bluuebunny/crossref_metadata_2025 huggingface dataset:
Increasing the Penetration of Primary Angioplasty in Europe
Authors: Kaifoszova Zuzana , Widimsky Petr ,   Stent for Life Initiative Project Manager Europe, Stent for Life Initiative, Dobrovskeho 28, 170 00 Prague, Czech Republic. E: info@stentforlife.com,   Stent for Life Initiative Past Chairman, Cardiocentre, Third Faculty of Medicine, Charles University Prague
Published: August 2014

Primary percutaneous coronary intervention (PPCI) is recommended by the European Society of Cardiology (ESC) treatment guidelines as the preferred treatment for ST-elevation acute myocardial infarction (STEMI) whenever it is available within 90–120 minutes of the first medical contact. A survey conducted in 2008 in 51 ESC countries found that the annual incidence of hospital admissions for acute myocardial infarction is around 1,900 patients per million population, with an incidence of STEMI of about 800 per million. It showed that STEMI patients’ access to reperfusion therapy and the use of PPCI or thrombolysis (TL) vary considerably between countries. Northern, western and central Europe already have well-developed PPCI services, offering PPCI to 60–90 % of all STEMI patients. Southern Europe and the Balkans are still predominantly using TL. Where this is the case, a higher proportion of patients are left without any reperfusion treatment. The survey concluded that a nationwide PPCI strategy results in more patients being offered reperfusion therapy. To address the inequalities in STEMI patients’ access to life-saving PPCI, and to support the implementation of the ESC STEMI treatment guidelines in Europe, the Stent for Life (SFL) Initiative was launched jointly by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and EuroPCR in 2008. National cardiac societies from Bulgaria, France, Greece, Serbia, Spain and Turkey signed the SFL Declaration at the ESC Congress in Barcelona in 2009. The aim of the SFL Initiative is to improve the delivery of, and STEMI patients’ access to, life-saving PPCI and thereby reduce mortality and morbidity. Currently, 10 national cardiac societies support the SFL Initiative in their respective countries. SFL national action programmes have been developed and are being implemented in several countries. The formation of regional PPCI networks involving emergency medical services, non-percutaneous coronary intervention hospitals and PPCI centres is considered to be a critical success factor in implementing PPCI services effectively. This article describes examples of how SFL countries are progressing in implementing their national programmes, thus increasing PPCI penetration in Europe.
Usefulness and Feasibility of Pocket-size Echocardiography in the Emergency Department
Authors: Van Camp Guy , Droogmans Steven , Kerkhove Dirk , Weytjens Caroline , Cosyns Bernard ,   Head of the Department of Cardiology, Center for Cardiovascular Diseases, UZ Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium. E: guy.vancamp@uzbrussel.be,   Cardiologist, Non-invasive Cardiac Imaging, Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium,   Cardiologist, Non-invasive Cardiac Imaging, Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium,   Cardiologist, Non-invasive Cardiac Imaging, Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium,   Cardiologist, Non-invasive Cardiac Imaging, Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
Published: August 2014

Pocket-size echocardiography (PSE) has entered the clinical arena and is a very attractive tool for point-of-care cardiac ultrasound. It has proven its utility in non-urgent settings such as the outpatient clinic and the patient’s bedside in hospital. In those environments, it increases the diagnostic power of the physical examination and can be seen as a ‘super stethoscope’. The accuracy of PSE is highly dependent on training and expertise. Introducing PSE in the accident and emergency (A&E) department will also increase the diagnostic power of the physical examination; however, in that setting, there is no room for error, and the use of a PSE device should never prevent a patient from undergoing a necessary comprehensive echocardiographic examination. Mobile portable computer ultrasound devices are widely available in the A&E department. This leads to the inevitable question: will literature support the supplementary use of PSE by nonechocardiographists and non-cardiologists in the A&E department, without raising medico-legal issues regarding patient safety? Another setting were PSE could result in a diagnostic bonus, since no competing technology is available, is the ambulance, but in that setting as well education and quality control will be of the utmost importance.
Preventing Sudden Cardiac Death in Patients with Ischaemic Cardiomyopathy
Authors: Floré Vincent , Willems Rik ,   Researcher,   Associate Professor, Division of Cardiology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium. E: rik.willems@uzleuven.be
Published: August 2014

Sudden cardiac death (SCD) is an important cause of mortality. In this article, we review the definition, impact and underlying aetiology of SCD. Ventricular tachyarrhythmia accounts for the majority of SCDs and can be caused by various underlying heart diseases, the most frequent being ischaemic cardiomyopathy. The most effective ways to reduce the risk of SCD in ischaemic cardiomyopathy are the optimal prevention of recurrent coronary ischaemia and the use of an implantable cardioverter-defibrillator (ICD) in high-risk patients. We discuss current patient selection for ICD implantation and focus on the need for, and possibilities to improve, SCD risk stratification.
Reprocessing Cardiology Devices – Reviewing 15 Years of Experience in Germany
Authors: Bracklo Marcus , Marczak Ulrike , Chergui Sabiha ,   Chief Executive Officer,   Head of Reprocessing, Vanguard AG,   Vanguard AG, Friedrichstrasse 78, 10117 Berlin, Germany. E: Sabiha.Chergui@vanguard-healthcare.com
Published: August 2014

This article reviews 15 years of experience with the reprocessing of cardiology medical devices in Germany, focusing on the requirements of the German regulatory framework, which, since 2002, are the same for the reprocessing of single-use and multiple-use devices. Since then, single-use device reprocessing has moved from a contentious procedure to the gold standard of product reprocessing in cardiology. In some cases, more than 70 % of single-use devices are now being reprocessed in Germany. The accumulated evidence clearly demonstrates that reprocessing, when carried out by experienced and certified reprocessors with validated skills, is safe, sustainable and brings significant economic benefits.
Telemonitoring in Patients with Heart Failure – Lessons from Recent Randomised Multicentre Trials
Authors: Mortara Andrea ,   Director, Heart Failure Unit, Cardiology Department, Policlinico di Monza, Via Amati 111, 20900 Monza, Italy. E: andreamortara@libero.it
Published: August 2014

Home telemonitoring (TLM) has been proposed as an effective tool to reduce cardiac events in patients with chronic heart failure (HF). In contrast to older and more recent meta-analyses, large randomised multicentre trials have failed to demonstrate any positive effect of TLM on HF rehospitalisation and all-cause mortality. However, these negative results do not preclude the potential role of TLM as an effective system for managing patients with HF. In this article, possible explanations for these negative results are presented and discussed, and a new model of TLM, with investments in technology but above all in personnel and organisation, is suggested.
New Sonographic Imaging Modalities for Carotid Disease Evaluation – A Review
Authors: Sprynger Muriel ,   Chef de Clinique, Centre Hospitalier Universitaire du Sart Tilman, Bâtiment B35, B-4000, Liège, Belgium. E: msprynger@chu.ulg.ac.be
Published: August 2014

Several imaging techniques (such as ultrasounds, computed tomography [CT] scan, magnetic resonance imaging [MRI], positron emission tomography [PET] scan, etc.) can provide interesting information on subclinical atherosclerosis and plaque stability. In fact sonographic imaging techniques can be very useful in this field. All of them have their limitations, but each of them has its own specificity and enlights a specific aspect of atherosclerosis – they are complementary. Will it be possible to one day differentiate high-risk from low-risk carotid plaques and stenosis – differentiate high from low cardiovascular risk patients? Who should or should not be treated? This is a major issue for people dealing with atherosclerosis. This article reviews the new sonographic imaging modalities for carotid valuation.
The Role and Potential of 3D Echocardiography in the Assessment of Mitral Regurgitation
Authors: Apor Astrid , Nagy Anikó , Nagy Andrea , Merkely Béla ,   Consultant Cardiologist, Semmelweis University Budapest, Heart Centre, Városmajor Street 68, Budapest, H-1122, Hungary. E: aporastrid@gmail.com,   Cardiologist,   Consultant Cardiologist,   Head, Heart Centre, Semmelweis University Budapest, Budapest, Hungary
Published: August 2014

Mitral regurgitation (MR) is the most commonly found valvular lesion in echocardiography laboratories. Moderate and severe mitral regurgitation have proven to be associated with increased morbidity and mortality, and surgical reconstruction is recommended in severe cases whenever feasible. Three-dimensional echocardiography (3DE) is superior to conventional echocardiography in the detailed assessment of the specific anatomical features and the pathomechanism of MR, and in the accurate grading of its severity. 3DE is adept in detecting and quantifying geometric distortion of the mitral annulus and analysing valve mechanics. Segmental analysis of leaflet pathology is considerably facilitated and quantification software packages offer new parameters for tailored surgical repair techniques. Direct visualisation of the anatomic regurgitant orifice and calculations of the effective regurgitant orifice area by 3D colour Doppler techniques promise to circumvent the limitations of conventional echocardiography in the quantification of mitral regurgitation.
Heart Failure with Preserved Ejection Fraction – A Review
Authors: Smiseth Otto A , Opdahl Anders , Boe Espen , Skulstad Helge ,   Department of Cardiology and Institute for Surgical Research, Rikshospitalet Oslo University Hospital, Medical Faculty, University of Oslo, Oslo, Norway Rikshospitalet Oslo University Hospital, N-0027 Oslo, Norway. E: osmiseth@ous-hf.no,   Department of Cardiology and Institute for Surgical Research, Rikshospitalet Oslo University Hospital, Medical Faculty, University of Oslo, Oslo, Norway,   Department of Cardiology and Institute for Surgical Research, Rikshospitalet Oslo University Hospital, Medical Faculty, University of Oslo, Oslo, Norway,   Department of Cardiology and Institute for Surgical Research, Rikshospitalet Oslo University Hospital, Medical Faculty, University of Oslo, Oslo, Norway
Published: August 2014

Heart failure with preserved left ventricular ejection fraction (HF-PEF), sometimes named diastolic heart failure, is a common condition most frequently seen in the elderly and is associated with arterial hypertension and left ventricular (LV) hypertrophy. Symptoms are attributed to a stiff left ventricle with compensatory elevation of filling pressure and reduced ability to increase stroke volume by the Frank–Starling mechanism. LV interaction with stiff arteries aggravates these problems. Prognosis is almost as severe as for heart failure with reduced ejection fraction (HF-REF), in part reflecting co-morbidities. Before the diagnosis of HF-PEF is made, non-cardiac aetiologies must be excluded. Due to the non-specific nature of heart failure symptoms, it is essential to search for objective evidence of diastolic dysfunction which, in the absence of invasive data, is done by echocardiography and demonstration of signs of elevated LV filling pressure, impaired LV relaxation or increased LV diastolic stiffness. Antihypertensive treatment can effectively prevent HF-PEF. Treatment of HF-PEF is symptomatic, with similar drugs as in HF-REF.
Diagnosis and Treatment of Pulmonary Hypertension
Authors: Charalampopoulos Athanasios , Gibbs J Simon R ,   Cardiology Clinical Fellow, 11A Park Avenue, West Twyford, NW10 7EX, London, UK. E: Athanasios.Charalampopoulos@imperial.nhs.uk,   Senior Lecturer in Cardiology, Honorary Consultant Cardiologist, National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
Published: August 2014

Pulmonary hypertension is a relatively common finding in patients with left heart disease and lung hypoxic disease. Nonetheless, some types of pulmonary hypertension, such as pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension, are rare. Despite the rarity of these diseases their impact on patients’ lives and healthcare system is significant because of their poor prognosis. In this review article we describe step-by-step the diagnostic algorithm for all types of pulmonary hypertension, focusing on the early detection of signs and symptoms of the disease. We are also reviewing the current vasodilatory treatments for pulmonary arterial hypertension and the therapeutic options for chronic thromboembolic pulmonary hypertension.
A Review of Sleep Apnoea and its Treatment in Cardiovascular Disease – An important Intervention in Cardiology?
Authors: Woehrle Holger , Müller-Ehmsen Jochen , Erdmann Erland ,   Medical Director, ResMed Science Centre, Martinsried and Consultant, Sleep and Ventilation Centre Blaubeuren, Blaubeuren,   Assistant Professor and Consultant, Heart Centre, University of Cologne, Cologne,   Director, Department of Internal Medicine III, Heart Centre, University of Cologne, Cologne, Str. 62, 50937 Cologne, Germany. E: erland.erdmann@uni-koeln.de
Published: August 2014

Sleep-disordered breathing (SDB) is a common finding in patients with cardiovascular disease (CVD). SDB can cause negative effects on the cardiovascular system and can contribute to the worsening of the underlying disease. Obstructive sleep apnoea (OSA) is a major independent risk factor for the manifestation and progression of cardiovascular diseases, whereas central sleep apnoea (CSA) and Cheyne-Stokes respiration (CSR) is a common finding in patients with advanced heart failure (HF), possibly leading to further progression. Therapy of SDB can reduce the risk of development and progression of cardiovascular diseases. Continuous positive airway pressure (CPAP) is the treatment of choice for OSA, which has been shown to reduce morbidity and mortality. Adaptive servo-ventilation (ASV) is currently the most effective treatment modality in patients with CSA/CSR and in HF patients, which leads to an improvement of symptoms, but still awaits its evaluation on patients’ prognosis (currently being tested in a large randomised clinical trial). It has to be noted that the beneficial effects for both treatment modalities are strongly dependent on adequate adherence.
A Rare Cardiac Neoplasm Presenting as a Chest Pain
Authors: Tokala Hemasri , Kalavakunta Jagadeesh , Laird-Fick Heather , Kamath Sreenivas , Gupta Vishal ,   Department of Internal Medicine, Michigan State University, B-301 Clinical Center, 138 Service Rd, East Lansing, Michigan 48824, US. E: hemasrit@gmail.com,   Kalamazoo Center for Medical Studies, Michigan State University and Department of Internal Medicine and Cardiology, Borgess Medical Center, Michigan, US,   Department of Internal Medicine, Michigan State University,   Kalamazoo Center for Medical Studies, Michigan State University and Department of Internal Medicine and Cardiology, Borgess Medical Center, Michigan, US,   Kalamazoo Center for Medical Studies, Michigan State University and Department of Internal Medicine and Cardiology, Borgess Medical Center, Michigan, US
Published: August 2014

Cardiac paragangliomas are the rarest primary cardiac tumours and account for less than one percent of cases. A 24-year-old man presented with complaints of sudden onset of chest pain. The pain started suddenly when he was skiing halfway down the slope and went into a tuck position. Physical examination was significant for elevated jugular venous distension. His electrocardiogram revealed diffuse ST elevation suggestive of acute pericarditis. The echocardiogram revealed pericardial effusion with tamponade physiology. He underwent emergent pericardiocentesis, but the effusion rapidly re-accumulated, requiring a second pericardiocentesis. Computed tomography scan of the chest revealed haemorrhage in the anterior left mediastinum with pericardial extension. The patient underwent emergency cardiac surgery. A 5.0 x 4.5 x 3.2 cm mass, diagnosed histopathologically as paraganglioma, was excised without complication. In all cardiac or extra cardiac tumours we should check pre-operatively for hormonal activity and pre-operative and intra-operative adrenergic blockade must be employed in all secretory paragangliomas.
Second- versus First-generation Drug-eluting Stents
Authors: Chitkara Kamal , Gershlick Anthony ,   Department of Cardiology, Glenfield Hospital, Consultant Cardiologist, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK. E: kamalchitkara@yahoo.co.uk,   Department of Cardiology, Glenfield Hospital, University Hospitals of Leicester NHS Trust
Published: August 2014

Drug-eluting stents (DES) have demonstrated their superiority over bare-metal stents (BMS) with respect to in-stent restenosis and the need for repeat revascularisation. BMS and first-generation DES, such as sirolimus-eluting (Cypher®) and paclitaxel-eluting stents (Taxus®), have further improved the results of percutaneous coronary intervention (PCI) by improving early results and reducing the risk of restenosis. However, there is currently a debate as to the safety of these first-generation DES given the potential for late stent thrombosis, especially after discontinuation of dual-antiplatelet therapy. Second-generation DES, such as zotarolimus-eluting (Endeavor®) and everolimus-eluting stents (Xience V®), have recently become available in the US and Europe. The available data already suggest the superiority of the Xience V stent in comparison with 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. This systematic review aims to provide a concise and critical appraisal of the available data to compare first- and second-generation stents.
A Critical Approach to the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) Trial
Authors: Ielasi Alfonso , Lamee Rasha Al , Chieffo Alaide ,   Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan,   Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan; Interventional Cardiology Unit, EMO GVM Centro Cuore Columbus, Milan; Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London,   Interventional Cardiology Unit, San Raffaele Scientific Institute, 60 Via Olgettina, 20100 Milan, Italy. E: chieffo.alaide@hsr.it
Published: August 2014

Management of severe coronary artery disease (CAD), defined as multivessel disease with or without significant left main coronary artery (LMCA) involvement, remains an important topic for debate. Although coronary artery bypass graft (CABG) surgery has been the historical mainstay of treatment, improvements in the field of interventional cardiology, particularly following the introduction of drug-eluting stents (DES), have led to an expansion of the use of percutaneous coronary intervention (PCI) in patients with complex coronary anatomy including severe three-vessel CAD. In view of these changes in the modern DES era, the Synergy Between PCI with Taxus and Cardiac Surgery (SYNTAX) trial was designed to investigate the optimal revascularisation strategy for patients with severe CAD. In this article, the SYNTAX trial is analysed in depth and the implications of its results for contemporary clinical management are discussed in order to ascertain whether PCI can be used appropriately in the management of patients with complex CAD or if CABG should remain the standard of care in most cases of severe CAD.
Best Treatment of Saphenous Vein Graft Lesions
Authors: Sbarzaglia Paolo , Notaristefano Salvatore , Cavallini Claudio ,   Division of Cardiology, S Maria della Misericordia Hospital, Perugia,   Division of Cardiology, S Maria della Misericordia Hospital, Perugia,   Division of Cardiology, Ospedale S Maria della Misericordia, Piazzale Meneghini 1, I-06156 Perugia, Italy. E: claudio.cavallini@ospedale.perugia.it
Published: August 2014

When used as conduits for coronary artery bypass surgery, saphenous vein grafts (SVG) develop atherosclerotic disease that may result in stenosis or occlusion in 50% of patients by 10 years. SVG intervention has become an attractive alternative to reoperation in these patients, but is associated with less favourable acute and long-term outcomes compared with percutaneous coronary intervention (PCI) of native vessels due to a higher incidence of periprocedural micro-embolisation and of late restenosis. The role of protection devices that reduce distal embolisation and no-reflow phenomenon has been well established, and they now represent a ‘must’ for almost all of the procedures of PCI in SVG. The potential role of drug-eluting stents (DES) in improving long-term results of SVG intervention is still debated and, to date, there is no clear evidence of their benefit in relevant clinical end-point. The aim of this article is to examine the best available therapeutic options for patients undergoing PCI of SVG lesions.
Percutaneous Coronary Intervention for Complex Bifurcation Lesions
Authors: Louvard Yves , Marie-Claude Morice , Hovasse Thomas , Lefèvre Thierry ,   Institut Cardiovasculaire Paris Sud, Massy,   Institut Cardiovasculaire Paris Sud, 6, Avenue du Noyer Lambert, F91300 Massy, France. E: Dr.MC.Morice@angio-icps.com,   Institut Cardiovasculaire Paris Sud, Massy,   Institut Cardiovasculaire Paris Sud, Massy
Published: August 2014

Coronary bifurcations are prone to the development of atherosclerosis. They pose technical difficulties for angioplasty treatment and are a predictor of stent thrombosis and restenosis. Treatment of coronary bifurcations is still subject to debate, especially when the side branch (SB) is large, not easily accessible and narrowed by a long lesion. There is currently no indexed treatment for this type of lesion (Medina classification), as the strategy of provisional SB stenting with drug-eluting stents (DES) has proved to be equally efficient as the dualstent technique. Complex techniques are associated with poor outcome in certain lesion types, such as T-stenting when the angle between the two distal branches is small or the crush and culotte technique in the presence of an open angle. Provisional SB stenting may be used when primary dual stenting is required, with a low risk of failure provided that the following guidelines are implemented: stenting of the main branch through the protected SB with a stent diameter adapted to the distal main branch, immediate optimisation of the proximal stent segment (Finet’s law), guidewire exchange, kissing balloon inflation with non-compliant balloons selected according to the diameter of the distal branches and T-stenting of the SB before final kissing inflation.
Limiting Complications During Carotid Artery Stenting in Complex Lesions
Authors: Fanelli Fabrizio , Boatta Emanuele , Lucatelli Pierleone , Passariello Roberto ,   Department of Radiological Sciences, Vascular and Interventional Radiology Unit, ‘La Sapienza’ University of Rome, 324 Viale Regina Elena 00161, Rome, Italy. E: fabrizio.fanelli@uniroma1.it,   Department of Radiological Sciences, Vascular and Interventional Radiology Unit, ‘La Sapienza’ University of Rome,   Department of Radiological Sciences, Vascular and Interventional Radiology Unit, ‘La Sapienza’ University of Rome,   Department of Radiological Sciences, Vascular and Interventional Radiology Unit, ‘La Sapienza’ University of Rome
Published: August 2014

Stroke is the third leading cause of death and permanent disability in the US and Europe. During the last decade, carotid artery stenting (CAS) has gained a role as an alternative option to carotid endoarterectomy (CEA). Both patient selection and plaque morphology are crucial to reduce the risk of complications. Technical aspects such as the employment and selection of different types of cerebral protection devices, distal occlusion balloons, filters, proximal protection systems and stent selection will be widely discussed.
Management and Prevention of Vascular Complications Related to Transcatheter Aortic Valve Implantation and Aortic Aneurysm Repair Procedures – A Technical Note
Authors: Pacchioni Andrea , Nikas Dimitris , Penzo Carlo , Saccà Salvatore , Favero Luca , Pasquetto Gianpaolo , Reimers Bernhard ,   Cardiology Division, Mirano Hospital,   Cardiology Division, Mirano Hospital,   Cardiology Division, Mirano Hospital,   Cardiology Division, Mirano Hospital,   Cardiology Division, Mirano Hospital,   Cardiology Division, Mirano Hospital,   Cardiology Division, Mirano Hospital, via Mariutto 13, 30035, Mirano, Venice, Italy. E: emodinamica@ulss13.mirano.ven.it
Published: August 2014

Transcatheter aortic valve implantation (TAVI) and endovascular aortic repair (EVAR) are increasingly being used as therapeutic options for patients with severe aortic stenosis who are ineligible for surgery and who have aortic aneurysm with suitable anatomical features. These procedures can be associated with severe complications, especially related to vascular access and the use of a large introducer sheath (from 18 to 24 French [Fr]). In this article we describe possible vascular complications emerging during TAVI and EVAR and their appropriate management, beginning with patient selection, the correct way to perform vessel puncture and the use of a vascular closure device, up to the recently proposed cross-over technique, which is thought to minimise the risk of dangerous consequences of vascular damage.
Femoral Closure – Devices and Strategies in 2010
Authors: Holland Benjamin H , Applegate Robert J ,   Section of Cardiology, Wake Forest University School of Medicine,   Section of Cardiology, Wake Forest University School of Medicine, Medical Centre Boulevard, Winston-Salem, NC 27157-1045, US. E: bapplega@wfubmc.edu
Published: August 2014

Vascular closure devices (VCDs) reduce the time to haemostasis and ambulation and improve patient comfort compared with manual compression in patients undergoing vascular procedures from a femoral artery access site. Recent large, single-centre studies andpost hocdata from the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial strongly suggest that newer generations of VCD decrease rates of vascular complications compared with manual compression, in contrast to earlier evaluations of first-generation devices. Unfortunately, utilisation of VCDs remains limited and mitigates the potential benefit that could result from expanded use of these devices. Newer entrants into the VCD market such as Starclose and Mynx are based on extravascular closure methodology. These devices address concerns of intravascular components of a VCD; however, whether these devices reduce vascular complications and bleeding has not been evaluated. In this brief article, we will examine these factors in greater detail and suggest an algorithm for VCD use in clinical practice.
Individualised Antiplatelet Therapy – Is There a Role for Platelet Function Testing in Routine Clinical Practice?
Authors: Jean-Philippe Collet , van Werkum Jochem Wouter ,   Institut de Cardiologie – INSERM U 937, Groupe Hospitalier Pitié-SalpGêtrière, 47–83, Bd de l’hopital, 75013, Paris, France. E: jean-philippe.collet@psl.aphp.fr,   St Antonius Centre for Platelet Function Research and Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands. E: woutervanwerkum@gmail.com
Published: August 2014

Antiplatelet therapies are often used to minimise complications in patients with acute coronary syndromes or who are undergoing percutaneous coronary intervention with stenting. However, the occurrence of ‘high on-treatment platelet reactivity’ associated with the gold standard treatments aspirin and clopidogrel in a subset of individuals limits the efficacy of these drugs. This lack of response, which has been attributed to a genetic polymorphism, is associated with an increased risk of subsequent atherothrombotic events. In recent years, platelet function assays have been used to monitor antiplatelet inhibition. Various tests have been introduced that allow physicians to evaluate pharmacological response and potentially permit risk stratification of patients. While some of these assays have proved to be labour-intensive, the development of point-of-care assays may ease the time burden in clinical practice. Preliminary findings demonstrate the effectiveness of altering therapy based on assay results in terms of improving clinical outcomes, suggesting an important role for platelet function testing in the future of antiplatelet therapy.
Pathology of First-generation Drug-eluting Stents in Humans
Authors: Otsuka Fumiyuki , Nakano Masataka , Yazdani Saami K , Ladich Elena , Kolodgie Frank D , Virmani Renu ,   CVPath Institute, Inc., Gaithersburg,   CVPath Institute, Inc., Gaithersburg,   CVPath Institute, Inc., Gaithersburg,   CVPath Institute, Inc., Gaithersburg,   CVPath Institute, Inc., Gaithersburg,   CVPath Institute, Inc., 19 Firstfield Road, Gaithersburg, MD 20878, US. E: rvirmani@cvpath.org
Published: August 2014

First-generation sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have dramatically reduced restenosis, although concern still exists about the long-term safety of this technology since observational studies have shown a steady increase in the rate of late stent thrombosis (LST), an infrequent but catastrophic complication. Although the mechanisms of LST are multifactorial, our laboratory has demonstrated that delayed arterial healing accompanied by poor endothelialisation is the primary pathogical substrate underlying this event. Delayed arterial healing is associated with penetration of necrotic core, long/overlapping stents and bifurcation stenting, especially in flow divider (high shear) regions. Grade V stent fracture is also associated with adverse pathogical findings including LST and restenosis. Moreover, localised hypersensitivity reaction is exclusive to SES as an underlying mechanism of LST, while malapposition secondary to excessive fibrin deposition is associated with PES. Uncovered struts are still identified in both SES and PES with implant duration beyond 12 months, particularly in stents placed for ‘off-label’ indications. In conclusion, the first generation of drug-eluting stents (DES) certainly reduce neointimal growth but this comes at the price of delayed healing.
Percutaneous Unprotected Left Main Coronary Artery Interventions – Updated Results and Current Recommendations
Authors: Ielasi Alfonso , Chieffo Alaide ,   Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan,   Interventional Cardiology Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy. E: alaide.chieffo@hsr.it
Published: August 2014

Current guidelines recommend coronary artery bypass grafting (CABG) as the treatment of choice for patients who have unprotected left main coronary artery disease (ULMCA). Several registries and two randomised controlled clinical trials have shown that hard end-points such as cardiac death, myocardial infarctions and cerebrovascular events are similar following percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation compared with CABG. However, current American and European guidelines do not endorse PCI as an appropriate alternative to CABG for patients with ULMCA. In this article we review the current evidence on PCI with DES for ULMCA stenosis treatment and propose future directions in this evolving topic of great interest.
Stroke Prophylaxis by Percutaneous Closure of Patent Foramen Ovale and Left Atrial Appendage
Authors: Bartorelli Antonio L , Tondo Claudio ,   Department of Cardiovascular Sciences, University of Milan Via Parea 4, Milan, Italy. E: antonio.bartorelli@ccfm.it,   Centro Cardiologico Monzino, Department of Cardiovascular Sciences, University of Milan
Published: August 2014

Innovative percutaneous procedures for stroke prevention have emerged in the last two decades. Transcatheter closure of the patent foramen ovale (PFO) is performed in patients who suffered a cryptogenic stroke or a transient ischaemic attach (TIA) in order to prevent recurrence of thromboembolic events. Percutaneous occlusion of the left atrial appendage (LAA) has been introduced to reduce stroke risk in patients with atrial fibrillation (AF). The role of PFO and LAA in the occurrence of cerebrovascular events and the interventional device-based therapies to occlude the PFO and LAA are discussed.
New Anticoagulants in Cardiac Surgery
Authors: Head Stuart J , Bogers Ad JJC , Kappetein A Pieter ,   Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam,   Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam,   Department of Cardiothoracic Surgery, Erasmus University Medical Center, Room Bd 569, PO Box 2040, 3000 CA Rotterdam, The Netherlands. E: a.kappetein@erasmusmc.nl
Published: August 2014

Antiplatelet and anticoagulant therapy is a key part of the management of patients undergoing cardiac surgery and one of the cornerstones to prevent complications after coronary bypass or valvular heart surgery. The use of anticoagulants and antiplatelets is life-saving, but these agents also contribute to the risk of bleeding. The only orally active anticoagulants that are licensed for long-term use are vitamin K antagonists (VKAs), such as warfarin and are often prescribed after mechanical heart valve implantation or in case of atrial fibrillation. Bleeding is a significant adverse event. Another major drawback of warfarin is the need for routine coagulation monitoring and even with monitoring, the international normalised ratio is frequently outside the therapeutic range. Development of new antithrombotic drugs has been targeted to improve the clinical benefit by reducing bleeding and thromboembolic complications and improving the ease of use. The many limitations of VKAs have provoked the development of new oral anticoagulants. Recently, dabigatran etexilate and ticagrelor have been introduced as possible substitutes. Furthermore, agents are evaluated to treat patients with acute coronary syndromes. Clopidogrel is often used, but this increases the risk of bleeding in patients in which coronary artery bypass grafting is necessary. This review outlines the alternatives of warfarin and clopidogrel therapy for patients with a mechanical heart valve or who undergo bypass surgery. It also establishes a five-year view for key contenders to replace the existing standard therapy.
Interventional Perspectives on Carotid Stenting – Examining the Trial Data
Authors: Myla Subbarao , Kazemi Sepideh ,   Hoag Memorial Hospital Presbyterian, Medical Director, Cardiac and Endovascular Cath Laboratories and CV Research, 520 Superi or Avenue 330, Newport Beach, CA 92663, US. E: subbaraomyla@yahoo.com,   Hoag Memorial Hospital Presbyterian, Newport Beach
Published: August 2014

Over the past two decades, carotid stenting has been one of the most extensively studied endovascular innovations for stroke prevention. The technique has evolved from a carotid balloon angioplasty, to treating a few hard-to-reach carotid lesions in the thorax or upper cervical and intracranial areas, to treating hostile necks not suitable for carotid endarterectomy. Eventually, refined carotid stenting with distal and more recently, proximal embolic protection rose to the challenge and is now competing for a legitimate position against carotid endarterectomy in the mainstream routine revascularisation of low-risk patients. As we track the evolution of carotid stenting from individual case studies through registries to randomised studies we gain insights into technique, pharmacological therapy, indications and unique complications.
Management of Acute Stroke by Cardiologists
Authors: Hopkins L Nelson ,   Departments of Neurosurgery and Radiology, and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 3 Gates Circle, Buffalo, NY 14209, US. E: lnhbuffns@aol.com
Published: August 2014

Every year in the US, nearly 800,000 patients experience an acute stroke. Stroke is the number one cause of adult disability in the US and poses a serious financial burden. Current treatments focus on re-establishing blood flow to the ischaemic territory or reperfusion, with intravenous thrombolytics, intra-arterial endovascular thrombolytics or mechanical clot retrievers. Comprehensive stroke centres offer the best opportunity for assessment and treatment of stroke patients. However, the number of well-trained neuroendovascular specialists (including neurosurgeons, radiologists, and neurologists) cannot offer 24/7 acute stroke coverage at all of the major centres across the US. One solution that has been proposed and is in fact being utilised at some centres is the use of an interventional cardiologist to treat acute stroke. In this article the background, pitfalls and requirements of cardiologists treating acute stroke are discussed.
Real-life Bifurcation – Challenges and Potential Complications
Authors: Narbute Inga , Jegere Sanda , Kumsars Indulis , Juhnevica Dace , Knipse Agnese , Erglis Andrejs ,   Cardiologist,   Cardiologist,   Cardiologist,   Cardiologist,   Resident Doctor, Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, Riga, Latvia,   Chief, Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital and Professor, Institute of Cardiology, University of Latvia, Pilsonu Street 13, Riga, Latvia, LV1002. E: a.a.erglis@stradini.lv
Published: August 2014

Together with calcified lesions, saphenous vein grafts, chronic total occlusions and unprotected left main lesions, bifurcation lesions are complex lesions that remain among the outstanding challenges of treatment with percutaneous coronary intervention. Bifurcation lesions are associated with increased rates of procedural complications, restenosis and adverse events than lesions in the body of the vessel. The introduction of drug-eluting stents for the treatment of bifurcation lesions has dramatically decreased restenosis rates, especially in patients suffering from diabetes. However, abrupt side branch closure, side branch ostial restenosis and stent thrombosis remain areas where further improvement is needed. Although a provisional T-stent strategy is most often used when side branch stenting is required, there are true bifurcation lesions where the selected use of more complex bifurcation approaches (such as the crush technique, T-stenting or the culotte technique) seem appropriate, particularly when the main branch and side branch are larger vessels with more diffuse side branch disease. The major challenge with any technique is to ensure that the side branch is protected and there is a satisfactory final result. Many technical questions rise in trying to ensure this outcome and lower the risk of intra- and post-procedural complications such as side branch closure and restenosis, stent thrombosis, dissection and fracture of a jailed wire: how can difficult side branch access be solved? How can unfavourable side branch anatomy be re-wired after main vessel stent placement? How can fracture of a jailed wire be avoided? Is side-strut dilation beneficial?
Coronary Chronic Total Occlusion Recanalisation – Current Techniques and Approaches
Authors: Ramanath Vijay S , Thompson Craig A ,   On behalf of the North American Total Occlusion (NATO) Operators: Division of Cardiovascular Medicine, Yale University School of Medicine, Connecticut, US,   On behalf of the North American Total Occlusion (NATO) Operators: Division of Cardiovascular Medicine, Associate Professor of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510, US. E: craig.thompson@yale.edu
Published: August 2014

Coronary chronic total occlusions (CTOs) are among the most challenging coronary artery lesions to treat percutaneously. In the last decade, great strides have been made to develop techniques to improve success rates. While success rates among high-volume operators are >90 %, non-CTO operators still continue to struggle with this lesion subset. Thus, efforts have been made to develop algorithms to help operators achieve successful recanalisation consistently and improve patient outcomes. The North American Total Occlusion (NATO) algorithm emphasises dual coronary injection using two guide catheters, which allows for switching from an antegrade to retrograde approach or vice versa should the initial strategy fail – the so-called ‘hybrid’ approach. Special attention is paid to four angiographic characteristics: 1) location of the proximal cap, 2) lesion length, 3) presence and suitability of collateral vessels for retrograde crossing and 4) location and quality of target vessel distal cap. The ultimate goal of this algorithm is to provide a strategy to achieve successful CTO revascularisation while using the least amount of fluoroscopy, contrast and equipment possible.
Endovascular Abdominal Aortic Aneurysm Repair – Patient Selection and Long-term Outcome Expectations – Current Challenges in 2013
Authors: von Allmen Regula S , Dick Florian , Wyss Thomas R , Greenhalgh Roger M ,   Imperial College Vascular Surgery Research Group, Division of Surgery, Oncology, ReproductiveBiology and Anaesthetics, Charing Cross Hospital, London, UK,   Imperial College Vascular Surgery Research Group, Division of Surgery, Oncology, ReproductiveBiology and Anaesthetics, Charing Cross Hospital, London, UK,   Imperial College Vascular Surgery Research Group, Division of Surgery, Oncology, ReproductiveBiology and Anaesthetics, Charing Cross Hospital, London, UK,   Imperial College Vascular Surgery Research Group, Division of Surgery, Oncology, ReproductiveBiology and Anaesthetics, Emeritus Professor of Surgery, Imperial College at Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK. E: r.greenhalgh@imperial.ac.uk
Published: August 2014

Endografts for repair of abdominal aortic aneurysm were first reported in the late 1980s and commercially available grafts were developed rapidly during the 1990s. This prompted a head-to-head comparison of the new, less invasive, endovascular technology with the existing gold standard of open repair. The first and largest randomised trial of open versus endovascular repair for large aneurysms started in the UK in 1999. Other trials comparing open and endovascular repair followed in the Netherlands, France and the US. Only the UK trial has reported long-term follow-up to 10 years. This has shown no statistically significant difference in long-term survival after open or endovascular repair. Aneurysm-related mortality curves converged at six years, which is described as endovascular aortic repair (EVAR) ‘catch up’ on open repair. It appears that this convergence is probably largely attributable to secondary sac rupture after endovascular repair, which is fatal in about two-thirds of cases. At this point, we have reached a crossroads and only longer-term follow-up data can provide the vital answer to the outcome of endovascular repair in the long run. This article gives a brief overview of the development and the current evidence of endovascular aortic repair and discusses the most important factors that are leading the way to the future of this technology.
The Anatomic–Functional Duality of So-called ‘Significant’ Atherosclerotic Stenosis – Update on Invasive Diagnostic Strategies in Coronaropathy
Authors: Finet Gérard , Rioufol Gilles ,   Department of Coronary Artery and Valvular Diseases and Interventional Cardiology, Cardiovascular Hospital – Hospices Civils de Lyon and Claude Bernard University, INSERM U1060 (CARMEN), Lyon, Hôpital Cardiologique, Groupement Hospitalier Est, 28 Avenue du Doyen Lépine, 69500 Bron Cedex, France. E: gerard.finet@univ-lyon1.fr,   Department of Coronary Artery and Valvular Diseases and Interventional Cardiology, Cardiovascular Hospital – Hospices Civils de Lyon and Claude Bernard University, INSERM U1060 (CARMEN), Lyon, France
Published: August 2014

So-called ‘significant’ atherosclerotic coronary stenosis is defined by a simple binary morphological index of tightness – percent diameter stenosis (%DS >50 %). Invasive diagnosis of atherosclerotic coronary lesions classically comprises two consecutive stages, which can be fairly accurately described as angiographic visual perception and functional deduction. This anatomic–functional duality should be seen as not so much antithetic as causal and finally quite complex. The present update seeks to: define the ambiguous relationship between functional impact and morphology in atherosclerotic coronary stenosis; to specify the means of invasive diagnosis complementing coronary angiography to compensate the anatomic and functional limitations intrinsic to the latter (cross-sectional intravascular ultrasound [IVUS] and optical coherence tomography [OCT] imaging and fractional flow reserve [FFR] determined by pressure guide); and to bring these preliminary considerations to bear on the design of algorithms to guide the use of complementary invasive diagnostic exploration and draw up a novel diagnostic strategy in interventional cardiology (first-line coronary angiography).
Application in Hypertension of Renal Sympathetic Denervation – A Review
Authors: Linz Dominik , Mahfoud Felix , Ewen Sebastian , Schirmer Stephan H , Reil Jan , Ukena Christian , Böhm Michael ,   Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, Geb. 40, D-66421, Homburg/Saar, Germany. E: Dominik.linz@uks.eu,   Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany,   Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany,   Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany,   Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany,   Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany,   Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
Published: August 2014

Afferent and efferent sympathetic nerves of the kidney located in the adventitia of the renal artery are involved in the regulation of blood pressure and play a pathophysiological role in the progression and maintenance of hypertension. Renal sympathetic denervation is a potent and safe catheter-based therapeutic approach for the treatment of patients with resistant hypertension. Clinical trials of renal sympathetic denervation have shown significant reduction in blood pressure, which was associated with a reduction in local renal norepinephrine spillover as well as a reduction of whole body sympathetic activation in resistant hypertensive patients.