Native Lesions Research Articles

Drug eluting balloons as stand alone procedure for coronary bifurcational lesions: results of the randomized multicenter PEPCAD-BIF trial.

We set out to investigate the benefit of distal main or side branch treatment with a DCB compared to POBA in coronary bifurcation lesions. The standard treatment of bifurcation lesions is application of a DES to the main branch with provisional side branch stenting. While this resulted in considerable improvement in overall MACE rate suboptimal side branch results remained a problem. The study was performed from 2011 to 2013 in six German centers. Native bifurcation lesions were included if side branch vessel diameter was ≥2 and ≤3.5mm and no proximal main branch lesions was found. After successful predilatation randomization was performed to either DCB application or no further treatment. Follow-up angiograms for QCA analysis were done after 9months. Primary endpoint was late lumen loss (LLL). 64 patients were successfully randomized. Minimal lumen diameter and grade of stenosis were equal in both groups. Only five stents were used as bail out. Angiographic follow-up was achieved in 75% of patients. No patient died. There was one NSTEMI in the POBA group. Restenosis rate was 6% in the DCB group vs 26% in the POBA group (p=0.045). TLR was necessary in one patient of the DCB group vs three patients of the POBA. The primary endpoint LLL was 0.13mm in the DCB vs 0.51mm in the POBA group (p=0.013). In bifurcation lesions that show only class A or B dissection and recoil not beyond 30% the use of DCBs is a sound strategy.

Abstract 13748: Predictors of Yellow Neointima After Stent Implantation in the Superficial Femoral Artery

Background: Neoatherosclerosis is known to occur after coronary stenting, but whether it occurs following stenting in the superficial femoral artery (SFA) remains unknown. Methods: This study comprised angioscopic evaluations of 149 stents implanted in the 102 SFA lesions from 92 patients from April 2012 to September 2014. Complete neointimal coverage (defined as struts fully embedded and invisible) was found in 87 stents in the 67 native lesions from the 61 patients. We compared characteristics between the cases with (23 stents, 26%) and without yellow neointima (YN) at the site of complete neointimal coverage, and evaluated the predictors of YN. Results: Median follow-up duration was significantly longer in the YN(+) than YN(-) group (370 [interquartile range: 282-884] days vs. 350 [95-394] days, P<0.001), while patient characteristics, medication use, rate of drug-eluting stent and bare-metal stent use (48% vs. 50%, P=1.0), and lesion and procedural characteristics were similar between them. Low-density lipoprotein cholesterol (LDL-C) level at intervention was higher in the YN(+) than YN(-) group (109±25 mg/dL vs. 97±25 mg/dL, P=0.049). At angioscopic follow-up, LDL and total cholesterol (TC) levels were higher in the YN(+) than YN(-) group (109±27 mg/dL vs. 97±25 mg/dL, P= 0.046; and 188±33 mg/dL vs. 172±34 mg/dL, P=0.048, respectively). Conclusions: YN was associated with the degree of dyslipidemia, suggesting the presence of neoatherosclerosis in the SFA following stenting.

Intense PSMA-expression using 68Ga-PSMA PET/CT in a paravertebral schwannoma mimicking prostate cancer metastasis

The prostate-specific membrane antigen (PSMA) is highly expressed in prostate cancer (PC) cells. The recently introduced PSMA-PET/CT has evolved as a powerful imaging tool for staging of PC [1–3]. Albeit the high specificity of PSMAtracers, there are reports of high PSMA-expression in nonprostatic malignant (e.g., renal cell carcinoma, bronchial carcinoma, and glioblastoma) and benign (schwannomas) lesions [4]. These reports raise concerns over the specificity of PSMA-PET imaging indicating the need for thorough review of accompanying morphological images besides exclusive interpretation of and reliance on PSMA-expression in PET. A 69-year-old patient with PC (Gleason 6 [3+3],iPSA 11.3 ng/ml) underwent Ga-PSMA-PET/CT for primary staging. Ga-PSMA-PET/CT showed intense PSMA-expression in the prostate representing the histological proven primary PC (A: MIP). Intense PSMA-expression was also observed in projection on a right paravertebral soft-tissue mass (B-D). Due to pain in the thoracic spine the patient had undergone MRI one month before. Images revealed typical features of a schwannoma showing a slightly hyperintense signal in T2w (E) and dumbbell configuration in coronal T2w stir with pathognomonic growth along the neuroforamen (F). In addition, T1w images showed a native hypointense lesion with inhomogeneous contrast enhancement (G,H). Thus, the patient was diagnosed with local PC without metastatic spread. This case advises caution particularly in patients with solitary Blesions^ as the interpretation of PSMA-PET/CT scans might directly influence therapy guidance (curative surgical vs. palliative medical treatment). In this case, typical MRI features (localization relative to the nerve, typical configuration) [5] as well as a former report of possible positive PSMAexpression in schwannomas [4] led to the diagnosis of this benign lesion.

Prediction of the filter no-reflow phenomenon in patients with angina pectoris by using multimodality: Magnetic resonance imaging, optical coherence tomography, and serum biomarkers

BackgroundAlthough the occurrence of no-reflow during percutaneous coronary intervention (PCI) has been shown to be associated with worse short- and long-term clinical outcomes, the clinical relevance of preventing flow deterioration by using the filter-based distal protection devices (DPDs) is controversial. We investigated predictors of the filter no-reflow (FNR) phenomenon during PCI by using multimodality, such as hyperintense plaques (HIPs) in the coronary artery on T1-weighted imaging (T1WI) non-contrast magnetic resonance, plaque composition by using optical coherence tomography (OCT), and serum biomarkers, in patients with angina pectoris. Methods and resultsFifty lesions from 50 patients with angina were examined. All patients underwent T1WI within 24h before invasive coronary angiography was performed, and preinterventional OCT was performed on a native atherosclerotic culprit lesion. The signal intensity of coronary plaque to cardiac muscle ratio (PMR) was calculated on a standard console of the magnetic resonance system. Of the 50 lesions, 20 lesions showed FNR during PCI, while non-FNR was observed in 30 lesions. A cut-off value >1.85 of PMR had a sensitivity of 65%, a specificity of 93%, a positive predictive value of 87%, and a negative predictive value of 80% for identifying lesions with FNR. Multivariate analysis revealed that the presence of HIPs with PMR >1.85 (p=0.008) was the only independent predictor of the FNR phenomenon during PCI. ConclusionsThis study shows that the presence of HIPs with PMR >1.85 on T1WI was a novel independent predictor of the FNR phenomenon during PCI in angina patients. This result may help in identifying high-risk lesions for no-reflow to deploy filter-based DPDs.

Mesh-covered embolic protection stent implantation in ST-segment-elevation myocardial infarction: final 1-year clinical and angiographic results from the MGUARD for acute ST elevation reperfusion trial.

The MGuard, a bare metal stent covered with a polymer mesh, was designed to reduce distal embolization during percutaneous coronary intervention in ST-segment-elevation myocardial infarction. In the MGUARD for Acute ST Elevation Reperfusion trial, the primary end point of complete ST-segment resolution was significantly improved with the MGuard compared with control. We evaluated 1-year clinical and angiographic results. Patients with ST-segment-elevation myocardial infarction ≤12 hours undergoing primary percutaneous coronary intervention of a single de novo native lesion were randomized to the MGuard versus any commercially available metallic stent (39.8% drug-eluting). Clinical follow-up was performed through 1 year, and angiography at 13 months was planned in 50 MGuard patients. There was no difference in major adverse cardiac events (1.8% versus 2.3%; P=0.75) at 30 days between the groups. Major adverse cardiac events at 1 year were higher with the MGuard, driven by greater ischemia-driven target lesion revascularization (8.6% versus 0.9%; P=0.0003). Conversely, mortality tended to be lower with the MGuard at 30 days (0% versus 1.9%; P=0.04) and at 1 year (1.0% versus 3.3%; P=0.09). Late lumen loss at 13 months in the MGuard was 0.99±0.80 mm, and binary restenosis was 31.6%. In patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, a trend toward reduced 1-year mortality was present in patients treated with the MGuard stent. Target lesion revascularization and major adverse cardiac events rates during follow-up were higher in the MGuard group than in the control stent group, and angiographic late loss of the MGuard was consistent with that expected from bare metal stents. http://www.clinicaltrials.gov. Unique identifier: NCT01368471.

The pathophysiology of Lennox-Gastaut syndrome – a review of clinico-electrophysiological studies

SUMMARYIntroduction.Lennox-Gastaut syndrome (LGS) is a type of therapy-resistant epileptic syndrome. Since the establishment of our Epilepsy Center in 1975 we have performed many studies to assess the clinical symptoms, seizure manifestations, sleep and long-term follow-up of the clinical course and changes on electroencephalographs (EEGs) in patients with LGS.Aim.To review the updated pathophysiology of LGS based on our own clinico-electrophysiological data referring to recent advances in brain research.Methods.All of our previously published and unpublished data were reviewed in order to investigate the pathophysiology of LGS and using PubMed database for relevant literature.Results and Discussion.While LGS usually occurs in infancy, it has become apparent that there is a form of late-onset LGS (L-LGS) that may occur at age eight or older. L-LGS often occurs when there is a history of encephalitis/encephalopathy or status epilepticus. The long-term progression of LGS includes mainly tonic seizures that persist and are the basis of LGS. In approximately 30% of cases, the basic symptoms of LGS remain 10 years or longer after long-term progression, while the rest lose their characteristics, although the condition is residual in 60% of cases and remission occurs in fewer than 10%. Among the characteristic seizures associated with LGS, atypical absence seizures occur in response to a diverse range of EEG features; wherein, while they are mostly short, they are accompanied by a state of enervation along with a tendency for it to be unclear when the seizure has ended. Drop attacks can in fact be categorized into those in which the subject falls over due to hypertonia in the muscles used to maintain body posture and those in which the subject falls over due to loss of tension in the posture-retaining muscles. Tonic seizures range from those manifesting in the form of extremely mild axial muscle tonicity, open eyes and respiratory changes, accompanied by high voltage, fast rhythm (averaging 14 ± 0.4 Hz), or tonicity from axorhyzomelic muscles to the peripheral muscles, accompanying global tonic seizures, and EEG features showing low voltage fast activity (averaging 22 ± 0.6 Hz) from desynchronization. A total of 1191 clinical seizures were recorded upon overnight polysomnography and videotape, and seizure symptoms and their ictal EEGs were analyzed. In LGS, seizure activity increases during slow wave sleep, inhibiting progression into the further sleep stages but falls significantly during rapid eye movement (REM) sleep.Conclusions.From the research into seizure symptoms, clinical progression, sleep and seizures during sleep, it was believed that in LGS epileptic native lesions occur due to mesencephalic reticular formation, in the thalamic reticular system and, as a result of recent of brain physiology research, it is considered that LGS is an epileptic reticulo-thalamo-cortical system disorder. This has been supported by EEG-fMRI findings (Siniatchikin et al., 2011). Further research is therefore necessary to elucidate the role of the reticular formation in controlling the thalamo-cortical networks in humans.

GuideLiner guide extension catheter for difficult coronary intervention: A large, single-centre case series

Background: The GuideLiner (Vascular Solutions, MN, USA) is a mother-and-child catheter enabling increased support for complex percutaneous interventions. There is limited published literature examining its use. Methods: A retrospective review of cases utilising GuideLiner from May 2011 to Feb 2015 was undertaken identifying 72 procedures in 70 patients. Data collected included demographics, presentation, access site, guide type and size, target vessel, lesion complexity, procedural success and complications. Results: All cases used a 5-in-6Fr GuideLiner, with 1 case also using a 7-in-8Fr. 55 (76.4%) were Type C lesions, and 8 (11.1%) were Type B2. 52 (80.6%) had femoral access. The median sheath size was 7Fr. Supportive guides were used in 61 cases (85%). 48 cases were mid or distal native vessel lesions (66.7%), with 2 (2.8%) saphenous vein grafts and 10 (13.9%) chronic total occlusions. GuideLiner success was reported in 61 (85%); final PCI success in 65 (90%). In 2 cases (2.8%) the GuideLiner could not pass into the artery. Complications occurred in 8 cases (11%): 6 (8.3%) cases of coronary dissection related to the guiding catheter or stent edge, 1 (1.4%) wire perforation, 1 (1.4%) acute stent thrombosis and 1 (1.4%) ventricular fibrillation. No complications related to GuideLiner use occurred. Discussion: GuideLiner use was predominantly for difficulty crossing tortuous and calcified lesions in distal vessels despite support of predominantly femoral access with appropriate guides. GuideLiner use was associated with a high proportion of procedural success in these difficult lesions, and provides a valuable adjunct to complex interventions.

Cellular Reprogramming Erases Aberrant DNA Methylation and the Malignant Phenotype in Chronic Myeloid Leukemia

Chronic Myeloid Leukemia (CML) is a myeloproliferative disorder characterized by the presence of the Philadelphia chromosome deriving from the genetic translocation t(9;22)(q34;q11.2) that encodes for the BCR-ABL fusion gene. BCR-ABL is a constitutively active tyrosine kinase believed to be the primary genetic event driving CML development (Daley and Baltimore, 1988; Huettner et al., 2000). Tyrosine Kinase Inhibitors (TKI) targeting the BCR-ABL kinase have revolutionized CML therapy, however, they fail to fully eradicate the disease due to the presence of a drug-resistant stem cell pool that sustains continued growth of the malignant cells. Indeed, discontinuation of TKI results in relapse and/or disease progression.It has been shown that the emergence of leukemic clones resistant to TKI and responsible for CML evolution is correlated with aberrant DNA methylation (Machova Polakova et al., 2013). DNA methylation is a key epigenetic signature implicated in regulation of gene expression (Robertson, 2001), that occurs predominantly within CpG dinucleotides. CpG-rich regions (namely CpG islands) are frequently located within promoter regions (~70%) of human protein-coding genes (Illingworth et al., 2010). Methylation of CpG-rich promoters negatively correlates with gene expression levels and it is considered an important regulatory mechanism for long-term gene silencing (Herman and Baylin, 2003). Although numerous studies have established a link between aberrant promoter DNA methylation and cancer (Costello et al., 2000; Feinberg et al., 2006), the impact of DNA methylation in CML is still poorly understood (Yamazaki et al., 2012), particularly due to the lack of the specific animal models.In this study we tested the functional relevance of aberrant methylome in CML development and investigated the possibility that BCR-ABL oncogene triggers DNA methylation changes leading to an aggressive leukemic phenotype. To this end, we have combined cellular reprogramming (Amabile and Meissner, 2009; Carette et al., 2010; Kumano et al., 2012; Miyoshi et al., 2010; Takahashi et al., 2007), due to its ability to erase tissue-specific DNA methylation and to re-establish an embryonic stem-like DNA methylation state (Mikkelsen et al., 2008), with a previously developed BCR-ABL inducible murine model (Koschmieder et al., 2005). Using this approach, we demonstrate that the presence of a single genetic aberration is sufficient to trigger DNA methylation changes and leads to an aggressive leukemic phenotype. We show that by resetting the normal DNA methylation profile of primary human CML cells through cellular reprogramming, we are able to re-establish normal myeloid differentiation, despite the persistence of the native genetic lesion. Finally, by combining a comprehensive genome-scale methylation analysis with cellular reprogramming of leukemic cells, we elucidate the sequential events driving leukemogenesis and reveal the reciprocal interplay of genetic and epigenetic mechanisms during malignant transformation.In conclusion, these results dissect the role of DNA methylation alterations in CML development and warrant an application of demethylating agents such as 5-azacytidine as adjuvant treatment in therapeutic approaches to CML. DisclosuresMartinelli:Novartis: Speakers Bureau; Bristol Myers Squibb: Speakers Bureau; Pfizer: Speakers Bureau.

A bioresorbable everolimus-eluting scaffold versus a metallic everolimus-eluting stent for ischaemic heart disease caused by de-novo native coronary artery lesions (ABSORB II): an interim 1-year analysis of clinical and procedural secondary outcomes from a randomised controlled trial

Despite rapid dissemination of an everolimus-eluting bioresorbable scaffold for treatment for coronary artery disease, no data from comparisons with its metallic stent counterpart are available. In a randomised controlled trial we aimed to compare an everolimus-eluting bioresorbable scaffold with an everolimus-eluting metallic stent. Here we report secondary clinical and procedural outcomes after 1 year of follow-up. In a single-blind, multicentre, randomised trial, we enrolled eligible patients aged 18-85 years with evidence of myocardial ischaemia and one or two de-novo native lesions in different epicardial vessels. We randomly assigned patients in a 2:1 ratio to receive treatment with an everolimus-eluting bioresorbable scaffold (Absorb, Abbott Vascular, Santa Clara, CA, USA) or treatment with an everolimus-eluting metallic stent (Xience, Abbott Vascular, Santa Clara, CA, USA). Randomisation was stratified by diabetes status and number of planned target lesions. The co-primary endpoints of this study are vasomotion (change in mean lumen diameter before and after nitrate administration at 3 years) and difference between minimum lumen diameter (after nitrate administration) after the index procedure and at 3 years. Secondary endpoints were procedural performance assessed by quantitative angiography and intravascular ultrasound; composite clinical endpoints based on death, myocardial infarction, and coronary revascularisation; device and procedural success; and angina status assessed by the Seattle Angina Questionnaire and exercise testing at 6 and 12 months. Cumulative angina rate based on adverse event reporting was analysed post hoc. This trial is registered at ClinicalTrials.gov, number NCT01425281. Between Nov 28, 2011, and June 4, 2013, we enrolled 501 patients and randomly assigned them to the bioresorbable scaffold group (335 patients, 364 lesions) or the metallic stent group (166 patients, 182 lesions). Dilatation pressure and balloon diameter at the highest pressure during implantation or postdilatation were higher and larger in the metallic stent group, whereas the acute recoil post implantation was similar (0.19 mm for both, p=0.85). Acute lumen gain was lower for the bioresorbable scaffold by quantitative coronary angiography (1.15 mm vs 1.46 mm, p<0.0001) and quantitative intravascular ultrasound (2.85 mm(2)vs 3.60 mm(2), p<0.0001), resulting in a smaller lumen diameter or area post procedure. At 1 year, however, cumulative rates of first new or worsening angina from adverse event reporting were lower (72 patients [22%] in the bioresorbable scaffold group vs 50 [30%] in the metallic stent group, p=0.04), whereas performance during maximum exercise and angina status by SAQ were similar. The 1-year composite device orientated endpoint was similar between the bioresorbable scaffold and metallic stent groups (16 patients [5%] vs five patients [3%], p=0.35). Three patients in the bioresorbable scaffold group had definite or probable scaffold thromboses (one definite acute, one definite sub-acute, and one probable late), compared with no patients in the metallic stent group. There were 17 (5%) major cardiac adverse events in the bioresorbable scaffold group compared with five (3%) events in the metallic stent group, with the most common adverse events being myocardial infarction (15 cases [4%] vs two cases [1%], respectively) and clinically indicated target-lesion revascularisation (four cases [1%] vs three cases [2%], respectively). The everolimus-eluting bioresorbable scaffold showed similar 1-year composite secondary clinical outcomes to the everolimus-eluting metallic stent. Abbott Vascular.

Coronary cardiac allograft vasculopathy versus native atherosclerosis: difficulties in classification.

Cardiac allograft vasculopathy is regarded as a progressive and diffuse intimal hyperplastic lesion of arteries and veins that leads to insidious vessel narrowing and to allograft ischemic disease, such as acute myocardial infarction or sudden cardiac death. The coronary lesions in transplanted hearts are considered as a particular type of arteriosclerosis with many similarities but also significant differences compared to native coronary atherosclerosis. It is particularly difficult for pathologists to systematically classify the lesions and to elucidate their origins, since over time, the allograft immune responses cause vascular pathology characterized by not only the onset of de novo fibrocellular lesions but also remodeling of already-existing native atherosclerotic lesions in the donor heart. Intraplaque hemorrhages, which result from newly formed leaky microvessels, may cause rapid increase of stenosis and generate a substrate for plaque destabilization. Comparing cardiac allograft vasculopathy from explanted hearts at autopsy with native coronary atherosclerosis from hearts removed at transplantation has revealed that ongoing intraplaque hemorrhages are also an important feature of cardiac allograft vasculopathy and may be important factors in the rapid progression of cardiac allograft vasculopathy.

Use of guideliner cathater in saphenous vein graft: A case report

Guideliner catheter (Vascular Solutions, Minneapolis, MN) is a novel, rapid exchange system which allows deep intubation and facilitate equipment delivery through the complex coronary lesions. We describe the use of this device in a percutaneous intervention of a native diagonal lesion through tortious and calcific saphenous vein graft.

Grayscale median analysis of primary stenosis and restenosis after carotid endarterectomy

Several studies have reported that echolucent carotid lesions, as determined by grayscale median (GSM) analysis, are associated with increased perioperative embolic complications during carotid artery stenting (CAS). However, there is limited research of the predictive value of GSM analysis comparing values for primary atherosclerotic lesions in the carotid artery with those for recurrent lesions after carotid endarterectomy (CEA). Retrospective data were collected and analyzed from all patients undergoing CAS from November 2005 to August 2010. Available preoperative images amenable to GSM analysis were processed in Adobe Photoshop (version CS4; San Jose, Calif). Statistical analysis included t-test, Fischer exact test, and generation of a receiver operating characteristic curve. With at least 29 days of follow-up, 212 patients underwent 228 CAS procedures. There were 189 stents placed for primary lesions (CAS for primary stenosis group) and 39 stents placed for restenosis after CEA (CAS for restenosis group). GSM analysis was feasible for 47 patients, and the mean GSM was 45.6 (n = 34; 95% confidence interval, ± 8.3) for the primary stenosis group and 20.5 (n = 13; 95% confidence interval, ±9.6) for the restenosis group (P < .01). The mean time from CEA to CAS intervention for the restenosis group was 8.6 years. There was no statistical difference in procedural individual and combined complications of ipsilateral stroke, 30-day stroke, or 30-day mortality between the CAS for primary stenosis group and the CAS for restenosis group. In the primary stenosis group, the mean GSM was lower in those with procedural complications compared with those without complications (15 ± 22 vs 49 ± 8; P = .02). A low GSM value was associated with increased perioperative risk when CAS was performed for native carotid lesions, but a low GSM value was not associated with higher procedural risk when carotid stenting was performed for carotid stenosis after CEA (restenosis). GSM analysis for restenosis may be altered by the time interval from CEA to restenosis.

Autograft reintervention after the Ross surgery: predictive factors in a prospective series

Purpose: Ross intervention is an alternative to mechanical prosthesis implantation in children and young adults who need aortic valvular replacement.Autograft regurgitation and the need of autograft reintervention are possible complications in these patients. Our Aim was to identify predictive factors of autograft reintervention in a prospective series of a reference cardiovascular surgery hospital. Methods: Since November 1997 to July 2009, a total of 107 patients diagnosed of aortic stenosis, aortic regurgitation or aortic double lesion requiring surgical treatment underwent Ross surgery (mean age 30±11 years, 69% male, 89 patients>14 years). In all of them, a comprehensive clinical and echocardiographic evaluation was performed before the intervention and at discharge, at 6, 12 months and annually after surgery. Results: After up to 15 years of follow up (median 11 years, interquartile rank 9-13 years) 11 patients (10%) required autograft reintervention. Probability of survival free from autograft reintervention at 5 and 10 years was 95% and 89%, respectively. In global series, a larger native pulmonary annulus size was the only factor, associated to autograft reintervention (HR 1.30, IC 95% 1.02-1.73, P=0.03). In patients aged>14 years, univariate analysis showed a significant association of larger native pulmonary annulus size (p=0.03) with autograft reintervention, and a non significant trend for larger native aortic annulus diameter (p=0.08) and double aortic lesion or aortic regurgitation versus pure aortic stenosis (p=0.09). In multivariate analysis, only a larger native pulmonary size (HR 1.38, IC 95% 1.027-1.863, P=0.03) resulted an independent predictive factor of autograft reintervention. Conclusion: Long term after Ross surgery, a not negligible percentage of patients required autograft reintervention. A larger size of the native pulmonary annulus predicted, independently, the need of autograft surgery in the global series and in adult patients.

THU0209 Efficacy of anti-TNF therapy in 15 patients with refractory takayasu’s arteritis: Long term unicentric follow-up

BackgroundTakayasu arteritis (TA) is a rare chronic-relapsing granulomatous vasculitis involving primarily the aorta and its major branches1. TA is associated with considerable morbidity and mortality2. Therapy is based on corticosteroids...

Avaliação muito tardia do uso de stents farmacológicos para tratamento de pacientes com lesões em enxertos de veia safena: experiência de uma década do Registro DESIRE

INTRODUÇÃO: A intervenção coronária percutânea (ICP) em pontes de safena ainda representa um desafio à cardiologia intervencionista, pelas complicações agudas e pela escassez de dados referentes à efetividade tardia dos stents farmacológicos (SFs). MÉTODOS: Entre maio de 2002 e janeiro de 2013, pacientes submetidos a ICP com SF no Hospital do Coração foram incluídos no Registro DESIRE. Avaliamos os resultados de pacientes submetidos a ICP em pontes de safena (grupo 1), que foram comparados aos submetidos a ICP em vasos nativos (grupo 2). RESULTADOS: De um total de 4.655 pacientes, 311 foram incluídos no grupo 1 e 4.344, no grupo 2. O grupo 1 contou com pacientes mais idosos (68,4 ± 9,7 anos vs. 64 ± 11,2 anos; P < 0,01), com mais pacientes do sexo masculino (87,1% vs. 76,7%; P < 0,01) e com maior incidência de comorbidades. Angina instável foi a apresentação clínica mais frequente nesse grupo. Pacientes do grupo 1 receberam stents de maior calibre (3,18 ± 1,11 mm vs. 2,86 ± 0,43 mm; P < 0,01) e foram submetidos menos frequentemente a pré-dilatação (36,3% vs. 50,7%; P < 0,01) e a pós-dilatação (38,3% vs. 58,4%; P < 0,01). Apresentaram mais infarto agudo do miocárdio não-fatal na fase hospitalar (11,3% vs. 4,1%; P < 0,01) e mais eventos cardiovasculares adversos maiores na fase tardia (32,8% vs. 13,9%; P < 0,01), à custa de óbito cardíaco (7,7% vs. 3,2%; P = 0,02) e de revascularização da lesão-alvo (9% vs. 4,3%; P < 0,01). Trombose definitiva do stent foi mais frequente no grupo 1 (3,5% vs. 1%; P < 0,01). CONCLUSÕES: A despeito do inquestionável benefício dos SFs nos resultados tardios de ICP em pacientes complexos, o tratamento de pacientes com lesões em pontes de safena ainda permanece um desafio, com resultados agudos e tardios menos favoráveis que os de pacientes com lesões em vasos nativos.

Two-Year Follow-Up of Outcomes of Second-Generation Everolimus-Eluting Stents Versus First-Generation Drug-Eluting Stents for Stenosis of Saphenous Vein Grafts Used as Aortocoronary Conduits

Second-generation everolimus-eluting stents (EESs) have demonstrated superiority in efficacy and safety compared with first-generation drug-eluting stents (DESs) in the treatment of native coronary artery lesions. The present study evaluated and compared the safety and efficacy of EESs and first-generation DESs in saphenous vein graft lesions. The EES group consisted of 88 patients with 96 lesions, and the first-generation DES group consisted of 243 patients with 317 lesions (sirolimus-eluting stents, n = 212; paclitaxel-eluting stents, n = 105). The end points included target lesion revascularization, target vessel revascularization, major adverse cardiovascular events (composite of all-cause death, myocardial infarction, and target vessel revascularization), and definite stent thrombosis at 2 years. The groups had similar baseline characteristics and graft ages (128.1 ± 77.5 vs 132.4 ± 90.8 months, p = 0.686). The EES group had more type C lesions and less embolic protection device use. The peak postprocedure values of creatinine kinase-MB and troponin I were similar between the 2 groups. Overall, major adverse cardiovascular events occurred in 18.2% of EES patients and 35.0% of first-generation DES patients (p = 0.003), mainly driven by a lower target vessel revascularization rate (6.8% vs 24.5%, p <0.001). The target lesion revascularization rate was lower in the EES group (1.1% vs 11.6%, p = 0.005). Stent thrombosis was low and similar between the 2 groups (0% vs 0.8%, p = 1.000). On multivariate analysis, the type of DES implanted and graft age were the only independent predictors of major adverse cardiovascular events. In conclusion, the superiority of EESs compared with first-generation DESs shown in native artery lesions has been extended to saphenous vein graft lesions and should be considered as the DES of choice for this lesion type.

ASSA13-15-3 The Pattern of Instent Neointimal Formation Compared to Native Atherosclerosis in the Coronary Bifurcation Lesions: Volumetric Intravascular Ultrasound Analysis

Objective To investigate and compare the pattern of instent neointimal formation and native atherosclerosis in the coronary bifurcation lesions by volumetric analysis using systematic intravascular ultrasound (IVUS). Methods This study examined 102 native coronary artery bifurcation lesions and 51 post-stenting bifurcation lesions treated with drug-eluting stents using the T-stenting technique at 9-month follow-up IVUS images for both main vessel and side branch. Three interested segments were analysed: proximal main vessel (MVp) ostium, distal main vessel (MVd) and side branch ostium (SBo). At each segment, four quadrant analysis was performed per 1 mm by measuring the vessel area (stent area in the post-stenting lesions), lumen area and calculating the plaque area for volumetric analysis. Results In the plaque group, the plaque volume differed significantly between the four quadrants (P When the left main (LM) bifurcation (n = 38) was analysed separately, the abcarinal quadrant still had the largest plaque volume and the carinal quadrant the least in all three segments, while the epicardial and myocardial quadrant did not differ in the MVp (P = 0.99). In the MVd and SBo, the plaque volume of myocardial quadrant was still significantly greater than the epicardial quadrant (P In the neointima group, the neointimal volume differed significantly in the MVp and MVd (P = 0.002, P = 0.002, separately), while the four quadrants did not differ in the SB (P = 0.281). In the MVp and MVd, the neointimal volume was larger in the abcarinal than the carinal quadrant (in MVp, 4.8 mm3 [IQR 2.7.6.3 mm3] vs.2.1 mm3 [IQR 0.5.3.9 mm3], P When comparing the eccentricity indices between plaque and neointima groups, there was no difference in the MVp, while the neointima group was significantly smaller than plaque group in the MVd (1.6 [IQR 0.8, 2.8] vs. 4.7 [IQR 2.1, 8.7], P Conclusions The distribution of neointimal proliferation and seems to have a similar pattern to that of atherosclerotic plaque in native coronary arteries, particularly in the main vessel, but the trend is less prominent.

Very Late Evaluation of the Use of Drug-Eluting Stents for the Treatment of Patients with Saphenous Vein Graft Lesions: One-Decade Experience of the DESIRE Registry

Percutaneous coronary intervention (PCI) in saphenous vein grafts remains a challenge for interventional cardiology, due to acute complications and the lack of data on the late efficacy of drug-eluting stents (DESs). Between May 2002 and January 2013, patients undergoing PCI with DES at Hospital do Coração were included in the DESIRE Registry. We evaluated the results of patients undergoing PCI in saphenous vein grafts (group 1), who were compared to those undergoing PCI in native vessels (group 2.) Of a total of 4,655 patients, 311 were included in group 1 and 4,344 in group 2. Group 1 included older patients (68.4 ± 9.7 years vs. 64 ± 11.2 years; P < 0.01), more frequently male (87.1% vs. 76.7%; P < 0.01) with a higher incidence of comorbidities. Unstable angina was the most frequent clínical presentation in this group. Group 1 patients received large caliber stents (3.18 ± 1.11 mm vs. 2.86 ± 0.43 mm; P < 0.01) and were less frequently submitted to pre-dilation (36.3% vs. 50.7%; P < 0.01) and post-dilation (38.3% vs. 58.4%; P < 0.01). They had a higher incidence of non-fatal acute myocardial infarction during hospitalization (11.3% vs. 4.1%; P < 0.01) and late major adverse cardiovascular events (32.8% vs. 13.9%; P < 0.01), at the expense of cardiac death (7.7% vs. 3.2%; P = 0.02) and target-lesion revascularization (9% vs. 4.3%; P < 0.01). Definitive stent thrombosis was more frequent in group 1 (3.5% vs. 1%; P < 0.01). Despite the unquestionable benefit of DESs in the late outcomes of PCI in complex patients, the treatment of patients with saphenous vein graft lesions remains a challenge, with less favorable acute and late results than in patients with native vessel lesions. Avaliação Muito Tardia do Uso de Stents Farmacológicos para Tratamento de Pacientes com Lesões em Enxertos de Veia Safena: Experiência de uma Década do Registro DESIRE A intervenção coronária percutânea (ICP) em pontes de safena ainda representa um desafio à Cardiologia intervencionista, pelas complicações agudas e pela escassez de dados referentes à efetividade tardia dos stents farmacológicos (SFs). Entre maio de 2002 e janeiro de 2013, pacientes submetidos à ICP com SF no Hospital do Coração foram incluídos no Registro DESIRE. Avaliamos os resultados de pacientes submetidos à ICP em pontes de safena (grupo 1),que foram comparados aos submetidos a ICP em vasos nativos (grupo 2). De um total de 4.655 pacientes, 311 foram incluidos no grupo 1 e 4.344, no grupo 2. O grupo 1 contou com pacientes mais idosos (68,4 ± 9,7 anos vs. 64 ± 11,2 anos; P < 0,01), com mais pacientes do sexo masculino (87,1% vs. 76,7%; P < 0,01) e com maior incidência de comorbidades. Angina instável foi a apresentação clínica mais frequente nesse grupo. Pacientes do grupo 1 receberam stents de maior calibre (3,18 ± 1,11 mm vs. 2,86 ± 0,43 mm; P < 0,01) e foram submetidos menos frequentemente a pré-dilatação (36,3% vs. 50,7%; P < 0,01) e a pós-dilatação (38,3% vs. 58,4%; P < 0,01). Apresentaram mais infarto agudo do miocàrdio não-fatal na fase hospitalar (11,3% vs. 4,1%; P < 0,01) e mais eventos cardiovasculares adversos maiores na fase tardia (32,8% vs. 13,9%; P < 0,01), à custa de óbito cardíaco (7,7% vs. 3,2%; P = 0,02) e de revascularizaçâo da lesäo-alvo (9% vs. 4,3%; P < 0,01). Trombose definitiva do stent foi mais frequente no grupo 1 (3,5% vs. 1%; P < 0,01).

Selected Abstracts of the TEEPGI 2013 Workshop (1st to 3rd March 2013)

Background Paravalvular or paraprosthetic leak (PVL) is a complication associated with the surgical/transcatheter implantation of a prosthetic heart valve, more commonly a mechanical than a bioprosthetic valve. Transthoracic echocardiography (TTE) is the most important diagnostic modality for prosthetic valve function/dysfunction. However, TTE often cannot differentiate the PVL from prosthetic regurgitation. Transesophageal echocardiography (TEE) is the modality of choice which is also able to detect small, nonsignificant jets. Case Report We present a case of 78-year-old male who had undergone mitral valve replacement with Epic St. Jude tissue valve 3 years back and now presented to our hospital with NYHA class III dyspnea since few months prior to admission. It was associated with cough with mucoid expectoration along with orthopnea. TTE revealed moderate PAH with increased gradient across bioprosthetic mitral valve with suspicion of peravalvular leak (Fig. 1). Three-dimensional (3D) volume rendering image analysis after cropping suggested oval perivalvular area of leakage which was confirmed with the help of 3D color rendering (Fig. 2). It showed early separation of perivalvular leak from paravalvular area. Discussion The majority of PVL are crescent, oval or roundish-shaped and their track can be parallel, perpendicular or serpiginous. Incidence of PVL, including small nonsignificant jets, is estimated to be as high as 20%.1 TEE is more useful than TTE in evaluating the shape of paravalvular defect. It may also help in assessing eccentric jets and differentiating between single and multiple jets. Major progress in TEE in the area of PVL imaging has been 3D reconstruction.2 A semiquantitative assessment of the size of PVL may be made by measurement of the ratio of total sewing ring circumference to the length of suture dehiscence (&gt;10%: Mild, 10-20%: Moderate, &gt;20%: Severe, &gt;40%: Instability of the prosthetic valve).3 Conclusion The TEE, especially if 3D volume rendering is used along with, provides a systematic method to accurately localize native and prosthetic mitral valve regurgitant lesions. Also, paravalvular leaks may be more easily delineated and quantified using 3D echo. Due to accurate localization of the defects, this modality helps to improve the preoperative assessment and decisions about patients with significant mitral regurgitation.

Retrograde percutaneous coronary intervention via critically degenerated saphenous vein grafts for chronic total occlusion in native coronary arteries

We report the case of a 78-year-old woman with saphenous vein graft (SVG) disease and chronic total occlusion (CTO) in three native coronary arteries [left anterior descending artery (LAD), left circumflex artery, and the right coronary artery], who was successfully treated by percutaneous coronary intervention (PCI) using the retrograde approach via the critically degenerated SVGs. The patient, a 78-year-old woman, presented with sudden chest pain and dyspnea. She had previously undergone coronary artery bypass surgery using SVGs for the three vessels and percutaneous coronary intervention with sirolimuseluting stent placement in the posterolateral branch 13 and 3 years ago, respectively. Electrocardiography revealed ST-segment elevation in leads V1-4, whereas emergent coronary angiography revealed total occlusion in her native coronary arteries. Primary PCI was scheduled. A channel dilator was advanced very smoothly and safely into the distal site of the CTO lesion in the LAD, which showed complete occlusion in the proximal region, via an SVG that was temporally occluded four days earlier. A reverse controlled antegrade and retrograde tracking technique was used to successfully perform percutaneous recanalization. Subsequently, the other two native CTO lesions protected by critically degenerated SVGs were treated with retrograde intervention via the SVGs. The retrograde approach via critically degenerated SVGs is safe, reliable, and fast. If an SVG bypassing the native CTO lesion is critically degenerated, percutaneous coronary intervention should be performed via the SVG.