terumo®-Coils. This led to the patient s clinical stabilization. Stage II surgery took place at the age of 5 months without difficulty. In the setting of a symptomatic neonate with HLHS and ventriculocoronary connections, embolization of the left ventricle is a feasible interventional therapy. © 2012 Wiley Periodicals, Inc.

01 enero 2013

JACC: CARDIOVASCULAR INTERVENTIONS. Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Replacements Using Transfemoral Devices Via the Transapical Approach

Jean-Michel Paradis, MD; Susheel K. Kodali, MD; Rebecca T. Hahn, MD; Isaac George, MD; Benoit Daneault, MD; Elana Koss, MD; Tamim M. Nazif, MD; Martin B. Leon, MD; Mathew R. Williams, MD

An 85-year-old man was recently admitted to our institution with congestive heart failure (New York Heart Association functional class III/IV) and hemolytic anemia. The patient had a prior history of Streptococcus viridans bacterial endocarditis that resulted in severe aortic and mitral regurgitations. In 2002, he underwent surgical aortic (Carpentier-Edwards #25, Edwards Lifesciences, Irvine, California) and mitral (Hancock modified #29, Medtronic, Minneapolis, Minnesota) valve replacements. Transesophageal echocardiogram (TEE) performed during the recent hospitalization showed that the left ventricular ejection fraction was 55%. The Hancock modified bioprosthesis in the mitral position was well seated, but there was severe mitral regurgitation caused by a flail leaflet ((Figure 18_gr1)A,Online Video 1). The mitral bioprosthesis was oval-shaped, and the internal diameters were measured to be 21 × 23.8 mm (Figure 18_gr1B). In addition, there was severe stenosis of the Carpentier-Edwards valve in the aortic position with an aortic valve area (AVA) of only 0.9 cm2. On 3-dimensional TEE, the internal diameter of the valve was measured to be 24 mm (Figure 18_gr2).

01 enero 2013

AMERICAN JOURNAL OF CARDIOLOGY. Managing Patients With an Indication for Anticoagulant Therapy After Transcatheter Aortic Valve Implantation

Filippo Figini, MD , Azeem Latib, MD , Francesco Maisano, MD , Matteo Montorfano, MD , Alaide Chieffo, MD , Mauro Carlino, MD , Micaela Cioni, MD , Sandeep Basavarajaiah, MD , Santo Ferrarello, MD , Francesco Giannini, MD , Ottavio Alfieri, MD , Antonio Colombo, MD

Patients who undergo transcatheter aortic valve implantation are generally discharged on dual-antiplatelet therapy. However, many of these patients also have indications for anticoagulant therapy, and it is unclear what the best antithrombotic strategy is in these cases. Data from 360 patients who underwent transcatheter aortic valve implantation were retrospectively analyzed, of whom 60 (16.7%) had indications for anticoagulant treatment, mainly because of atrial fibrillation. The antithrombotic regimen was decided according to clinical evaluation of thrombotic and hemorrhagic risk; most of these patients (n = 43) were discharged with warfarin plus a single antiplatelet drug. Their outcomes were compared to those in a group with no indications for anticoagulation (n = 300) treated with dual-antiplatelet therapy. During the follow-up period (median 11 months), 53 patients (15%) died; mortality was not associated with antithrombotic regimen. The incidence of cerebral events or intracranial hemorrhage (4.6% and 1.1%, respectively) was low in the study population, and no significant differences were detected between groups; the bleeding rate was also unaffected by antithrombotic therapy. In conclusion, when anticoagulation is indicated after transcatheter aortic valve implantation, many variables must be taken into account. The most frequent scenario in this study was patients in atrial fibrillation, most of whom were discharged with warfarin plus a single antiplatelet medication. When bleeding was a concern, especially in the absence of coronary disease, warfarin alone was prescribed. These results suggest that this approach is safe, but data from larger, randomized studies are needed.

01 febrero 2013

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS. Five-year clinical outcomes of a polymer-free sirolimus-eluting stent versus a permanent polymer paclitaxel-eluting stent: Final results of the intracoronary stenting and angiographic restenosi

Lamin King MB MS, Robert A. Byrne MB BCh, PhD, Julinda Mehilli MD, Albert Schömig MD, Adnan Kastrati MD, Jurgen Pache MD

Background: Limited evidence exists regarding the long-term performance of polymer-free (PF) drug-eluting stents (DES) in comparison to permanent polymer DES. This study investigated the 5-year efficacy and safety of a PF sirolimus-eluting stent (PF-SES) versus a permanent polymer paclitaxel-eluting stent (PES) in the setting of the Intracoronary Stenting and Angiographic Restenosis-Test Equivalence Between Two Drug-Eluting Stents (ISAR-TEST) randomized trial.

01 enero 2012

CIRCULATION. Six-Month Versus 12-Month Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stents

Hyeon-Cheol Gwon, MD*; Joo-Yong Hahn, MD*; Kyung Woo Park, MD; Young Bin Song, MD; In-Ho Chae, MD; Do-Sun Lim, MD; Kyoo-Rok Han, MD; Jin-Ho Choi, MD; Seung-Hyuk Choi, MD; Hyun-Jae Kang, MD; Bon-Kwon Koo, MD; Taehoon Ahn, MD; Jung-Han Yoon, MD; Myung-Ho Jeong, MD; Taek-Jong Hong, MD; Woo-Young Chung, MD; Young-Jin Choi, MD; Seung-Ho Hur, MD; Hyuck-Moon Kwon, MD; Dong-Woon Jeon, MD; Byung-Ok Kim, MD; Si-Hoon Park, MD; Nam-Ho Lee, MD; Hui-Kyung Jeon, MD; Yangsoo Jang, MD; Hyo-Soo Kim, MD

Background—The optimal duration of dual antiplatelet therapy (DAPT) after implantation of drug-eluting coronary stents remains undetermined. We aimed to test whether 6-month DAPT would be noninferior to 12-month DAPT after implantation of drug-eluting stents.

01 enero 2013

JACC: CARDIOVASCULAR INTERVENTIONS. Left Main Coronary Artery Compression by an Enlarged Pulmonary Artery

Wassef Karrowni, MD; Gardar Sigurdsson, MD; Phillip A. Horwitz, MD

A 43-year-old woman with World Health Organization group I severe pulmonary hypertension, associated with systemic lupus erythematosus, was referred for cardiac catheterization as part of a lung transplant evaluation. She was also having anginal symptoms during walking. Physical examination was significant for a loud P2 and right ventricular lift. Coronary angiogram revealed a tight ostial left main (LM) stenosis (Figure 10_gr1A). (Online Video 1) thought due to compression by a markedly enlarged pulmonary artery (PA) ((Figure 10_gr1)A and (Figure 10_gr1)B, Online Video 1 and 2). This was confirmed by a coronary 64-slice multidetector computed tomography (Figure 10_gr1C). She underwent successful LM stenting with a 4 × 15-mm bare-metal stent. Since that time, she has had no recurrence of the angina. Follow-up coronary multidetector computed tomography was done at 5 months and confirmed patency of the stent (Figure 10_gr1D). Given the severity of the underlying disease, the patient continues to be evaluated for lung transplant.

01 enero 2013

AMERICAN JOURNAL OF CARDIOLOGY. Comparison of Early Strut Coverage Between Zotarolimus- and Everolimus-Eluting Stents Using Optical Coherence Tomography

Seunghwan Kim, MD , Jung-Sun Kim, MD, PhD , Dong-Ho Shin, MD , Byeong-Keuk Kim, MD, PhD , Young-Guk Ko, MD , Donghoon Choi, MD, PhD , Yun-Kyeong Cho, MD, PhD , Chang-Wook Nam, MD, PhD , Seung-Ho Hur, MD, PhD , Yangsoo Jang, MD, PhD , Myeong-Ki Hong, MD, PhD

There have been no optical coherence tomographic (OCT) data directly comparing the pattern of strut coverage between the 2 second-generation drug-eluting stents in the early period. The aim of this prospective study was to evaluate early strut coverage using optical coherence tomography 3 months after Resolute zotarolimus-eluting stent (ZES-R) or everolimus-eluting stent (EES) implantation in de novo coronary artery lesions. A total of 40 patients who were suitable for the OCT procedure and consented to the study protocol were randomized 1:1 to receive either ZES-R or EES. Among these patients, 35 stented lesions (18 ZES-R, 17 EES) in 34 patients were evaluated by optical coherence tomography immediately and 3 months after stent implantation. Neointimal hyperplasia thickness, percentage of uncovered struts, and the proportion of malapposed struts were measured at 1-mm intervals. An uncovered strut was defined as having a neointimal hyperplasia thickness of 0 μm. At the 3-month OCT evaluation, mean neointimal hyperplasia thickness (ZES-R vs EES 74 ± 41 vs 75 ± 35 μm, p = 0.89) and mean percentage of uncovered struts (ZES-R vs EES 6.2 ± 6.9 vs 4.7 ± 5.1%, p = 0.62) were not significantly different between the groups. The percentage of malapposed struts was also similar between the groups (0.7 ± 2.2% for ZES-R and 0.7 ± 1.7% for EES, p = 0.64). Thrombi were documented in 3 stents (1 [5.6%] in a ZES-R vs 2 [11.8%] in EES, p = 0.60). In conclusion, early stent strut coverage on the basis of serial OCT evaluation was comparable between ZES-R and EES 3 months after stent implantation.

01 febrero 2013

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS. Long-term serial angiographic outcomes after sirolimus-eluting stent implantation

Euihong Ko MD, Kenya Nasu MD, Maoto Habara MD, Nobuyoshi Tanaka MD, Mitsuyasu Terashima MD, Yoshihisa Kinoshita MD, Etsuo Tsuchikane MD, Yasushi Asakura MD, Osamu Katoh MD, Takahiko Suzuki MD

Objective: We evaluated, using quantitative coronary angiography, the natural history of change that occurred in target lesions after successful sirolimus-eluting stent (SES) implantation.

01 enero 2013

JACC: CARDIOVASCULAR INTERVENTIONS. Catheter Closure of a Right Aortico-Atrial Tunnel in a Patient 4 Years of Age

Basil (Vasilios) D. Thanopoulos, MD, PhD; Vlassis Ninios, MD; John Germanakis, MD

A 4-year-old boy (body weight 14 kg) was referred to our department with the clinical diagnosis of patent ductus arteriosus for further evaluation and treatment. Besides a poor weight gain (body weight below the 10th percentile for age) and frequent respiratory infections, the patient was otherwise asymptomatic. Echocardiographic evaluation showed a dilated (for age) left ventricle with normal function. A connection between the origin of the right coronary artery and the right atrium was interpreted as a congenital arteriovenous fistula. Multislice computed tomography (MSCT) showed the presence of a tunnel-like communication between the right coronary sinus and the superior part of the right atrium (Figure 20_gr1). A narrowing was seen in the middle position of the communication. Cardiac catheterization and aortography performed under general anesthesia confirmed the findings of MSCT. The diameter of the stenosis was measured to be approximately 4.9 mm (Figure 20_gr2A). The tunnel was entered from the aorta using a 5-F right Judkins coronary catheter. Following the formation of an arteriovenous loop, a 5-mm (waist diameter) × 4-mm (length) Amplatzer Duct Occluder II (ADO II) (St. Jude Medical, St. Paul, Minnesota) was deployed through a 5-F sheath across the narrowed part of the tunnel ((Figure 20_gr2)B and Figure 20_gr2C).

01 enero 2013

JACC: CARDIOVASCULAR INTERVENTIONS. Successful Management of Annulus Rupture in Transcatheter Aortic Valve Implantation

Kentaro Hayashida, MD, PhD; Erik Bouvier, MD; Thierry Lefèvre, MD

An 82-year-old woman with severe aortic stenosis was referred to our center. Transcatheter aortic valve implantation (TAVI) was scheduled due to her high surgical risk (logistic EuroSCORE = 25.8%). The annulus diameter measured by transesophageal echocardiography (TEE) was 22.2 and 23.6 mm by multidetector computed tomography (CT). A 26-mm Edwards valve (Edwards Lifesciences, Irvine, California) was subsequently implanted via the transfemoral approach. After implantation, sudden hemodynamic collapse occurred, and aortography revealed contrast protrusion from the aortic cusp ((Figure 20_gr1)A,Online Video 1). Fluoroscopic detection of restricted heart motion with surrounding white area (Online Video 1) facilitated immediate diagnosis of tamponade before echocardiography. After percutaneous pericardial drainage via the subxiphoid approach and heparin neutralization, blood autotransfusion was performed via a circuit connecting the drainage catheter and the femoral vein sheath. Hemodynamics were stabilized within 30 min, and contrast protrusion disappeared (Online Video 2) Pre-procedural CT showed a calcified nodule (5 × 7.5 mm) at the epicardial fat segment between the interventricular septum and left atrium (Figure 20_gr1B, arrow), and contrast leakage was observed in post-procedural CT (Figure 20_gr1C, arrow). The patient was discharged on Day 8 without any complications. We successfully treated a similar case (with a 26-mm valve for the 22-mm TEE-measured annulus diameter) with contrast protrusion ((Figure 20_gr1)D, Online Videos 3 and 4) and similar pre- and post-CT findings ((Figure 20_gr1)E and Figure 20_gr1F).

01 enero 2013

AMERICAN JOURNAL OF CARDIOLOGY. Comparison of Three-Year Outcomes After Primary Percutaneous Coronary Intervention in Patients With Left Ventricular Ejection Fraction <40% Versus ≥40% (from the HORIZONS-AMI Trial)

Benoit Daneault, MD , Philippe Généreux, MD , Ajay J. Kirtane, MD, SM , Bernhard Witzenbichler, MD , Giulio Guagliumi, MD , Jean-Michel Paradis, MD , Martin P. Fahy, MSc , Roxana Mehran, MD , Gregg W. Stone, MD

Left ventricular (LV) dysfunction and multivessel disease (MVD) have been associated with greater mortality after ST-segment elevation myocardial infarction. The aim of this study was to evaluate the impact of LV dysfunction and MVD in patients with ST-segment elevation myocardial infarctions treated with primary percutaneous coronary intervention (PCI). Patients from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial treated with primary PCI in whom baseline LV function was assessed using left ventriculography were included in this study. Early and late (3-year) outcomes were examined in groups of patients with reduced (<40%) and preserved (≥40%) LV ejection fractions (LVEFs), further stratified by the presence of MVD. A total of 2,430 patients were included. Patients with reduced LVEFs were older; were more likely to be women; were more likely to have histories of myocardial infarction, PCI, and heart failure; and were more likely to present in heart failure. Patients with reduced LVEFs had greater 30-day (8.9% vs 0.9%, hazard ratio 9.81, 95% confidence interval 5.23 to 18.42, p <0.0001) and 3-year (17.1% vs 3.7%, hazard ratio 5.03, 95% confidence interval 3.37 to 7.50, p <0.0001) mortality. Among patients with LVEFs <30% (n = 45), 30% to 40% (n = 157), 40% to 50% (n = 373), 50% to 60% (n = 659), and ≥60% (n = 1,196), 3-year mortality was 29.4%, 13.5%, 6.4%, 3.8%, and 2.9%, respectively (p for trend <0.0001). MVD was associated with greater mortality in patients with preserved but not reduced LVEFs. By multivariate analysis, LV dysfunction was the strongest predictor of 30-day and 3-year mortality. In conclusion, the presence of LV dysfunction as assessed on baseline left ventriculography in patients who undergo primary PCI in the contemporary era is a powerful predictor of early and late mortality, regardless of the extent of coronary artery disease.

01 febrero 2013

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS. Ambulatory transradial percutaneous coronary intervention: A safe, effective, and cost-saving strategy

Philippe Le Corvoisier MD, PhD, Barnabas Gellen MD, Ph, Pierre-François Lesault MD, Remy Cohen MD, Stéphane Champagne MD, Anne-Marie Duval MD, Gilles Montalescot MD, PhD, Simon Elhadad MD, Olivier Montagne MD, Isabelle Durand-Zaleski MD, PhD, Jean-Luc Dubois-Randé MD, PhD, Emmanuel Teiger MD, PhD

Objectives: The aim of this prospective, multicenter study was to assess the safety, feasibility, acceptance, and cost of ambulatory transradial percutaneous coronary intervention (PCI) under the conditions of everyday practice. Background: Major advances in PCI techniques have considerably reduced the incidence of post-procedure complications. However, overnight admission still constitutes the standard of care in most interventional cardiology centers. Methods: Eligibility for ambulatory management was assessed in 370 patients with stable angina referred to three high-volume angioplasty centers. On the basis of pre-specified clinical and PCI-linked criteria, 220 patients were selected for ambulatory PCI. Results: The study population included a substantial proportion of patients with complex procedures: 115 (52.3%) patients with multivessel coronary artery disease, 50 (22.7%) patients with multilesion procedures, and 60 (21.5%) bifurcation lesions. After 4-6 hr observation period, 213 of the 220 patients (96.8%) were cleared for discharge. The remaining seven (3.2%) patients were kept overnight for unstable angina (n = 1), atypical chest discomfort (n = 2), puncture site hematoma (n = 1), or non-cardiovascular reasons (n = 3). Within 24 hr after discharge, no patients experienced readmission, stent occlusion, recurrent ischemia, or local complications. Furthermore, 99% of patients were satisfied with ambulatory management and 85% reported no anxiety. The average non-procedural cost was lower for ambulatory PCI than conventional PCI (1,230 ± 98 Euros vs. 2,304 ± 1814 Euros, P < 10−6). Conclusions: Ambulatory PCI in patients with stable coronary artery disease is safe, effective, and well accepted by the patients. It may both significantly reduce costs and optimize hospital resource utilization. © 2012 Wiley Periodicals, Inc.

01 enero 2012

CIRCULATION. Collagenase Total Occlusion-1 (CTO-1) Trial

Bradley H. Strauss, MD, PhD; Azriel B. Osherov, MD; Sam Radhakrishnan, MD; G.B. John Mancini, MD; Allison Manners, BSc; John D. Sparkes, MSc; Robert J. Chisholm, MD

Background—Percutaneous interventions for chronic total occlusions have low success rates, primarily because of failure of guide wire crossing. Collagen-rich matrix constitutes the main barrier to chronic total occlusion crossing. In preclinical studies, local delivery of a bacterial collagenase formulation improved guide wire crossing. The Collagenase Total Occlusion-1 (CTO-1) Trial is a phase I, dose-escalation trial to assess the safety and efficacy of collagenase therapy to facilitate guide wire crossing in coronary artery chronic occlusions.

01 febrero 2013

CIRCULATION: CARDIOVASCULAR INTERVENTIONS. Efficacy and Safety of Postdilatation to Reduce Paravalvular Regurgitation During Balloon-Expandable Transcatheter Aortic Valve Replacement

Benoit Daneault, MD, Elana Koss, MD, Rebecca T. Hahn, MD, Susheel Kodali, MD, Mathew R. Williams, MD, Philippe Généreux, MD, Jean-Michel Paradis, MD, Isaac George, MD, George R. Reiss, MD, Jeffrey W. Moses, MD, Craig R. Smith, MD and Martin B. Leon, MD

Background—Paravalvular regurgitation (PVR) is common after transcatheter aortic valve replacement (TAVR) and may be associated with adverse outcomes. Postdilatation (PD) has been proposed to treat PVR without being formally studied. We performed a study to evaluate the safety and efficacy of PD after balloon expandable TAVR.

01 enero 2013

AMERICAN JOURNAL OF CARDIOLOGY. Safety and Efficacy of Everolimus-Eluting Stents Versus Sirolimus-Eluting Stents in Women

Salem Badr, MD , Israel M. Barbash, MD , Danny Dvir, MD , Rebecca Torguson, MPH , Zhenyi Xue, MS , Hironori Kitabata, MD , Gabriel Sardi, MD , Joshua P. Loh, MBBS , Augusto D. Pichard, MD , Ron Waksman, MD

Drug-eluting stents have shown promising clinical results in the treatment of coronary artery disease, including in women. Studies with first-generation drug-eluting stents, however, have reported higher rates of stent thrombosis (ST). The aim of this study was to evaluate the safety and efficacy of second-generation everolimus-eluting stents (EES) versus first-generation sirolimus-eluting stents (SES) in women. The study included 1,649 women; 1,152 (70%) received SES and 497 (30%) received EES. In-hospital and 1-, 6-, and 12-month clinical outcomes were analyzed and compared. Correlates of major adverse cardiac events and ST were identified. Baseline clinical characteristics were similar between stent types, although more peripheral vascular disease and family history of coronary artery disease were seen in the SES group, while more unstable angina pectoris at initial diagnosis was more prevalent in the EES group. The EES group had more type C and distal lesions. There was a higher rate of target vessel revascularization and major adverse cardiac events in the SES group (14.7% vs 10.8%, p = 0.04) at 1 year. ST tended to be higher in the SES group (1.5% vs 0.4%, p = 0.06) at 6 and 12 months. After adjustment, multivariate analysis indicated that the EES group was less likely to have target vessel revascularization and major adverse cardiac events (hazard ratio 0.67, 95% confidence interval 0.47 to 0.95, p = 0.024) and had lower rates of ST (hazard ratio 0.09, 95% confidence interval 0.01 to 0.70, p = 0.022) at 1 year. In conclusion, contemporary use of EES in women is associated with improvement in efficacy and safety profiles compared to SES; however, a large randomized trial is needed to confirm this conclusion.