bluuebunny/crossref_metadata_2025 huggingface dataset:
483 CORONARY ATHEROSCLEROSIS PHENOTYPES IN FOCAL AND DIFFUSE DISEASE
Authors: Belmonte Marta , Sakai Koshiro , Mizukami Takuya , Leipsic Jonathon , Sonck Jeroen , Norgaard Bjarne L , Ko Brian , Maeng Micheal , Jansen Jesper Moller , Andreini Daniele , Ohashi Hirofumi , Shinke Toshiro , Taylor Charles , Bruyne Bernard De , Collet Carlos
Published: December 2022

Introduction

The pathophysiological interplay between coronary physiology and plaque characteristics remains poorly understood. Pullback pressure gradient (PPG) is a novel physiological index that discriminates focal from diffuse coronary artery disease (CAD) based on coronary physiology. We aimed to compare plaque characteristics using between atherosclerotic patterns defined by coronary physiology.

Methods

Multicenter, prospective, controlled, single-arm study conducted in five countries (NCT03782688). Patients with functionally significant lesions based on invasive fractional flow reserve (FFR<0.80) were included. Subjects underwent coronary computed tomography angiography (CCTA) with quantitative plaque analysis followed by an invasive procedure with optical coherence tomography (OCT) and motorized intracoronary pressure recordings. Fractional flow reserve (FFR) pullback curves were processed to calculate the PPG. The PPG ranges from 0, indicating diffuse disease, to 1, pointing to focal CAD. Focal and diffuse CAD were defined according to the median PPG value.

Results

Overall, 117 patients (120 vessels) were included. The mean age was 64±9, 80% were male, and 22% had diabetes (no difference between focal vs. diffuse). Median PPG was 0.66 [0.54, 0.75]. In CCTA analysis, the plaque burden at minimum lumen area was higher in patients with focal CAD (87±8% focal vs. 82±10% diffuse, p=0.003). Calcifications were significantly more prevalent in patients with diffuse CAD (Agatston score per vessel 50 [9, 166] focal vs. 151 [46, 360] diffuse, p=0.019). In OCT plaque analysis, patients with focal CAD had a significantly higher prevalence of circumferential lipid-rich plaque (37% focal vs. 4% diffuse, p=0.001) and thin-cap fibroatheroma (TCFA 47% focal vs. 10% diffuse, p=0.002). High PPG predicted the presence of TCFA with an AUC of 0.73 (95% CI 0.58 to 0.87). PPG and fibrous cap thickness were negatively correlated (r=-0.55, 95% CI -0.74 to -0.28) independently of FFR.

Conclusions

Atherosclerotic plaque phenotypes associate with intracoronary hemodynamics. Vessels with focal disease (high PPG) had a higher plaque burden and predominantly lipid-rich plaque with a high prevalence of TCFA, whereas calcifications were the hallmark of vessels with diffuse pressure loss.
76 INSIDE VEIN GRAFT FAILURE: A WORK FOR OCT
Authors: Bendandi Francesco , Ciurlanti Leonardo , Chietera Francesco , Mazzapicchi Alessandro , Foroni Marco
Published: December 2022

An 84-years-old woman with prior history of triple coronary artery bypass graft and subsequent percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) for right coronary artery (RCA) was admitted for non-ST-elevation myocardial infarction and newly diagnosed atrial fibrillation. Coronary angiography showed chronic occlusion of native vessels and good flow in all grafts, in absence of critical stenoses. However, SVG for RCA presented a small filling defect of non-univocal interpretation (atherothrombosis, thromboembolus, venous valve). Optical coherence tomography (OCT) was performed for better assessment of the lesion, which was found to be a red thrombus, overlying a ruptured thin-cap fibroatheroma. To reduce the risk of distal embolization, a well-known complication of SVG PCI, direct stenting with conservative stent sizing was performed: everolimus-eluting stent diameter (3,5 mm) was chosen according to mean reference lumen diameter, while length (18 mm) was determined to obtain complete plaque coverage. Repeated OCT showed proximal stent malapposition and underexpansion at the mid portion. The stent was post-dilated with 4,0×12 mm non-compliant balloon and final OCT showed correction of both malapposition and underexpansion.

The presented case offers an example of the advantages of intravascular imaging in diagnosis and treatment of SVG lesions. Venous grafts have high failure rate: up to 12% of graft are occluded before hospital discharge and up to 60% after 10 years. While in the first year graft occlusion is mainly caused by neointimal hyperplasia, after this period neoatherosclerosis is the leading cause of failure, as exemplified in the case. Intravascular imaging, and particularly OCT, may help to elucidate graft failure mechanism, with important implications for treatment strategy. Moreover, SVG interventions have higher incidence procedural complications, particularly no-reflow and periprocedural myocardial infarction, due to high plaque burden and friable atheromatous material. Proposed strategies to mitigate procedural risk include use of embolic protection devices, direct stenting and use of undersized stents. In this complex setting, intravascular imaging can guide stent sizing and optimization, thus reducing procedural complications and long-term lesion failure.
1127 APPLICABILITY OF THE EXCEL TRIAL CRITERIA IN AN ALL-COMERS REAL-WORLD POPULATION OF UNPROTECTED LEFT MAIN PCI
Authors: Castaldi Gianluca , Benedetti Alice , Zivelonghi Carlo , Buongiorno Antonia Luisa , Vermeersch Paul , Agostoni Pierfrancesco
Published: December 2022

Background

The Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is the largest randomized trial comparing percutaneous coronary intervention (PCI) with 2nd generation drug eluting stents (DES) and bypass surgery in unprotected left main disease (ULMD). Our aim was to assess which proportion of patients from a contemporary all-comers population of ULMD-PCI would be eligible for the EXCEL trial and whether these patients showed different short- and long-term outcomes than the rest of the population.

Methods and results

A total of 246 consecutive patients that underwent ULMD-PCI between January 2018 and December 2021, were retrospectively analyzed. After application of the EXCEL trial inclusion ed exclusion criteria, 98 patients (38.9%) were allocated in the "Excel-like" cohort and 148 in the "Non-Excel-like". Baseline characteristics of the two groups were substantially comparable. Mean baseline Syntax Score (SS) was significantly lower in the "Excel-like" patients (Excel 20.1 ± 7.1 VS Non-Excel 23.0 ± 11.2; p-value = 0.025) than the "Non-Excel-like" group with the latter showing also a higher degree of incomplete revascularization (rSS >8: Excel 11.2%.VS Non-Excel 25.7%; p-value 0.005). At 1 year the cumulative major adverse cardiovascular and cerebral events (MACCEs) rates were 7.2% and 17.2% for the "Excel-like" and "Non-Excel-like" patients respectively (Log-rank p-value = 0.03). At last follow-up available the significant difference in MACCEs rate persisted (Excel 19.3%, VS Non-Excel 37%, Log-rank p-value 0.02) and a significant difference in any unplanned revascularization was also shown (Excel 1.5% VS Non-Excel 12.6%; p-value 0.04).

Conclusions

in a contemporary real-world cohort of ULMD-PCI only a minority of the patients could be enrolled in the EXCEL trial. This cohort of patients showed a more extensive revascularization and less clinical events at long-term follow-up despite comparable burden of cardiovascular risk factors and atherosclerotic coronary disease. These findings "challenge" the external applicability of the results of the Excel trial in the routine clinical activity.
209 A COMMON CASE OF AORTIC STENOSIS IN A UNIQUE QUADRICUSPID ANATOMY: MANAGEMENT IN REAL LIFE
Authors: Melania Minnocci , Rampini Francesca , Bagnoli Alberto , Demola Pierluigi , Benatti Giorgio , Tadonio Iacopo , Boriani Giuseppe , Navazio Alessandro , Vignali Luigi , Guiducci Vincenzo
Published: December 2022

A 85-year-old lady with severe dyspnea presented in emergency dept. of our institution in Reggio Emilia last July. Typical signs and symptoms of heart failure were associated with high voltage at ECG and echocardiographic findings show a reduced EF (40%) with trans-aortic mean gradient of 42 mmHg, aortic valvular area of 0.8 cm2 and moderate aortic regurgitation.

At CT scan analysis, a dismorphic quadricuspid aortic valve (QAV) was detected. This is a rare congenital heart disease generally unrelated to other cardiac abnormalities and usually diagnosed incidentally. Due to QAV stenosis rarity, many considerations in Trans Aortic Valve Implantation (TAVI) in QAV are unclear.

Some individuals with QAV develop aortic regurgitation and rarely other cardiovascular complications such as aortic aneurysm. Because of its infrequency, it is difficult to characterize these patients and standardize their management. Tailored therapy is more than ever necessary.

Our patient also had bicameral pacemaker for grade II Mobitz 2 atrioventricular blockage. At coronarography angiography mild atheromasia was detected;

AngioCT reconstructions in figure 1 panel A and B show the presence of QAV. Severe wall atheromasia along the entire course of the aorta was also detected.

A few days later the patient underwent the TAVI procedure. A coronary guidewire was positioned in right coronary artery in order to protect its ostium that was slightly lower and, as known from literature, QAV has a longer leaflet height and a shallower cusp depth. After implantation of a Balloon Expandable Valve, a chimney stenting was also performed.

An excellent final result was achieved with a safe deployment and a 90/10 final position (last aortography frame in Figure 2, where both coronary arteries are well visible).

Post-procedural echo follow-up showed a well functioning aortic prosthesis (with mean gradient of 9 mmHg).

The case presented is particularly interesting mainly for three reasons: Extreme rarity of this condition that can be challenging especially in the elderly people with calcific valve affected by stenosis and regurgitation;Paucity of procedural data in literature on QAV;It is a real life management example with subsequent successful implantation of the BEV and chimney stenting in QAV;
666 OBSTRUCTIVE CORONARY ARTERY DISEASE: WHEN CORONARY ANGIOGRAPHY IS NOT ENOUGH.
Authors: Di Paolantonio Diana , Falcone Stefania , De Ponti Roberto
Published: December 2022

Background

Coronary angiography is the gold standard approach to assess coronary artery disease, especially in acute settings. Additional morphological and functional methods such as intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve or instantaneous wave free ratio (FFR or iFR) are used to confirm hemodynamic relevance of stenoses, to characterise plaque morphology and vessel size and to optimise stent implantation. This abstract presents a clinical case in which intracoronary imaging, in particular OCT, was essential in proper diagnosis and treatment of a patient presenting with acute coronary syndrome (ACS).

Case Summary

A 43-year-old female patient with no cardiac medical history presented with new onset chest pain occurring at rest from the night before. At admission, a 12-lead ECG showed sinus rhythm with negative T-waves in the precordial leads, hypokinesia of the anterior and apical wall of the left ventricle was found at echocardiography, and high sensitive cardiac troponin was slightly elevated at the first two measurements. The patient was admitted to the Intensive Coronary Unit with the diagnosis of non-ST segment elevation myocardial infarction and underwent coronary angiography within 24 hours of presentation. A slightly inhomogeneous distribution of dye was found at the ostium of left anterior descending artery (LAD). It was interpreted as a possible type 3 spontaneous coronary artery dissection or as the presence of a non obstructive stenoses. No significant findings were observed in the other cardiac vessels. Due to the discrepancy between the clinical presentation and the angiographic findings, additional morphological and functional assessment of LAD was performed. The OCT revealed the presence of an eccentric obstructive plaque on ostial LAD, and the functional study with FFR confirmed the hemodynamic significance of the stenosis. The patient therefore underwent revascularization with drug-eluting stent implantation on left-main/LAD axis; post-angioplasty OCT confirmed the correct stent position. The patient remained hemodynamically stable during the following hospital stay and was discharged on day 7, with a preserved global left ventricular function and persistence of apical wall hypokinesia, slow ECG evolution with regression of negative anterior T-waves and no sign of necrosis was also observed.

Discussion

There are several angiographically undetectable lesions that can be identified only by IVUS or OCT. In this case the angiographic findings were of difficult interpretation, coronary angiography alone would have been inconclusive and would have led to the diagnosis of myocardial infarction with non-obstructive coronary arteries. This case highlights the importance of intravascular imaging and functional study to guide revascularization also in the acute settings of an ACS.
840 ASSESSMENT OF ABSOLUTE CORONARY FLOW AND MICROVASCULAR RESISTANCE RESERVE IN PATIENTS WITH AORTIC STENOSIS
Authors: Gallinoro Emanuele , Paolisso Pasquale , Vanderheyden Marc , Esposito Giuseppe , Bertolone Dario Tino , Belmonte Marta , Bermpeis Konstantinos , Fabbricatore Davide , De Colle Cristina , Candreva Alessandro , Penicka Martin , Collet Carlos , Sonck Jeroen , De Bruyne Bernard , Barbato Emanuele
Published: December 2022

Introduction

The development of left ventricular hypertrophy in patients with severe aortic stenosis (AS) is accompanied by adaptive coronary flow regulation, both in epicardial and microvascular compartment, which ultimately lead to a chronic ischemic insult even in the absence of obstructive coronary artery disease. Intracoronary continuous thermodilution of saline through a dedicated infusion catheter (RayFlow ®) is a novel tool that allows to measure absolute coronary flow and microvascular resistance at rest and during hyperemia and to calculate both coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR)

Purpose

We aimed to assess absolute coronary flow, microvascular resistance, CFR and MRR in patients with AS, assessed by continuous intracoronary thermodilution, comparing these hemodynamic findings with a propensity-score matched contemporary cohort of patients without AS.

Methods

Absolute coronary blood flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and compared to 15 controls matched for age, gender, diabetes mellitus and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and LAD-specific mass were quantified by echocardiography and cardiac-CT.

Results

Patients with AS presented a significantly positive LV remodeling with lower global longitudinal strain and higher global work index compared to controls (p<0.02). Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS. Compared to matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (86 [66–107] ml/min vs 68 [52–75] ml/min, p=0.036), resulting, in lower CFR (2.30 ± 0.69 vs 2.89 ± 0.77, p=0.005) and MRR (2.73 ± 0.74 vs 3.53 ± 0.95, p=0.005) in the AS cohort compared to controls (Figure 1). No differences were found in hyperemic flow and resting and hyperemic resistances. Interestingly, hyperemic myocardial perfusion (calculated as the ratio between the absolute coronary flow subtended to the LAD and expressed in mL/min/g), but not resting, was significantly lower in the AS group (1.9 [1.5–2.5] ml/min/g vs 2.3 [2–3.1] ml/min/g p=0.036).

Conclusions

In patients with severe aortic stenosis and non-obstructive coronary artery disease, with the progression of LVH, the compensatory mechanism of increased resting flow maintains an adequate perfusion at rest, but not during hyperemia (Figure 2). As consequence, both CFR and MRR are significantly impaired.
851 REPEATABILITY OF BOLUS AND CONTINUOUS THERMODILUTION FOR ASSESSING CORONARY MICROVASCULAR FUNCTION
Authors: Gallinoro Emanuele , Paolisso Pasquale , Bertolone Dario Tino , Bermpeis Konstantinos , Fernandez-peregrina Estefania , Esposito Giuseppe , Belmonte Marta , Vanderheyden Marc , Fabbricatore Davide , Sonck Jeroen , Barbato Emanuele , Collet Carlos , De Bruyne Bernard
Published: December 2022

Introduction

The bolus thermodilution-derived index of microcirculatory resistance (IMR) has emerged over years as the standard of reference to invasively define coronary microvascular dysfunction (CMD). However, the technique still presents some limitations, mainly related to the fact that manual injection of saline bolus accounts for some variance in the measurements. Continuous intracoronary thermodilution has been recently introduced as a tool to directly quantify absolute coronary flow and microvascular resistance both at rest and during hyperemia and has shown to be safe and operator independent. Microvascular resistance reserve (MRR), derived from continuous thermodilution, has been validated as novel index specific for microcirculation and independent from myocardial mass.

Purpose

To compare head-to-head the intra-observer repeatability of bolus and continuous thermodilution for assessing microvascular function.

Methods

Patients undergoing coronary angiography in the absence of obstructive coronary artery disease were prospectively enrolled. Bolus and continuous intracoronary thermodilution measurements were performed in duplicates in the left anterior descending artery (LAD). Patients were randomly assigned in a 1:1 ratio to undergo first bolus thermodilution or first continuous thermodilution assessment.

Results

A total of 102 patients were enrolled. Average FFR was 0.86±0.06. Coronary Flow Reserve (CFR) calculated with continuous thermodilution (CFRthermo) was significantly lower than bolus thermodilution-derived CFR (CFRbolus) (2.63±0.65 and 3.29±1.17, respectively, p<0.001). CFRthermo showed a lower variability and a higher agreement than CFRbolus (variability 12.74 ± 10.41% vs 31.26±24.85%, respectively, p<0.001; ICC= 0.78 (0.70-0.85) and 0.48 (0.32-0.62), respectively, p<0.001, Figure 1). Both MRR and IMR showed a good agreement (ICC 0.81 (0.74-0.87) and 0.80 (0.71-0.86)) but the variability of the MRR was significantly lower (12.44 ± 10.06% vs 24.24±19.27, respectively, p<0.001, figure 1). Reproducibility data of all indices derived from duplicated measurements of bolus and continuous thermodilution are reported in Figure 2.

Conclusion

Continuous intracoronary thermodilution has a higher repeatability than bolus thermodilution in the assessment of CMD.
487 LEFT MAIN TRIFURCATION RESTENOSIS: A COMBINED STRATEGY FOR A COMPLEX ANATOMICAL SCENARIO
Authors: Gioia Francesco Paolo , Ferrante Giuseppe , Liccardo Gaetano , Barberis Giancarlo
Published: December 2022

Unprotected left main trifurcations (ULMT) are highly challenging lesions for the interventionalist. There is still no evidence on the best revascularization strategy, and the risk of short-term procedural complications and long-term adverse outcomes remains high.

We report the case of a 62-years-old with multiple risk factors and a high bleeding risk attributable to severe pancytopenia. Due to an episode of unstable angina, he underwent coronary angiography showing a left main stem (LM) trifurcation with critical ostial left anterior descending (LAD) stenosis, and a proximal LAD sub-occlusive lesion extending to the ostium of the first diagonal (D1) Percutaneous coronary intervention (PCI) consisted of intravascular ultrasound (IVUS)-guided deployment of two drug-eluting stents (DES) from LM to mid-LAD.

One year later he was admitted for chest pain relapse. Coronary angiogram demonstrated critical in-stent restenosis at the proximal LAD and sub-occlusions of ostial ramus intermediate (RI) and ostial circumflex (Cx) (Figure 1).

Re-do PCI consisted of multiple pre-dilations and deployment of a DES on proximal-mid LAD within the previous stent, with two sequential triple kissing inflations on LAD-RI-Cx (Figure 2). Angioplasty on RI and Cx was accomplished with two drug-coated balloons (DCBs) kissing inflation, followed by final triple kissing, with an optimal angiographic result (Figure 3).

In our opinion, the combined use of DCBs and main branch stenting, further optimized by multiple triple kissing balloons, seems to be the most harmonious approach to treat such complex coronary lesions, where the use of multiple stenting strategies might be an overly cumbersome strategy, especially when an intrinsic bleeding risk makes long or powerful anti-thrombotic protocols not feasible.
303 IMPACT OF LEAD POSITION IN THE TRICUSPID ANULUS ON THE DEVELOPMENT OF CARDIAC IMPLANTABLE ELECTRONIC DEVICES RELATED TRICUSPID REGURGITATION
Authors: Gitto Mauro , Fazzari Fabio , Del Monaco Guido , Monaco Maria Lo , Lisi Costanza , Regazzoli Damiano , Frontera Antonio , Reimers Bernhard , Monti Lorenzo , Francone Marco , Mangieri Antonio , Colombo Antonio , Sticchi Alessandro
Published: December 2022

Introduction

Originally considered as the “forgotten valve disease”, tricuspid regurgitation (TR) has recently been shown to correlate with consistent morbidity and mortality, suggesting the need for a deeper understanding of its natural course. Direct injury from Cardiac Implantable Electrical Device (CIED) leads is one of the most common causes of primary TR, with a prevalence up to 40%. The aim of the present proof-of-concept study was to evaluate the effect of CIED right ventricular (RV) lead position within the tricuspid anulus on TR development.

Methods

Consecutive patients undergoing CIED implantation at our institution (Humanitas Research Horpital IRCCS, Milan, Italy) were included, as long as they had been performed pre- and post- transthoracic echocardiogram (TTE) and a chest CT scan after the implantation. TTE and CT images were retrospectively reviewed. TR severity was graded using a pre-specified 4-class grading scheme: mild, moderate, severe and massive. CIED RV lead position was defined as postero-septal, antero-septal or antero-posterior, based on the commissure in which the lead was observed on a cross-sectional view of the tricuspid anulus at CT scan.

Results

64 patients undergoing CIED implantation from January 2015 to December 2021 were included. All CT scans were non-ECG gated. TR was detected in 42 patients (65.62%) at pre-implantation TTE. The RV lead was implanted across the postero-septal, antero-posterior and antero-septal commissures in 35 (54.7%), 16 (25%) and 13 (20.3%) patients respectively. After the implantation, 12 individuals (18.75%) had new-onset or worsening TR, with CIED lead contributing to TR in 46.88% of cases (30/64), and 26 (40.63%) had worse RV function. At logistic regression analysis, the absence of atrial fibrillation was the only independent predictor of new-onset or worsening TR (OR: 0.17, 95% CI: 0.03-0.86, p=0.032), while CIED RV lead in the postero-septal commissure was associated with a numerically lower risk as compared to other sites (OR: 0.34, 95% CI: 0.09-1.27, p=0.108). Consistently, the degree of increase in TR severity was numerically lower in patients with a lead in the postero-septal commissure (Δ = 0.38±0.10 vs. 0.63±0.13, p=0.07).

Conclusions

CIED implantation is associated with increasing TR severity and worsening RV function. Positioning a lead across the postero-septal commissure of the tricuspid anulus might have a lower impact on TR development and worsening, thus representing a feasible option to prevent CIED-related TR.
215 PREDICTORS OF RECURRENT CEREBRAL ISCHEMIA AFTER PATENT FORAMEN OVALE CLOSURE: A SINGLE CENTER OBSERVATIONAL STUDY
Authors: De Gregorio Mattia , Gurgoglione Filippo Luca , Vignali Luigi , Cattabiani Maria Alberta , Solinas Emilia , Benatti Giorgio , Tadonio Iacopo , Barocelli Federico , Tuttolomondo Domenico , Indrigo Elia , Signoretta Gianluca , Ardissino Diego , Niccoli Giampaolo
Published: December 2022

Background

Transcatheter patent foramen ovale (PFO) closure is an effective therapy in patients with cryptogenic stroke (CS) or transient ischemic attack (TIA) and evidence of PFO. However, the incidence of recurrent cerebral ischemia is not negligible and underlying pathogenic mechanisms remain largely unknown. We sought to evaluate the magnitude of the problem and to assess predictors of recurrent stroke/TIA after transcatheter PFO closure.

Methods

We enrolled non-randomized consecutive patients who underwent PFO closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2004 and 2021. Clinical, echocardiographic and procedure-related features were collected for each patient. The incidence of recurrent ischemic neurological events was assessed at follow-up.

Results

We enrolled a total of 154 patients. The primary indication for PFO closure was previous stroke (85 [55.2%] subjects) and a third of patients (51 [33.1%]) suffered from migraine, 22 [14.3%] with and 29 [18.8%] without aura. Moreover, mean Risk of Paradoxycal Embolism (ROPE) score at hospital admission was 6.4 ± 1.5. After a median follow-up of 112 months, the incidence of recurrent cerebral ischemia occurred in 13 [8.4%] patients, with an annualized rate of 0.92/100 patients. The presence of migraine, obesity and ROPE < 7 were independent positive predictors of recurrent stroke/TIA.

Conclusion

The presence of obesity, a familiar history of CVD, ROPE < 7 and migraine were independent positive predictors of recurrent ischemic neurological events after PFO closure.
372 PLATYPNEA-ORTHODEOXIA SYNDROME CAUSING POSITIONAL DYSPNEA AND ARTERIAL DESATURATION IN AN ELDERLY WOMAN: A CASE REPORT
Authors: Monte Marco Angelo , Di Salvo Maria Elena , Capodanno Davide , Tamburino Corrado
Published: December 2022

A 72-years-old woman was admitted to the Emergency Department due to acute stroke in April 2022. Some days later the patient developed acute respiratory failure with oxygen arterial desaturation (SpO2 <80%). Interestingly, she experienced deep hypoxia when she was in the orthostatic position, with partial resolution in the supine position, thus necessitating continuous oxygen therapy. Her pertinent medical history included hypertension for which she was taking valsartan 80 mg daily and bisoprolol 2.5 mg daily, obstructive sleep apnea syndrome under treatment with nocturne continuous positive airway pressure, thyroidectomy for multinodular goiter in replacement therapy with levothyroxine 100 mcg daily, and anxious-depressive syndrome for which she was taking trazodone 75 mg daily and escitalopram 10 mg daily. Given her presentation, our top differential diagnosis included acute pulmonary embolism, pneumonia, Sars-CoV-2 infection, and platypnea-orthodeoxia syndrome. The patient was then admitted to the Pneumology Department, where she underwent computed tomography angiography, which was negative for acute pulmonary embolism and pneumonia, and two SARS-CoV-2 nasal swabs, which were both negative. The transcranial Doppler showed a high-grade shunt (curtain effect). The transesophageal echocardiography with bubble test showed a lipomatous and aneurismatic interatrial septum with a massive right-to-left shunt through a patent foramen ovale (PFO) during the Valsalva maneuver. In the absence of other obvious cause of the positional desaturation and hypoxia, a diagnosis of platypnea-orthodeoxia syndrome was made. Platypnea-orthodeoxia syndrome is a rare clinical condition difficult to diagnose. However, it represents a potentially reversible cause of positional dyspnea and arterial desaturation. The patient then underwent percutaneous PFO closure with the Gore Septal Occluder 30/30 mm (W.L. Gore and Associates, Inc.) through intracardiac echocardiography guidance without any residual shunt. Although unfavorable anatomical features were present (atrial septal aneurism and lipomatous septum), the procedure was straightforward and without complication. The oxygen saturation on pulse oximeter, which was 91% in supine position with oxygen therapy with FiO2 60% during the procedure, rapidly became 97% soon after the placement of the prosthesis. The patient then experienced relief of the dyspnea and the oxygen therapy was stopped. The clinical follow-up performed three weeks later showed an asymptomatic patient with no limitation of daily physical activity.
210 TAVI WITH SAPIEN 3 ULTRA AND ACURATE NEO2: OUTCOMES FROM A HIGH VOLUME CENTER
Authors: Motta Silvia Crescenzia , Costa Giuliano , Strazzieri Orazio , Di Pietro Elena , Frittitta Valentina , Barbanti Marco , Tamburino Corrado
Published: December 2022

Background

Latest iterations of devices for transcatheter aortic valve implantation (TAVI) have brought refinements to further improve patients outcomes, but comparisons of balloon-expandable Sapien 3 ULTRA (ULTRA) and self-expanding Acurate Neo 2 (NEO2) valves are lacking.

Objectives

To compare hemodynamic and clinical outcomes of patients undergoing TAVI with ULTRA or NEO 2 devices.

Methods

Patients undergoing TAVI with ULTRA and NEO 2 and enrolled in the REPLACE Registry from June 2019 to July 2022 (n=174) were analyzed. The primary efficacy and safety outcomes were VARC-3 device success and early safety, respectively. Secondary outcomes included technical success, 30-day clinical outcomes and echocardiographic device performance.

Results

A total of 119 patients receiving ULTRA (68.4%) and 55 receiving NEO 2 (31.6%) were compared. The primary efficacy (90.8% vs. 87.3%, for ULTRA and NEO2 respectively, p=0.483) and safety (87.4% vs. 85.5%, for ULTRA and NEO2 respectively, p=0.725) outcomes did not differ between patients receiving ULTRA or NEO 2 transcatheter aortic valves. On post-TAVI echocardiography, no cases of severe PVR were detected. The rate of mild-to-moderate paravalvular regurgitation (PVR) was lower in the ULTRA group (0.9% vs. 6.1%, p=0.002), with similar mean transvalvular gradients between the study groups (median 10 vs. 8.5 mmHg, for ULTRA and NEO2 respectively, p=0.11).

Conclusions

In this comparison, device success rates were high with both new-generation devices, with overall low rates of adverse events at 30 days after TAVI. Very low PPI rates were reported with both devices. PVR rates were low, but higher in patients receiving NEO 2.
757 DIRECT ORAL ANTICOAGULANTS OR VITAMIN K ANTAGONISTS IN AFTER TAVR
Authors: Oliveri Federico , Montalto Claudio , Tua Lorenzo , Lanzillo Giuseppe , Compagnoni Sara , Fasolino Alessandro , Gentile Francesca Romana , Ferlini Marco , Pepe Antonella , Visconti Luigi Oltrona , Bongiorno Andrea , Leonardi Sergio
Published: December 2022

Background

Several patients undergoing transcatheter aortic valve replacement (TAVR) also require oral anticoagulation (OAC) for atrial fibrillation (AF) or deep vein thromboembolism. However, the optimal type of OAC strategy (direct oral anticoagulants, DOACs, or vitamin K antagonists, VKA) is still unclear in this setting.

Method

We performed systematic literature research and meta-analysis in PubMed, Medline, and EMBASE databases for studies reporting either all-cause mortality, major/life-threatening bleeding or stroke events.

Results

Ten observational studies and one randomized controlled trial (RCT), including 29,333 patients, were eligible for inclusion. Compared to VKA, DOACs use after TAVR was associated with a modest but significantly lower rates of all-cause mortality (RR 0.88; 95% CI: 0.78-0.99, p-value 0.04). Total stroke events (RR 0.97; 95% CI: 0.76-1.23, p-value 0.79) and major/life-threatening bleeding (RR 0.94; 95% CI: 0.70-1.27, p-value 0.69) were comparable among the two treatments. In the following sensitivity analysis including observational studies only, results in terms stroke events were consistent (RR 1.00;95% CI: 0.75-1.34, p-value 0.99) . However, the overall mortality was comparable between the two treatments (RR 0.88; 95% CI: 0.77-1.00, p-value 0.99), while major/life-threatening bleeding occurred less in the DOACs group (RR 0.80; 95% CI: 0.68-0.94, p-value 0.006).

Conclusion

Considering the totality of published evidence in TAVR patients with a concomitant indication for OAC, DOACs use was associated with reduced all-cause mortality and comparable major/life-threatening bleeding and stroke events compared to VKA.
521 IMPACT OF CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY DERIVED “FULL MOON“ CALCIFICATIONS IN CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTIONS (CTO-PCI)
Authors: Panuccio Giuseppe , Tonini Greta , Erbay Aslihan , Skurk Carsten , Landmesser Ulf , Werner Gerald S , Leistner David M , Abdelwahed Youssef S
Published: December 2022

Background

There is an increasing incidence of chronic total coronary occlusions (CTO). CTO are complex coronary lesions and known to represent a technical challenge for percutaneous recanalization procedures. However, the success rates of CTO- percutaneous coronary interventions (CTO-PCI) have increased tremendously with the continuous innovations in equipment and procedural techniques.

Circular heavily calcified “Full Moon”- like plaques have been observed in CTO patients, however their frequency and relevance for CTO-PCI outcomes remain unclear, despite they can be straightforward identified by Coronary Computed Tomographic Angiography (CCTA) during CT-scans to select the CTO-PCI recanalization strategy.

Purpose

The aim of this study was to investigate the clinical value of CCTA – derived “Full Moon”-like plaques and to analyze its impact on percutaneous CTO recanalization.

Methods and Results

Out of the Charité CTO-PCI registry a total of 29 consecutive patients undergoing CTO-PCI and upstream CCTA-imaging for CTO planning were enrolled into the entire analysis. One patient was excluded due to stent artefacts with insufficient CCTA quality. Within the study cohort 17.9% (n=5) presented a “Full Moon”-like stenosis as CTO-causing target lesion. During CTO-PCI all these lesions (100%) required extensive debulking techniques as rotablation or ultrasound lithoplasty due to difficulties in device crossing compared to 13% (n=3) lesions in the non “Full Moon” group (p<0.001).

In detail, 40% of lesions in the “Full Moon” group had to be prepared by rotablation-therapy (compared to 0% in the non- “Full Moon” group; p<0.05) and 20% of lesions underwent shockwave therapy as compared to 13% non- “Full Moon” lesions (n=3; p=.0.69). However, 40% of the “Full Moon” interventions resulted in a complete failure of crossing the device compared to 13.0% in the non- “Full Moon” group (p=0.15).

Conclusions

: “Full Moon”- like calcification derived by CCTA represents a frequently observed phenomenon in CTO and represents an important predictor for complexity during CTO-PCI. Coronary Computed Tomography can be used to identify such a marker of calcium complexity and therefore to plan the procedure in advance.
417 CLINICAL IMPACT OF HEALED CORONARY PLAQUES: AN OPTICAL COHERENCE TOMOGRAPHY STUDY
Authors: Ricchiuto Alfredo , Zella Samuela , Lombardi Marco , Buonpane Angela , Bianchini Emiliano , Maino Alessandro , Busco Marco , D´amario Domenico , Leone Antonio Maria , Aurigemma Cristina , Romagnoli Enrico , Burzotta Francesco , Trani Carlo , Crea Filippo , Vergallo Rocco
Published: December 2022

Introduction

Pathological studies have shown that many atherosclerotic plaques destabilize without resulting in a clinical manifestation. Recent in vivo studies showed that healed plaques are more common in patients with chronic coronary syndrome (CCS) than in those with acute coronary syndrome (ACS), suggesting that they might be a marker of clinical stability. The aim of the present study was to evaluate the clinical impact of healed coronary plaques detected by optical coherence tomography (OCT) imaging.

Methods

A total of 208 patients with CCS or ACS who underwent OCT imaging of non-target/non-culprit vessels were enrolled. Only non-culprit segments were analyzed. Patients were divided into two groups according to the presence or absence of healed plaques detected by OCT. The incidence of major adverse cardiac events (MACE) at follow-up was assessed, defined as the composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularization (TVR).

Results

Healed coronary plaques were observed in 39.7% of patients, and the prevalence was higher in those presenting with chronic coronary syndrome. Median follow-up time was 4 years, and was not different between the two groups. Patients with healed plaques had a significantly lower incidence of MACE at follow-up (13.6% vs 22%, p=0.019), mainly driven by a lower rate of non-fatal myocardial infarctions (4.9% vs 10.2%, p=0.05). The incidence of cardiac death and TVR was not significantly different between the two groups (1.2% vs. 3.1%, p=0.288; and 13.6% vs. 15.0%, p= 0.187, respectively). At multivariate Cox regression analysis, the presence of plaque disruption was an independent predictor of MACE (odds ratio [OR] 3.33, 95% confidence interval [CI] 1.39-7.98, p=0.007), while the presence of healed plaque was an independent protective factor (OR 0.44, 95% CI 0.22-0.89, p=0.022).

Conclusions

Healed coronary plaques detected by OCT imaging are associated with a favorable clinical outcome at long-term follow-up.
395 ASSESSMENT OF VENTRICULAR ARRHYTHMIAS IN PATIENTS UNDERGOING TRANCATHETER AORTIC VALVE IMPLANTATION (TAVI): IMPACT ON CLINICAL OUTCOME
Authors: Tremamunno Saverio , Gnan Eleonora , Telesca Alessandro , Cambise Nello , Belmusto Antonietta , Gentile Giuseppe , De Vita Antonio , Crea Filippo , Lanza Gaetano Antonio
Published: December 2022

Background

Transcatheter aortic valve implantation (TAVI) in the treatment of severe aortic stenosis has considerably grown in the latest years. There are limited data, however, about predictors of long-term prognosis in this population. Particularly, whether arrhythmic burden is associated with clinical outcome has poorly been investigated.

Methods

We performed 24-hour 3-channel ECG Holter recording (HM) in 284 consecutive patients who underwent TAVI for severe aortic stenosis at our Center within 30 days from a successful procedure (average 10.2 days, range 2-30). For each patient we obtained the number of premature ventricular complexes (PVCs) and the presence of non-sustained ventricular tachycardia (NSVT, ≥3 PVCs with a rate ≥100 bpm). Assessment of clinical events at follow-up was performed by clinical visits or telephone interview of patients or relatives (in case of fatal events). The primary end-point of the study was a composite of cardiovascular death and resuscitation from cardiac arrest (CVE); total mortality was assessed as secondary end-point.

Results

Frequent PVCs (≥30/hour) and episodes of NSVT were found in 49 (20.2%) and 52 (21.4%) patients, respectively. Clinical outcome was obtained for 243 patients (85.6%). At an average follow-up of 3.5 year (range 1.0-8.6), CVE occurred in 25 patients (8.8%) and 64 died (22.5%). Frequent PVCs at HM were detected in 11/25 (44.0%) and 38/218 (17.4%) patients with and without CVE, respectively (p=0.006). Episodes of NSVT were detected in 9/25 (36.0%) and 43/218 (19.7%) patients with and without CVE, respectively (p=0.07). Furthermore, frequent PVCs were present in 18/64 (28.1%) and 31/179 (17.3%) patients dead and alive, respectively (p=0.07), whereas NSVT episodes were detected in 17/64 (26.6%) and 35/179 (19.6%) patients dead and alive, respectively (p=0.29). Frequent PVCs maintained independent association with CVE after correction for confounding variables at multivariable analysis (HR 2.63; 95 CI 1.05-6.62; p=0.04).

Conclusions

Our data indicate that assessment of ventricular arrhythmic burden after TAVI is helpful to identify patients at increased risk of cardiovascular death/cardiac arrest during medium follow-up.
982 NON CULPRIT LESION IN ACS PATIENTS DISCREPANCY BETWEEN HYPERAEMIC AND RESTING INDEXES
Authors: Velato Letizia , Polimeni Alberto , Spaccarotella Carmen , Mongiardo Annalisa , Sorrentino Sabato , De Rosa Salvatore , Indolfi Ciro
Published: December 2022

Background

Multivessel disease occurs in approximately half of patients presenting with STEMI and the best management non-culprit lesions is still unclear. The case reported a patient with inferior STEMI, in which the non-culprit lesion has been evaluated with a “full-physiology” approach by a pressure wire.

Case Description

A 52-year-old woman with a history of hypertension and diabetes was admitted to our center diagnosed with inferior STEMI. Coronary angiography showed a thrombotic occlusion (TIMI 0) of the right coronary artery (culprit lesion) and intermediate stenosis of proximal left anterior descending (LAD). Primary PCI (p-PCI) of the right coronary artery has been performed. After 4 days a stepwise complete physiological approach on the LAD artery has been performed. The physiological study showed a negative discrepancy between FFR - and RFR + with increased index of microvascular resistance (IMR).

Discussion

The fractional flow reserve (FFR) represents the best-known invasive method for the

functional evaluation of intermediate coronary stenosis. Unlike the FFR, the resting flow ratio RFR is a non-hyperemic index that does not require the administration of a vasodilator such as adenosine as does the iwFR. There are many factors that can lead to a negative discrepancy between hyperemic and non-hyperemic indices. In the case presented, the functional values found were: FFR: 0.90 RFR: 0.86 and IMR = 76; CFR = 1.0. The FFR-/ RFR+ disagreement may reflect the attenuating influence of microvascular disease on adenosine-mediated vasodilation. Therefore, we decided to treat the LAD lesion according the RFR value with a DES 3.0×33 mm implantation.

Conclusion

Myocardial infarction can result in altered microvascular and endothelial dysfunction also in the non-culprit territory. The FFR - / RFR + disagreement may reflect the attenuating influence of microvascular disease on adenosine-mediated vasodilation.
1106 CLINICAL AND MULTIMODAL IMAGING FOLLOW-UP OF PATIENTS WITH MYOPERICARDITIS FOLLOWING MRNA COVID-19 VACCINATION
Authors: Ballatore Federico
Published: December 2022

Background

Myopericarditis following coronavirus disease-2019 (COVID-19) vaccine is a described entity, but its evolution is still unclear.

Methods

Patients with a diagnosis of myopericarditis after mRNA COVID-19 vaccine represented our population. Clinical evaluation, laboratory tests and non-invasive cardiac tests were performed at baseline and at six months.

Results

Between January and August 2021, we identified 7 patients with myopericarditis following mRNA vaccination. The median age was 29 years (IQR: 25.5–53.5 years) and all patients were males. The median time from vaccine administration to symptoms onset was 5 days (IQR: 4–7 days); five patients received BNT162b2, two mRNA-1273 and only one patient developed symptoms after first dose of vaccine. The most common symptoms at presentation were chest pain (100%) and fatigue (71.4%). Left Ventricular Ejection Fraction (LVEF) was preserved in 6 of them while was mildly reduced in one (median LVEF: 61.3% [IQR: 60–62.9%]). Late Gadolinium Enhancement was detected at Cardiac Magnetic Resonance in the 42.9% of cases. Treatment was conservative for all patients except one; a pericardiocentesis was necessary due to massive pericardial effusion.

At six months follow-up all patients were asymptomatic with normal troponin level, electrocardiogram and echocardiogram confirming the complete healing of the inflammatory process. Two patients received a COVID-19 vaccine booster dose without evidence of myopericardial involvement.

Conclusions

Myopericarditis associated with mRNA COVID19 vaccination is more frequent in young males and is usually characterized by a benign evolution.
85 ATRIAL FIBRILLATION INCIDENCE IN SARS-COV-2 INFECTED PATIENTS: PREDICTORS AND RELATIONSHIP WITH IN-HOSPITAL MORTALITY
Authors: Maloberti Alessandro , Giannattasio Cristina , Rebora Paola , Occhino Giuseppe , Ughi Nicola , Rizzo Jacopo , Fabbri Saverio , Leidi Filippo , Cartella Iside , Rossetti Claudio , Epis Oscar Massimiliano , Molon Giulio , Bonfanti Paolo , Valsecchi Maria Grazia , Genovesi Simonetta
Published: December 2022

Background

Among the different CardioVascular (CV) manifestation of the COronaVIrus-related Disease (COVID) particular attention has been paid to arrhythmia and particularly to Atrial fibrillation (AF). The aim of our study was to assess the incidence of AF episodes in patients hospitalized for COVID and to evaluate its predictors and its relationship with in-hospital all-cause mortality.

Methods

We enrolled 3435 cases of SARS-CoV2 infection admitted in four hospitals in Northern Italy. We collected data on clinical history, vital signs, Intensive Care Unit (ICU) admission, laboratory tests and pharmacological treatment. AF incident and all-cause in-hospital mortality were considered as outcomes.

Results

145 (4.2%) patients develop AF during hospitalization, with a median time of 3 days (IQR: 0, 11.5) from admission. Incident AF patients were older and had lower eGFR, lower platelet and lymphocytes count and higher C-Reactive Protein (CRP), were admitted more frequently to ICU and more frequently died compared to subjects that didn't present AF. At the Cox regression model significant determinants of incident AF were older age (HR 1.070; 95% CI: 1.048, 1.092), history of AF (HR 2.800; 95% CI: 1.465, 5.351), ischemic heart disease (HR 0.324; 95% CI: 0.130, 0.811) and ICU admission (HR 8.030; 95% CI: 4.511, 14.292). Incident AF was a predictor of all-cause mortality (HR 1.679; 95% CI: 1.170, 2.410), together with age (HR 1.053; 95% CI: 1.042, 1.065), dementia (HR 1.553; 95% CI 1.151, 2.095), platelet count (HR 0.997; 95% CI: 0.996, 0.999) higher CRP (HR 1.004; 95% CI: 1.003, 1.005) and eGFR (HR: 0.991; 95% CI: 0.986, 0.996)

Conclusion

AF present as the main arrhythmia in COVID-19 patients and its development during the hospitalization strongly relates with in-hospital mortality.