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Introduction: Compared to bare-metal stents (BMS), drug-eluting stents reduce stent restenosis and improve subsequent revascularization rates. The impact on patients' survival has been the subject of debate., Objective: To assess the long-term (10-year) survival of patients undergoing percutaneous coronary intervention (PCI) with first-generation sirolimus-eluting stents (SES) in comparison with BMS., Methods: In a single-center registry, 600 consecutive patients who underwent successful PCI with SES between April 2002 and February 2003 were compared to 594 patients who underwent PCI with BMS between January 2002 and April 2002, just before the introduction of SES. Clinical and procedural data were collected at the time of intervention and 10-year survival status was assessed via the national life status database., Results: All baseline characteristics were similar between groups except for smaller stent diameter (2.84±0.38 vs. 3.19±0.49 mm; p<0.001), greater stent length (18.50±8.2 vs. 15.96±6.10 mm; p<0.001) and higher number of stents per patient (1.95 vs. 1.46, p<0.001) in the SES group. Overall five- and 10-year all-cause mortality was 9.6% (n=110) and 22.7% (n=272), respectively. The adjusted HR for 10-year mortality in patients undergoing PCI with SES was 0.74 (95% CI 0.58-0.94; p=0.013), corresponding to a relative risk reduction of 19.8%. Other than PCI with BMS, older age, chronic kidney disease, chronic obstructive pulmonary disease and lower ejection fraction were independent predictors of 10-year mortality., Conclusion: To date, this is the longest follow-up study ever showing a potential survival benefit of first-generation sirolimus-eluting stents versus bare-metal stents, supporting prior observations on their sustained efficacy and safety relative to contemporary BMS., (Copyright © 2020. Publicado por Elsevier España, S.L.U.)

Although rheumatic heart disease is becoming uncommon in industrialized countries, its global burden is still significant. We report the case of a 70-year-old male with rheumatic heart disease, who underwent 4 previous heart valve replacement surgeries, and presented to our hospital with refractory heart failure (NYHA functional class IV) due to severe stenosis of a previously implanted tricuspid bioprosthesis. The Heart Team deemed the patient as inoperable/high-risk for surgery. As an alternative, a transcatheter tricuspid valve-in-valve replacement was decided upon and later executed through the right femoral vein, with the insertion of an Edwards SAPIEN XT 29 no. (Edwards Lifesciences, Irvine, CA, USA) through the inferior vena cava, towards the RV, followed by direct implantation in the tricuspid bioprosthesis (valve-in-valve), under rapid pacing, without complications. A substantial clinical and echocardiographic improvement was noted after the procedure and the patient was subsequently discharged in NYHA functional class II. These favourable outcomes persisted through the 1-year follow-up period. This case report adds to the current body of evidence that tricuspid valve implantation stands as a viable and reliable alternative in the treatment of degenerated bioprosthesis in high-surgical-risk patients.

Introduction: Until the development of drug-eluting stents (DES), diffuse in-stent restenosis (ISR) was the main limitation of bare-metal stents in percutaneous coronary intervention (PCI). Among the different treatments available, intracoronary brachytherapy (BT) emerged as one of the most promising, although it was almost abandoned with the increasing use of DES., Objective: To assess the Portuguese experience with 90Sr/90Y beta brachytherapy for the treatment of diffuse ISR regarding long-term (>10 years) major adverse cardiac events (MACE) and angiographic restenosis., Methods: This single-center, retrospective, observational study included 12 consecutive patients treated between January and June 2001, mean age 58.6±9.9 years (range 43-77 years), 11 male. All had chronic stable angina, 75% had dyslipidemia, 58% had hypertension, 50% had peripheral arterial disease, 42% had diabetes and 50% had multivessel disease. Recurrent ISR was present in half of the patients and 11 had normal left ventricular function. After balloon dilatation, BT was performed using an Sr90/Y90 (Novoste Beta-CathTM) beta radiation source. All patients remained under dual antiplatelet therapy until scheduled nine-month follow-up angiography. Patients were followed for the occurrence of death (all-cause and cardiovascular), non-fatal myocardial infarction (MI), revascularization, stent thrombosis and angiographic restenosis. MACE were defined as the combined incidence of cardiac death, MI and urgent target vessel revascularization., Results: In all cases there was both clinical and angiographic success. In a mean follow-up of 10.9±2.5 years, 19 events occurred in seven patients: death in three (25%), only one cardiac (8.3%); ST-elevation MI in one (related to a non-target vessel) (8.3%); and 15 revascularizations in five (42%), of which nine were of the target vessel (mainly in the first two years). There was only one case of probable stent thrombosis. Angiographic restenosis at nine months was 27% (three out of 11 patients), of which two were total occlusions. Ten-year MACE-free survival was 42% (5 patients)., Conclusions: Intracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious, with no late adverse events related to intracoronary radiation., (Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Objectives: The present analysis was performed to evaluate the impact of diabetes mellitus (DM) status on the severity of coronary artery disease (CAD) and current approaches in interventional treatment., Background: Little is known about the effect of DM treated with diet, oral agents, or insulin on lesion characteristics and anatomical pattern of CAD and their interventional treatment., Methods and Results: Patients (n = 46,779) of the contemporary Euro Heart Survey PCI registry with known DM status were included in this analysis. Nondiabetics (n = 35,280, 75.4%) were compared with diabetics treated with diet (n = 1,533, 3.3%), oral agents (n = 7,222, 15.4%), and insulin (n = 2,744, 5.8%). Diabetic patients were older, suffered more frequently from comorbidities and presented more often with cardiogenic shock. The number of severely stenosed (≥ 70%) segments incrementally increased from nondiabetics to insulin-requiring diabetics. The location of lesions did not differ between patients with and without DM. The ratio stenosed/treated segments progressively rose among the four patient cohorts. The severity of DM negatively correlated with the extent of complete revascularization. After adjustment for confounding variables no significant differences in hospital mortality could be observed between patients without DM and diabetics treated with diet, but a significantly higher rate of death was seen in diabetic patients with oral medication and insulin therapy., Conclusions: Although CAD was more severe in patients with DM the percentage of treated segments with ≥ 70% stenosis was lower. Adjusted hospital mortality was increased among diabetics treated with oral medication or insulin, but not among those treated with diet., (Copyright © 2011 Wiley-Liss, Inc.)

Background: The percentage of elderly treated with percutaneous coronary intervention (PCI) has been increasing year by year. Little is known about predictors of hospital mortality in elderly undergoing PCI for acute coronary syndromes (ACS) and stable angina., Methods: Between 2005 and 2008 a total of 47,407 consecutive patients undergoing PCI were prospectively enrolled into the PCI-Registry of the EHS Programme. For the present analysis patients were divided into four categories: ACS patients ≥ 75 (n=4,943) and < 75 years (n=19,446), and patients with stable angina ≥ 75 (n=3,393) and < 75 years (n=19,625). A multiple logistic regression analysis was conducted to detect independent predictors of mortality in patients ≥ 75 years undergoing PCI. In addition, differences in clinical characteristics, procedural details and in-hospital outcomes between the subgroups were evaluated., Results: Patients ≥ 75 years had more co-morbidities, and more severe coronary pathology. The use of guideline-recommended adjunctive therapy and procedural success was high in all groups. The incidence of in-hospital death was highest in ACS patients ≥ 75 years (5.2%) and < 75 years (1.7%), followed by patients with stable angina ≥ 75 (0.5%) and < 75 years (0.2%). Haemodynamic instability and acute ST-elevation myocardial infarction were the strongest determinants of hospital mortality among patients ≥ 75 years with ACS, whereas interventional complications were the most meaningful predictors of death in older patients undergoing elective PCI., Conclusions: Patients ≥ 75 years undergoing PCI face a relatively low risk of hospital death. However, complication rates were significantly higher compared to younger patients, strongly influenced by clinical, angiographic and interventional variables., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Aims: The intra-aortic balloon pump (IABP) is recommended by current guidelines as adjunct in patients with cardiogenic shock, despite the lack of larger clinical trials. We sought to investigate the use and impact on mortality of IABP in current practice of percutaneous coronary interventions in Europe., Methods and Results: Between May 2005 and April 2008 a total of 47,407 consecutive patients undergoing percutaneous coronary intervention (PCI) in 176 centres in 33 countries in Europe and the Mediterranean basin were enrolled into the registry. From these, 8,102 had ST-elevation myocardial infarction and 7,999 non-ST elevation myocardial infarction and cardiogenic shock was observed in 7.9% and 2.1%, respectively. Of the 653 patients with cardiogenic shock 25% were treated with an IABP. In-hospital mortality, with and without IABP, was 56.9% and 36.1%. In the multivariate analysis the use of IABP was not associated with an improved survival (odds ratio 1.47; 95% CI 0.97-2.21, p=0.07)., Conclusions: In current clinical practice in Europe, IABP is used only in one quarter of patients with cardiogenic shock treated with primary PCI. However, there was no hint of a beneficial effect of IABP on outcome. Therefore, a large randomised clinical trial is urgently needed to define the role of IABP in patients with PCI for shock.

Aims: The applicability of currently available risk prediction models for patients undergoing percutaneous coronary interventions (PCIs) is limited. We aimed to develop a model for the prediction of in-hospital mortality after PCI that is based on contemporary and representative data from a European perspective., Methods and Results: Our analyses are based on the Euro Heart Survey of PCIs, which contains information on 46 064 consecutive patients who underwent PCI for different indications in 176 participating European centres during 2005-08. Patients were randomly divided into a training (n = 23 032) and a validation (n = 23 032) set with similar characteristics. In these sets, 339 (1.5%) and 305 (1.3%) patients died during hospitalization, respectively. On the basis of the training set, a logistic model was constructed that related 16 independent patient or lesion characteristics with mortality, including PCI indication, advanced age, haemodynamic instability, multivessel disease, and proximal LAD disease. In both the training and validation data sets, the model had a good performance in terms of discrimination (C-index 0.91 and 0.90, respectively) and calibration (Hosmer-Lemeshow P-value 0.39 and 0.18, respectively)., Conclusion: In-hospital mortality in PCI patients was well predicted by a risk score that contains 16 factors. The score has strong applicability for European practices.

Background: Accurate models to predict mortality are needed for risk stratification in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI)., Methods and Results: We examined 5745 patients with STEMI undergoing primary PCI in the Assessment of Pexelizumab in Acute Myocardial Infarction Trial within 6 hours of symptom onset. A Cox proportional hazards model incorporating regression splines to accommodate nonlinearity in the log hazard ratio (HR) scale was used to determine baseline independent predictors of 90-day mortality. At 90 days, 271 (4.7%) of 5745 patients died. Independent correlates of 90-day mortality were (in descending order of statistical significance) age (HR, 2.03/10-y increments; 95% CI, 1.80 to 2.29), systolic blood pressure (HR, 0.86/10-mm Hg increments; 95% CI, 0.82 to 0.90), Killip class (class 3 or 4 versus 1 or 2) (HR, 4.24; 95% CI, 2.97 to 6.08), heart rate (>70 beats per minute) (HR, 1.45/10-beat increments; 95% CI, 1.31 to 1.59), creatinine (HR, 1.23/10-μmol/L increments >90 μmol/L; 95% CI, 1.13 to 1.34), sum of ST-segment deviations (HR, 1.25/10-mm increments; 95% CI, 1.11 to 1.40), and anterior STEMI location (HR, 1.47; 95% CI, 1.12 to 1.93) (c-index, 0.82). Internal validation with bootstrapping confirmed minimal overoptimism (c-index, 0.81)., Conclusions: Our study provides a practical method to assess intermediate-term prognosis of patients with STEMI undergoing primary PCI, using baseline clinical and ECG variables. This model identifies key factors affecting prognosis and enables quantitative risk stratification that may be helpful in guiding clinical care and for risk adjustment for observational analyses.

Background: The most recent ESC guidelines for percutaneous coronary intervention (PCI) recommend the use of glycoprotein IIb/IIIa inhibitors (GPI) in high risk patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), particularly in diabetics. Little is known about the adherence to these guidelines within Europe., Methods and Results: Between May 2005 and April 2008 a total of 47,407 consecutive patients undergoing PCI were prospectively enrolled into the PCI-Registry of the Euro Heart Survey Programme. In the present analysis we examined the use of GPI in 2,922 diabetics who underwent PCI for NSTE-ACS. In this high risk population only 22.2% received a GPI; 8.9% upstream and 13.4% during PCI. The strategy of the individual institution had a major impact on the usage of GPI. In the multiple regression analysis clinical instability and complex lesion characteristics were strong independent determinants for the use of GPI, whereas renal insufficiency was negatively associated with its use. After adjustment for confounding variables no significant differences in hospital mortality could be observed between the cohorts, but a significantly higher rate of non-fatal postprocedural myocardial infarction was observed among patients receiving GPI upstream., Conclusions: Despite the recommendation for its use in the current ESC guidelines, only a minority of the diabetics in Europe undergoing PCI for NSTE-ACS received a GPI. The use of GPI was mainly triggered by high-risk interventional scenarios.

Aims: To characterize a population with stable coronary artery disease (CAD) in an outpatient setting and to evaluate the importance of resting heart rate (HR), a recently recognized prognostic risk factor., Type of Study: A prospective and observational registry of patients with stable CAD followed mainly by cardiologists in private outpatient clinics., Methods: Patients were selected by at least one of the following inclusion criteria: coronary angiography with at least one significant stenosis; positive stress test; previous myocardial infarction; or revascularization by angioplasty or surgery. Demographics, concomitant diseases, HR, blood pressure (BP), presence of angina and medical therapy were all recorded. Data compilation and statistical analysis were performed by a CRO independent of the sponsor and the investigators., Results: Between May and October 2009, 3477 consecutive patients were included by 186 doctors. Mean age was 66.6 +/- 10.1 years and 26.3% were female, 76% had arterial hypertension, 34% diabetes, 47% previous infarction, 42% angioplasty and 25% coronary surgery. Of concomitant diseases, 13% of patients had peripheral vascular disease or erectile dysfunction. Medical therapy included antiplatelet agents (97%), lipid-lowering agents (92%), beta-blockers (72%), ACEIs (54%), nitrates (39%), calcium blockers (36%), ARBs (28%), ivabradine (24%) and trimetazidine (17%). Mean HR was 67 +/- 12 bpm and 67% of patients had HR > 60 bpm. Mean systolic BP was 134 +/- 18 mmHg and mean diastolic BP was 76 +/- 10 mmHg. Angina was present in 31.3% of patients and 53.4% had class II angina. The population with angina was more severe, 74% had HR > 60 bpm and 68% were taking beta-blockers. In patients with angina and HR > 60 bpm, beta-blocker use was only 64%., Conclusion: In an outpatient population with stable CAD of whom a third had angina, there was an increased number of patients with HR > 60 bpm and decreased use of beta-blockers with increasing disease severity. These findings support increased use of newly developed drugs for the treatment of stable CAD and angina.

Background: Spontaneous reperfusion (SR) in ST elevation myocardial infarction (STEMI) improves clinical outcome, yet its incidence and impact among diabetic patients is unclear., Objective: To carry out a systematic analysis of SR in the diabetic cohort of a large primary percutaneous coronary intervention (PCI)-treated population with STEMI., Methods and Results: 4944 patients (15.5% diabetic) undergoing primary PCI in the APEX AMI study were evaluated. SR defined as pre-PCI Thrombolysis in Myocardial Infarction (TIMI) 3 flow occurred in 11.5% of patients; it was more common in non-diabetic (11.9%) than in diabetic patients (9.2%) (p = 0.028). Patients with SR versus no SR had improved post-PCI TIMI 3 flow: in non-diabetic patients (99.8% vs 90.3%, p<0.001) and in diabetic patients (98.6% vs 84.9%, p<0.001). Non-diabetic patients with SR showed a significant improvement in 90-day death/shock/congestive heart failure (CHF) compared with those without SR: 4.4% versus 8.9% (p = 0.001), respectively. The composite outcome in diabetic patients with versus without SR was 10.0% versus 14.9% (p = 0.270), respectively. When outcomes were examined according to tertiles of baseline blood glucose, both non-diabetic and diabetic patients with normoglycaemia showed higher SR rates (15.5%, 10.3%, 7.3% for non-diabetic patients, p<0.001; 17.4%, 7.2%, 9.1% for diabetic patients, p = 0.132), greater ST resolution (55.4%, 52.6%, 49.7% for non-diabetic patients, p = 0.030; 50%, 46.4%, 39.1% for diabetic patients, p = 0.179), and improved 90-day death/shock/CHF (5.2%, 8.3%, 14% for non-diabetic patients p<0.001; 8.7%, 4.2%, 15.8% for diabetic patients, p = 0.006)., Conclusions: These data indicate that SR is less common in diabetic patients with STEMI. Diabetic patients without SR have worse post-PCI epicardial patency, which contributes to adverse outcomes. Diabetic patients with normal baseline blood glucose and SR have enhanced epicardial flow after PCI and improved prognosis.

Background: In previous randomized studies levosimendan improved hemodynamics and clinical course, with a still unclear effect on prognosis. There are, however, few data regarding its effects when used in daily practice., Aims: We evaluated the clinical effectiveness and safety of levosimendan in the treatment of acute systolic heart failure (SHF) in daily practice conditions., Methods: In this prospective, multicenter, nonrandomized trial, a continuous infusion of levosimendan (0.05 microg/kg/min-0.2 microg/kg/min) was administered for 24 hours. An optional loading dose of 12 microg/kg over 10 minutes was used. The primary combined endpoint of clinical effectiveness (as defined by a eight-variable clinical score) and safety (defined by the absence of serious adverse events) was assessed at 24 hours after the beginning of treatment; a second similar primary combined endpoint was assessed at 5 days., Results: One hundred and twenty-nine consecutive patients requiring inotropes despite optimal oral background heart failure therapy were recruited. The primary endpoint was reached in 80.6% at 24 hours and in 79.7% at 5 days. During the six months before levosimendan the number of patient days of hospitalization for heart failure was 14.9 +/- 14.6 versus 3.1 +/- 7.6 during the six months following levosimendan (p < 0.001)., Conclusions: In daily practice, levosimendan was clinically effective and safe in 80.6% and 79.7% of patients with acute SHF at 24 hours and 5 days respectively after the beginning of treatment. A marked reduction in the number of days of hospitalization for heart failure was also seen during the subsequent six months.

Background: Treatment of patients with in-stent restenosis (ISR) remains a challenge. We sought to compare results of sirolimus-eluting stents (SES) with those of bare-metal stents (BMS) in patients with ISR., Methods: The results obtained in the stent arm of two randomized studies were analyzed. The RIBS I study (450 patients with ISR) allocated 224 patients to BMS; the RIBS II study (150 patients with ISR) allocated 76 patients to SES. Complete 1-year follow-up was obtained in all 300 patients treated with stents., Results: Although inclusion/exclusion criteria were identical in the two studies, when compared with patients in the BMS group, patients in the SES arm had more adverse baseline characteristics, more diffuse lesions, and smaller vessels. However, late angiographic findings including in-segment recurrent restenosis rate (11 vs. 38%, P < 0.001), minimal lumen diameter (2.52 vs. 1.63 mm, P < 0.001), and late loss (0.13 vs. 1.04 mm, P < 0.001) were significantly better after SES. The 1-year event-free survival was also significantly improved in the SES group (88 vs. 78%, P < 0.05), as the result of a lower requirement for repeated revascularizations (10.5 vs. 19.6%, P < 0.05). Prespecified subgroup analyses were consistent with the main outcome measures. After adjusting for (a) imbalances in baseline characteristics (restenosis OR 0.11 [95% confidence interval (CI) 0.03-0.36]; adverse events hazard ratios (HR) 0.33 [95% CI 0.13-0.84]) and (b) the propensity score (restenosis OR 0.08 [95% CI 0.03-0.28]; adverse events HR 0.24 [95% CI 0.09-0.66]), results of the SES group were superior to those obtained in the BMS group., Conclusions: When compared with BMS, SES improved the long-term clinical and angiographic outcome of patients with ISR., (2008 Wiley-Liss, Inc.)

Aims: Recent studies of drug-eluting stents for unprotected left main coronary artery (LMCA) disease have been encouraging. We examined the performance of sirolimus-eluting stents (SES) for this indication., Methods and Results: This retrospective study included 228 consecutive patients (mean age = 68 +/- 11 years, 80.6% men, 26.3% diabetics) who underwent implantation of SES for de novo LMCA stenoses. The mean additive and logistic EuroSCOREs were 5.2 +/- 3.9 and 8.2 +/- 13.2, respectively. The main objective of this study was to measure the rate of major adverse cardiac events (MACE), including death, myocardial infarction and target lesion revascularisation (TLR) at 12 months. Other objectives were to measure the rates of in-hospital MACE and 12-month TLR. Outcomes in 143 patients with (BIF+ group), versus 84 patients without (BIF-group) involvement of the bifurcation were compared. The pre-procedural percent diameter stenosis (%DS) was 60.1 +/- 11.2 in the BIF+ versus 54.7 +/- 12.2% in the BIF- group (p=0.008), and decreased to 18.0 +/- 9.7 and 13.9 +/- 11.3%, respectively (ns), after SES implant. The overall in-hospital MACE rate was 3.5%, and similar in both subgroups. The 1-year MACE rate was 14.5% overall, 16.8% in the BIF+ and 10.7% in the BIF- subgroup (ns)., Conclusions: SES implants in high-risk patients with LMCA stenoses were associated with a low 1-year MACE rate. Stenting of the bifurcation was associated with significant increases in neither mortality nor 1-year MACE rate.

Aims: To assess the effectiveness and safety of sirolimus-eluting stents (SES) in de novo native coronary lesions in small vessels (/= 23 mm).The mean (SD) reference vessel diameter of the treated segment was 2.08 (0.33) mm and lesion length 11.04 (6.0) mm. After six months, LL was 0.07 (0.37) mm. BR was 5.1% in-stent and 9.1% in-segment. At one year, TLR was 5.6% and TVR was 9.0%. MACE rate was 2.6% at six months and 8.6% at one year with 2.3% cardiac death and 1.5% non-fatal myocardial infarction. Stent thrombosis rate at one year was 0.8% per protocol. There were more MACE in diabetic patients (12.8%) than in non-diabetic (5.4%, p=0.046), but no other significant differences in clinical and angiographic parameters were noted between the subgroups analysed., Conclusions: The use of SES for lesions in very small coronary arteries proved to be safe and efficacious, irrespective of the size and length of the stents, with low restenosis and repeat revascularisation rates at one year.

In the main Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) report, we investigated outcomes in 15 245 high-risk hypertensive subjects treated with valsartan- or amlodipine-based regimens. In this report, we analyzed outcomes in 7080 patients (46.4%) who, at the end of the initial drug adjustment period (6 months), remained on monotherapy. Baseline characteristics were similar in the valsartan (N=3263) and amlodipine (N=3817) groups. Time on monotherapy was 3.2 years (78% of treatment exposure time). The average in-trial blood pressure was similar in both groups. Event rates in the monotherapy group were 16% to 39% lower than in the main VALUE trial. In the first analysis, we censored patients when they discontinued monotherapy ("censored"); in the second, we counted events regardless of subsequent therapy (intention-to-treat principle). We also assessed the impact of duration of monotherapy on outcomes. No difference was found in primary composite cardiac end points, strokes, myocardial infarctions, and all-cause deaths with both analyses. Heart failure in the valsartan group was lower both in the censored and intention-to-treat analyses (hazard ratios: 0.63, P=0.004 and 0.78, P=0.045, respectively). Longer duration of monotherapy amplified between-group differences in heart failure. New-onset diabetes was lower in the valsartan group with both analyses (odds ratios: 0.78, P=0.012 and 0.82, P=0.034). Thus, despite lower absolute event rates in monotherapy patients, the relative risks of heart failure and new-onset diabetes favored valsartan. Moreover, these findings support the feasibility of comparative prospective trials in lower-risk hypertensive patients.

Background: The implications of the American College of Cardiology/American Heart Association (ACC/AHA) lesion classification in patients with in-stent restenosis (ISR) are unknown., Methods: Four hundred fifty patients included in the RIBS randomized study were analyzed. A centralized core laboratory assessed ISR classifications including ACC/AHA, the classification of Mehran et al (Circulation 1999;100:1872-8), diffuse/focal, and a new quantitative ISR index (lesion length/stent length). Logistic regression models were constructed for prespecified outcome measures including (1) unsatisfactory acute results and (2) recurrent restenosis rate., Results: Complex (B2/C) lesions (78%) more frequently obtained unsatisfactory acute results (20% vs 8%, P = .007), smaller minimal lumen diameter after the procedure (2.45 +/- 0.5 vs 2.73 +/- 0.5 mm, P = .001) and at follow-up (1.48 +/- 0.8 vs 1.94 +/- 0.8 mm, P = .0001), and had a higher restenosis rate (43 vs 24%, P = .001) than simple (A/B1) lesions. On logistic regression analysis, all classification schemes were useful to predict unsatisfactory initial results (area under the curve: 0.63, 0.61, 0.59, and 0.62) and recurrent restenosis (area under the curve: 0.60, 0.64, 0.61, and 0.63). The predictive ability of these schemes persisted despite adjustment for potential confounders. Although the ACC/AHA classification was a better predictor of acute results, the classification of Mehran was superior to predict restenosis., Conclusions: The ACC/AHA classification provides a useful tool to determine acute procedural results and the long-term angiographic outcome of patients with ISR.

Background: Atherothrombotic coronary artery disease is increasingly recognized as part of a systemic metabolic disorder. However, little is known about the significance of metabolic dysfunction in the setting of acute coronary syndrome., Objective: Our aim was to assess the prognostic implications of markers of metabolic dysfunction at hospital admission obesity (BMI > 30), previous history of hypertension, admission glucose > 128 mg/dl, triglycerides > 150 mg/dl, and HDL cholesterol < 40 mg/dl for men, or < 50 mg for women--in patients with non-ST elevation acute coronary syndromes (ACS)., Methods: A total of 303 consecutive patients admitted to the CCU with ACS were included in the study. Mean age was 63 +/- 10 years, and 86% were male. The primary end-point was a composite of death or non-fatal acute myocardial infarction (MI) at one-year follow-up. Each marker was assigned one point, and a metabolic score (MetScore) was calculated for each individual patient by adding together the number of markers present at hospital admission. Three groups were considered: group 1 (MetScore 0) with 0 markers (n = 30); group 2 (MetScore 1 to 3) with 1 to 3 markers (n = 222); and group 3 (MetScore 4 to 5) with 4 to 5 markers (n = 51)., Results: The cumulative incidence of death or MI was 14.5%. We found a statistically significant relation between MetScore and outcome at one-year follow-up. The event rate was 3.3% in the MetScore 0 group, 13.9% in the MetScore 1 to 3 group and 23.5% in the MetScore 4 to 5 group (p = 0.0114). MetScore was an independent predictor of death or MI at one year, with a 2.3-fold risk increase (95% CI: 1.32-4.01; p = 0.003) from one group to the next. Other variables identified as independent predictors of outcome were advanced age, Killip class, ST-segment depression and previous CABG. The incidence of the primary end-point in diabetic patients without significant metabolic dysfunction and non-diabetic patients with SMD was similar (21.2% vs. 22.7%; p = NS)., Conclusion: Assessment of markers of metabolic dysfunction on admission in patients with non-ST elevation acute coronary syndromes, adds important prognostic information to conventional clinical, ECG and risk stratification markers and could prove useful in establishing secondary prevention strategies.

Background: Heparin coating is an attractive alternative to counterbalance intrinsic stent thrombogenicity and to decrease the incidence of stent thrombosis., Methods: We compared, based on the data of an international multicenter prospective registry, the rates of stent thrombosis after percutaneous coronary interventions in native coronary arteries using a Bx VELOCITY heparin-coated stent versus a bare metal stent of the same design in a total of 3098 patients at high risk for stent thrombosis. Most patients in both groups underwent percutaneous coronary intervention for unstable angina (48.4% vs 47.5%, respectively) with > 25% of the patients treated for acute myocardial infarction (30.8% and 28.1%, respectively)., Results: Procedural success was high and very similar in patients with heparin-coated and bare metal stents (99.3% vs 98.8%, respectively, P = .11). The primary end point, a 30-day stent thrombosis, occurred in 0.6% of the 1417 patients treated with the heparin-coated stent and 0.9% of the 1681 patients treated with the bare metal stent (relative risk reduction 33%, P = .41). The rates of cardiac death, myocardial infarction, and target lesion revascularization did not differ significantly between the groups. By multivariate analysis, variables independently associated with 30-day stent thrombosis included the evidence of thrombus at baseline (odds ratio [OR] 3.0, 95% CI 1.29-7.0, P = .01), small vessel stenting (OR 2.41, 95% CI 1.01-5.74, P = .05), and target left anterior descending artery (OR 2.32, 95% CI 1.00-5.38, P = .05)., Conclusion: This large-scale registry comparing the use of heparin-coated stent versus bare metal stent in the reality of daily practice showed no significant difference in stent thrombosis in patients with a high-risk profile for thrombotic complications.

Background: Triptans are contraindicated in patients with known or suspected coronary artery disease (CAD); however, few studies have evaluated triptans in patients with obstructive CAD to quantify the vasoconstrictive effect on diseased coronary vessels., Methods: Patients undergoing percutaneous transluminal coronary angioplasty for symptomatic single-vessel CAD were randomised to one of three parallel cohorts to receive (1) 6 mg intravenously (IV) infused eletriptan plus subcutaneous (SC) placebo, (2) IV infused placebo plus 6 mg SC sumatriptan or (3) IV infused placebo plus SC placebo, as simultaneous administrations in a double-blind manner. Serial arteriograms, hemodynamic indices, electrocardiography and triptan plasma concentrations were obtained., Results: . Fifteen minutes after triptan challenge, median (95% confidence interval) changes in coronary artery diameter (CADM) at the focal point of the stenosed segment were: dilation of 2.6% (-5.0, 11.4), eletriptan 6 mg IV (n = 18); constriction of 6.8% (-12.6, 0.4), sumatriptan 6 mg SC (n = 17), and constriction of 4.5% (-7.0, 7.9), placebo (n = 10). One patient had angiographic evidence of a new thrombus at the stenosis site, necessitating termination of study infusion and successful stenting of the lesion. There was no correlation between effects on CADM and triptan concentration, or between hemodynamic or electrocardiograph changes and the presence (n = 13) or absence (n = 33) of chest pain., Conclusions: Triptans had very little effect on diseased epicardial coronary arteries in a small group of angina sufferers with established CAD. Results should be interpreted cautiously since there may be instances where even modest triptan-associated epicardial constriction is sufficient to precipitate myocardial ischemia in patients with severe obstructive CAD.

Background: There is disagreement concerning the prognostic value of a prior history of percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation acute coronary syndromes (ACS). This study characterizes these patients and investigates the impact of prior PCI on their prognosis., Methods: 448 consecutive patients admitted due to ACS between 1998 and 2000 were evaluated. Patients with prior PCI were compared to the others with regard to baseline demographic and clinical features. The study endpoint was death or myocardial infarction at one-year follow-up. The impact of prior PCI on the outcome was analyzed. In patients with prior PCI, the prognostic value of the time interval between PCI and current admission was assessed. In those patients who underwent coronary angiography during the index hospitalization, the culprit lesion features were evaluated., Results: 134 patients (30%) with prior PCI were identified. Overall ACS patients had an event rate of 19% at one year. A history of prior PCI was not an independent predictor of outcome, but in the 44 patients with PCI performed during the 117 days before the index hospitalization, the event rate was significantly higher (30% versus 13%). Prior PCI in the previous 117 days was an independent risk predictor (adjusted OR 4.81; 95% CI, 1.57-14.71; p = 0.006). In these patients restenosis was the most frequent culprit lesion (60% versus 30%; p = 0.003)., Conclusions: In ACS patients, a history of PCI in the previous four months is an independent predictor of adverse outcome at one-year follow-up.

Introduction: Patients with coronary heart disease and left ventricular dysfunction are at increased risk for the development of ventricular tachycardia (VT) related to areas of myocardial fibrosis. Although the mechanism and the circuit of this arrhythmia are well understood, little is known about the triggers that precipitate VT episodes. Purkinje fiber potentials may be responsible for idiopathic VT, and recent studies have related them to polymorphic VT and ventricular fibrillation., Methods: Between January 2002 and December 2003, we performed ablation in 10 patients with coronary heart disease, left ventricular systolic dysfunction and VT refractory to pharmacological therapy. All patients had implantable cardioverter-defibrillators. Electroanatomical activation and voltage mapping (CARTO) and electrophysiological criteria (premature activation during VT, pace mapping, and presence of diastolic potentials) were used to define scar regions, slow conduction areas and the reentry circuit isthmuses., Results: Spike potentials were recorded in the scars of three patients. These potentials were almost fused with the ventricular electrogram during sinus rhythm, and were more premature during VT, probably reflecting local activation of Purkinje fibers. During ablation, we were able to dissociate the spike from the ventricular electrogram, thus terminating the VT. In the cases with conduction recovery, ventricular; ectopic beats recurred, preceded by a spike and degenerating into short runs of VT. The ablation strategy was not modified since persistence of the VT required the isthmus., Conclusion: The results suggest that residual Purkinje fibers may be present in scar regions and that the activity of these fibers may trigger VT in pre-established circuits.

Aims: Regarding prognosis, patients with a non-ST elevation acute coronary syndrome (ACS) are a very heterogeneous population, with varying risks of early and long-term adverse events. Early risk stratification at admission seems to be essential for a tailored therapeutic strategy. We sought to compare the prognostic value of three ACS risk scores (RSs) and their ability to predict benefit from myocardial revascularization performed during initial hospitalization., Methods and Results: We studied 460 consecutive patients admitted to our coronary care unit with an ACS [age: 63+/-11 years, 21.5% female, 55% with myocardial infarction (MI)]. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Platelet glycoprotein IIb/IIIa in Unstable agina: Receptor Suppression Using Integrilin (PURSUIT), and Global Registry of Acute Coronary Events (GRACE) RSs were calculated using specific variables collected at admission. Their prognostic value was evaluated by the combined endpoint of death or MI at 1 year. The best cut-off value for each RS, calculated with receiver operating characteristic curves, was used to assess the impact of myocardial revascularization on the combined incidence of death or MI. Death or MI at 1 year was 15.4% (32 deaths/49 MIs). The best predictive accuracy for death or MI at 1 year was obtained by the GRACE RS (AUC) [area under the curve: 0.715; confidence interval (CI: 0.672-0.756)] but the performance of the PURSUIT RS (AUC: 0.630; CI: 0.584-0.674), and TIMI RS (AUC: 0.585; CI: 0.539-0.631) was also good. We found a statistically significant interaction between the risk stratified by the best cut-off value for the GRACE and PURSUIT RSs and myocardial revascularization, with a better prognosis for the high-risk patients. The high-risk patients represented 36.7, 28.7, and 57.8% of the population, for the GRACE, PURSUIT, and TIMI RSs, respectively., Conclusion: The RSs studied demonstrated a good predictive accuracy for death or MI at 1 year and enabled the identification of high-risk subsets of patients who will benefit most from myocardial revascularization performed during initial hospital stay.

Background: The exercise test has a recognized lower risk of complications when used in the general population and in coronary artery diseased patients, but from a theoretical point of view should have a higher rate of complications when performed in patients with chronic heart failure (CHF)., Aims: To characterize and assess the type and incidence of complications during cardiopulmonary stress test (CPX) in patients with depressed left ventricular systolic function in comparison with a group of patients and individuals with normal function., Methods: Retrospective analysis of the 334 consecutive CPX performed for risk stratification in 198 patients with a left ventricular ejection fraction below 40% (Group A) and 180 consecutive CPX performed in 78 subjects with normal function (Group B). The two groups were compared with respect to demographic data, CPX parameters and specific complications., Results: Major complications during the tests occurred only in 14 tests of Group A (4.2%, p = 0.012). Non-sustained ventricular tachycardia, <6 beats, occurred in 7 group A and 2 group B tests. The absence of coronary artery disease was the only independent predictor for complications., Conclusions: Major CPX complications occurred only in patients with impaired left ventricular systolic function. Heart failure patients showed a low probability (around 4%) for complications during CPX, significantly higher and more severe than the risk in the group of patients with normal ventricular function, allowing us to recommend that CPX in patients with heart failure should be performed in a hospital setting under the supervision of a physician with specific training.

Introduction: The LIDO and RUSSLAN trials showed that levosimendan was well tolerated and had a stronger hemodynamic effect than dobutamine and a positive impact on prognosis. There are, however, few data regarding its effectiveness and safety when used in an everyday clinical setting., Objective: To test the hypothesis that in day-to-day practice conditions levosimendan is both effective and safe for the treatment of decompensated heart failure (HF). This primary combined endpoint of effectiveness and safety was evaluated at 24 hours and 5 days after the beginning of the treatment., Design: Prospective, multicenter, nonrandomized clinical trial with evaluations at baseline, 24 hours, 5 days, and 3 and 6 months. Follow-up for 6 months., Setting: The intensive care units of 15 cardiology or internal medicine departments., Patients: 129 consecutive patients requiring inotropes due to decompensated systolic HF despite maximally tolerated oral therapy., Intervention: 24-hour infusion of levosimendan via a central or peripheral vein. MEASUREMENTS AND EVALUATION OF RESULTS: 1. Monitoring: Continuous ECG monitoring, non-invasive blood pressure, urinary output, oximetry. Invasive monitoring was not required. 2. Follow-up. Baseline evaluation: history, physical examination, ECG, 2D echocardiogram, hemogram, ionogram, liver and kidney function. 24-hour and 5-day evaluations: symptoms, physical examination, recording of medical therapy and previous 24-hour urinary output, ECG, hemogram, ionogram, liver and kidney function, and evaluation of arrhythmic episodes and heart rate and blood pressure trends in previous 24 hours. 3- and 6-month evaluations: number of hospital admissions and length of hospital stay due to HF, and mortality. 3. Evaluation of primary endpoint., Effectiveness: assessed by a clinical score including 2 subjective parameters (1. NYHA functional class, 2. patient self-evaluation symptom class) and 6 objective parameters (3. body weight, 4. pulmonary congestion, 5. previous 24-hour diuresis, 6. serum creatinine, 7. oral HF medication, 8. intravenous HF medication). Definition of clinical effectiveness: improvement in > or = 1 subjective parameters plus improvement in > or = 1 objective parameters, with all other parameters unchanged., Safety: The therapy was judged safe in the absence of any serious adverse event with a probable or undetermined causal relationship with levosimendan. Primary endpoint evaluation: Patients reached the primary endpoint when levosimendan was both effective and safe according to the above definitions.

Background: Calcium antagonists are widely prescribed for angina pectoris but their effect on clinical outcome is controversial. We aimed to investigate the effect of the calcium antagonist nifedipine on long-term outcome in patients with stable angina pectoris., Methods: We randomly assigned 3825 patients with treated stable symptomatic coronary disease to double-blind addition of nifedipine GITS (gastrointestinal therapeutic system) 60 mg once daily and 3840 to placebo. The primary endpoint was the combination of death, acute myocardial infarction, refractory angina, new overt heart failure, debilitating stroke, and peripheral revascularisation. Mean follow-up was 4.9 years (SD 1.1). Analysis was by intention to treat., Findings: 310 patients allocated nifedipine died (1.64 per 100 patient-years) compared with 291 people allocated placebo (1.53 per 100 patient-years; hazard ratio 1.07 [95% CI 0.91-1.25], p=0.41). Primary endpoint rates were 4.60 per 100 patient-years for nifedipine and 4.75 per 100 patient-years for placebo (0.97 [0.88-1.07], p=0.54). With nifedipine, rate of death and any cardiovascular event or procedure was 9.32 per 100 patient-years versus 10.50 per 100 patient-years for placebo (0.89 [0.83-0.95], p=0.0012). The difference was mainly attributable to a reduction in the need for coronary angiography and interventions in patients assigned nifedipine, despite an increase in peripheral revascularisation. Nifedipine had no effect on the rate of myocardial infarction., Interpretation: Addition of nifedipine GITS to conventional treatment of angina pectoris has no effect on major cardiovascular event-free survival. Nifedipine GITS is safe and reduces the need for coronary angiography and interventions.

Background: Ablation of typical atrial flutter relies on the suppression of electrical conduction along the cavo-tricuspid isthmus. Bidirectional isthmus block is a criterion of successful ablation and is associated with the presence of different activation times on each side of the ablation line., Objective: The aim of this study was to determine whether the difference in isthmic activation times correlates with the length of the atrial flutter cycle., Population and Methods: We studied 31 patients with typical atrial flutter (93.6% male, mean age 66 +/- 9 years) who underwent successful ablation during tachycardia. CARTO electroanatomic mapping was used to confirm diagnosis of isthmus-dependent atrial flutter, guide the ablation line creation and assess its efficacy. At the end of the procedure, a three-dimensional activation map of the right atrium was constructed, under pacing from the coronary sinus ostium (with a 500 ms cycle). Activation times on the lateral (right) and septal (left) sides of the ablation line were measured. The difference between these two activation times was termed the difference in isthmic activation times (delta IAT), and was compared to the flutter cycle length., Results: Mean activation times were 173.7 +/- 34.3 ms on the lateral border of the ablation line and 19.1 +/- 12.5 ms on the septal border. Mean delta IAT was 154.6 +/- 27.8 ms and mean atrial flutter cycle length was 257.5 +/- 30.6 ms. delta IAT and flutter cycle length were significantly correlated (r = 0.503, p = 0.0039). The linear regression equation that best described this result was: delta IAT = 37 + (0.46 x flutter cycle)., Conclusion: After atrial flutter ablation, a difference in isthmic activation times of more than half the flutter cycle length was associated with isthmus conduction block.

The development of surgical and percutaneous techniques for treatment or palliation of congenital heart disease has prolonged survival in these patients and has increased late complications, particularly arrhythmias. Such arrhythmias are more frequently refractory to medical therapy, requiring percutaneous ablation. We present the clinical case of a 14-year-old child with complex congenital heart disease (double outlet right ventricle) who underwent two corrective surgeries (Rastelli operation and subsequent replacement of the homograft in the conduit connecting the right ventricle to the pulmonary artery; ventricular septal defect closure and tricuspid valve repair). After the second surgery the patient presented with wide complex syncopal tachycardia, refractory to medical therapy. Electrophysiologic study (EPS) identified an isthmus-dependent atrial flutter that was successfully treated by radiofrequency (RF) ablation (a linear block was created along the cavo-tricuspid isthmus). Three months later a new episode of tachycardia occurred, but without syncope. The second EPS revealed an atrial tachycardia originating from the lateral wall of the right atrium, which was treated by ablation with focal application of RF energy. Four months after the last EPS the child remains free of arrhythmic symptoms, under no anti-arrhythmic therapy.

Primary malignant cardiac tumors, particularly lymphoma, are rare entities. Cardiac involvement or metastization of the heart from neoplasia located elsewhere are more frequently found. We present the case of a 79-year-old patient admitted with heart failure symptoms with a 3-week evolution. Evaluation led to the identification of a cardiac tumor with unusual clinical presentation and with a rapid and fatal evolution. Pathologic analysis identified a B-cell non-Hodgkin lymphoma.

Objectives: This randomized trial compared repeat stenting with balloon angioplasty (BA) in patients with in-stent restenosis (ISR)., Background: Stent restenosis constitutes a therapeutic challenge. Repeat coronary interventions are currently used in this setting, but the recurrence risk remains high., Methods: We randomly assigned 450 patients with ISR to elective stent implantation (224 patients) or conventional BA (226 patients). Primary end point was recurrent restenosis rate at six months. Secondary end points included minimal lumen diameter (MLD), prespecified subgroup analyses, and a composite of major adverse events., Results: Procedural success was similar in both groups, but in-hospital complications were more frequent in the balloon group. After the procedure MLD was larger in the stent group (2.77 +/- 0.4 vs. 2.25 +/- 0.5 mm, p < 0.001). At follow-up, MLD was larger after stenting when the in-lesion site was considered (1.69 +/- 0.8 vs. 1.54 +/- 0.7 mm, p = 0.046). However, the binary restenosis rate (38% stent group, 39% balloon group) was similar with the two strategies. One-year event-free survival (follow-up 100%) was also similar in both groups (77% stent vs. 71% balloon, p = 0.19). Nevertheless, in the prespecified subgroup of patients with large vessels (> or =3 mm) the restenosis rate (27% vs. 49%, p = 0.007) and the event-free survival (84% vs. 62%, p = 0.002) were better after repeat stenting., Conclusions: In patients with ISR, repeat coronary stenting provided better initial angiographic results but failed to improve restenosis rate and clinical outcome when compared with BA. However, in patients with large vessels coronary stenting improved the long-term clinical and angiographic outcome.

Introduction: The growing use of abciximab during coronary angioplasty, with 12 hours of intravenous perfusion, prolongs hospital stay and increases the risk of hemorrhage after sheath removal at the puncture site. Femoral percutaneous closure devices can reduce immobilization time, but their safety in the presence of abciximab in respect to hemorrhage has not been clearly determined., Objectives: To evaluate the safety and efficacy of the Perclose system in patients undergoing angioplasty with abciximab., Population and Methods: The Perclose system was used in 79 patients undergoing angioplasty, with abciximab in 31 patients (58.6 +/- 12.2 years, 90% male, p = NS)--Group 1, and 48 pts without abciximab (61.8 +/- 10.9 years, 79% male, p = NS)--Group 2. We compared heparin dose, sheath diameters, primary success rate, coronary care unit admissions and minor and major complications. One patient was previously anticoagulated with warfarin and all the others were on oral antiplatelet therapy before and after angioplasty., Results: Primary success with the use of the Perclose system was 78%. We found no significant statistical differences between groups in respect to the presence of diabetes, sheath diameter or referral for intervention. Heparin dosage was slightly higher in group 2 (p = 0.09) and ACT was also higher in group 2 (p = 0.01). More patients in group 1 had delayed ambulation (p = 0.04) due to abciximab perfusion. In 7 patients in group 1 and 9 in group 2, additional manual/mechanical compression was needed for moderate bleeding in the first hours (p = NS). One rupture of the femoral artery with need for surgical repair (primary failure) and another delayed rupture (48 hours) occurred in group 1 (both with an associated infection), and 1 pseudoaneurysm in a patient from group 2, without abciximab but taking warfarin (p = NS). None of the variables analyzed determined the occurrence of complications. Only oral anticoagulation determined the occurrence of major complications., Conclusions: User of the Perclose system for percutaneous closure of the femoral artery in patients undergoing coronary angioplasty with simultaneous use of abciximab was not associated with greater morbidity than in patients without glycoprotein IIb/IIIa receptor antagonists.

Background: The association between atrial fibrillation (AF) and mitral valve disease is frequent. Isolation of the pulmonary veins by radiofrequency energy applications performed intraoperatively has been proposed for patients with AF in whom mitral valve surgery has been indicated. Balloon mitral valvuloplasty is currently the preferred procedure for patients with mitral stenosis and a favorable valve anatomy., Aim: To evaluate the short- and long-term results of percutaneous pulmonary vein isolation for the treatment of AF in patients with mitral stenosis undergoing balloon mitral valvuloplasty., Methods: Five patients (four male and one female, age 43 +/- 4 years) underwent balloon mitral valvuloplasty concomitant with pulmonary vein isolation between August 1996 and February 1997. These patients had permanent AF, diagnosed 31 +/- 12 months previously; their mitral valve area was 1.0 +/- 0.25 cm2 and their left atria measured 54 +/- 5 mm. Balloon mitral valvuloplasty was performed via a transseptal approach, and then four ablation lines were created in the left atrial posterior wall to encircle all four pulmonary veins. Radiofrequency applications lasted 45 seconds each, and aimed at a maximum preset temperature of 65 degrees C. Electrical cardioversion was performed at the end of the procedure., Results: Mitral valve area increased 1.0 +/- 0.3 cm2 after valvuloplasty. The number of radiofrequency applications per patient was 37 +/- 3, and the average duration of the entire treatment was 131 +/- 28 minutes. Fluoroscopy time averaged 32 +/- 12 minutes. All patients were discharged in sinus rhythm, and mitral flow Doppler evaluation at one month showed a biphasic pattern in all cases, with the A wave measuring 70 +/- 15 cm/sec. Three patients maintained sinus rhythm at five-year follow-up. Of these patients, one had developed a left atrial flutter at four-year follow-up and underwent ablation. The remaining two patients presented AF at five year follow-up., Conclusions: Percutaneous isolation of the pulmonary veins concomitant with balloon mitral valvuloplasty had suppressed AF in 60% of patients by five-year follow-up.

Unlabelled: Eight patients (pts; 2 female, 58 +/- 12 yrs) with paroxysmal atrial fibrillation (AF) (duration 39 +/- 20 months) underwent AF surgery, with concomitant myocardial revascularization in 2 pts and myomectomy in 1 (HOCM). AF was idiopathic in the remaining 5 pts. AF surgery consisted of bilateral isolation of the pulmonary veins (PV) using radiofrequency (RF) energy applied epicardially by a heptapolar catheter (Thermaline) in 5 pts and by a new system (Atricure) in 3 pts. For the former, each set of 7 simultaneous applications aimed at a maximum duration of 2 + 2 min., preset temperature 80 degrees C and output 150 watts. With the new system, bipolar applications were carried out; energy delivery was controlled by impedance monitoring and applications were ended after abrupt, sustained elevation of impedance. Epicardial bipolar voltage mapping (CARTO) was performed before and after each RF procedure. Using the navigator catheter, points were recorded at the insertion of each PV and at the non-isolated left atrial posterior wall. The amplitude of the local electrograms (LE) was measured before and after RF applications. If the LE amplitude inside the isolated zone was not 0.1 mV and not reduced by > 80%, a second application was performed. A maximum of 2 epicardial applications were carried out in each pt and if the final result was unsatisfactory, further endocardial applications were performed., Results: Baseline LE amplitudes were > 1 mV in all cases. Successful isolation of right PVs was achieved in 7 pts, after one set of applications in 5 and a second set in 2. Left PV isolation required 2 sets of epicardial applications in all pts, being successful in only 2; 4 pts (one with associated myomectomy and 3 with idiopathic AF) received endocardial applications. Overall, bilateral PV isolation was achieved in 5 pts., Conclusions: CARTO bipolar voltage mapping is a fast, simple means for evaluation of epicardial PV isolation.

Objective: There are currently two techniques for percutaneous electrical isolation of the pulmonary veins (PV): anatomical isolation and electrical disconnection. The aim of the present study was to assess the continuity and circumferential extension of the radiofrequency applications necessary for PV electrical disconnection in order to evaluate the differences between this technique and anatomical isolation., Methods: We studied 9 patients with paroxysmal atrial fibrillation who underwent PV electrical disconnection. The electrophysiologic study was performed with a decapolar circular catheter (Lasso) introduced in the PV ostia and a mapping and ablation catheter (CARTO). Ablation was performed following the activation sequence of PV potentials. Using the CARTO system we evaluated the number of applications, their distribution in quadrants, and the maximum distance between contiguous and opposite RF applications. We assessed the number of veins with circumferential applications. The number of applications and maximum distance between contiguous applications were compared to the maximum distance between opposite applications., Result: A total of 26 PV were isolated, including 9 right superior, 5 right inferior, 6 left superior and 6 left inferior. On average more than 10 applications were necessary, with a heterogeneous distribution. In 80.8% of the PVs the maximum distance between contiguous application was less than 1 cm and maximum distance between opposite application were highest in the right superior PV and lowest in the right inferior PV. The applications were circumferential in 80.8% of the disconnections. The number of RF applications was significantly higher in PVs with greater distances between opposite applications (correlation coefficient 0.51; p=0.008). No relation was found between maximum distances in contiguous and opposite applications (correlation coefficient r=0.13; p=NS)., Conclusion: Electrical disconnection was achieved in the great majority of cases with circumferential applications, similarly to anatomical isolation. However, the heterogeneous distribution of the applications implies the existence of areas that need a greater number of applications and that can only be identified during electrophysiologic study. Therefore, rather than two aspects of the same treatment for atrial fibrillation, electrical disconnection and anatomical isolation complement each other in the achievement of effective PV isolation.

Background: Several studies relate cytomegalovirus (CMV) infection to the development of atherosclerosis. Its influence in triggering acute coronary syndromes (ACS) is not known., Objectives: We set out to identify a relationship between CMV infection, occurrence of ACS and prognosis., Methods: Serologic markers (IgM and IgG) for CMV were tested prospectively at admission and at 30 days, in patients (pts) admitted to our CCU for ACS. Serologic markers for CMV were also tested in a group of pts with stable coronary artery disease admitted for elective coronary angiography. A greater than two-fold elevation of IgG titer at 30 days was defined as reactivation/reinfection. At 30 days and six months, the composite endpoint of death, myocardial (re)infarction and re-admission for unstable angina was evaluated., Results: There were 60 pts with ACS in the study group (age 63 +/- 10 years, 75% male) and 31 pts in the control group (age 64 +/- 10 years, 71% male). On admission, 95% of the pts with ACS and 81% in the control group presented a positive IgG (p = 0.029). In the study group, at 30 days, the only pt with a 3-fold titer elevation had an endpoint. The percentage was 17% for the group with a > or = 2- and < 3-fold elevation and 11% in the group without reactivation (p = 0.034). At six months, 50% of the patients with a greater than 2-fold titer elevation and 15% of the remaining patients had an endpoint (p = 0.017). In the control group, at 30 days, 3 pts (10%) had a significant elevation in IgG titer, > or = 2- and < 3-fold, without endpoint., Conclusions: In pts with ACS, we found a higher prevalence of serologic markers for CMV than in pts with stable coronary disease. An elevation in IgG titer for CMV was associated with a worse outcome at 30 days and six months.