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To broaden the data supporting the use of the residual SYNTAX score (rSS) to define "reasonable" incomplete coronary revascularization (ICR) in order to improve the allocation of patients with severe coronary artery disease (CAD) to surgical/percutaneous revascularization and long-term clinical outcomes.ICR is associated with a worse prognosis in patients with severe CAD, yet no consensus exists regarding its definition.We studied 148 consecutive patients with triple vessel/left main (3VD/LM) CVD treated by percutaneous coronary interventions (PCI). Clinical outcomes at 3 years were collected; the SS and rSS were calculated. We used various definitions of "reasonable" ICR:no post-PCI total occlusion, single vs. mutivessel residual post-PCI disease, and the rSS at a cutoff value determined according to ROC curve fitted for 3 years major adverse cardiovascular and cerebrovascular adverse events (MACCE) in order to determine which definition has the strongest correlation with long-term outcomes.rSS ≤ 8 was associated with significant reductions in 3 year MACCE (19.4 vs. 51.1%, HR = 3.62, P = 0.014) Death/MI/CVA (13.7 vs. 28.8%, HR = 6.01, P = 0.030) and repeat revascularization (8.6 vs. 28.9%, HR = 3.44, P = 0.033) using a Cox proportional hazard ratio model adjusted to baseline characteristics, whereas single vessel residual disease and absence of total occlusion were not."Reasonable" ICR as determined by rSS carries better long-term prognosis in terms of clinical outcomes vs. more extensive residual coronary disease in patients with 3VD/LM coronary artery disease treated by PCI. The rSS may improve the allocation of coronary patients to the optimal mode of revascularization.

Accurate positioning of the valve device during transcutaneous aortic valve implantation (TAVI) is of crucial importance. The Paieon C-THV navigation system has been designed to correctly guide device deployment during TAVI.Using this navigation system we aimed to determine the correlation between the anatomic measures of the native aortic valve and the deployed self-expandable valve positioning and to explore the impact upon procedural outcomes.We analyzed data of 68 patients with severe symptomatic aortic stenosis undergoing TAVI, using the catheter-based Medtronic-CoreValve self-expandable system. Patients were subdivided into two groups according to whether the C-THV system was used (50) or not (18) during the implantation process. Analysis of geometrical outcomes vs. clinical outcomes including postprocedural electrical conduction defect and/or para-valvular leaks was performed.Taking the target implantation line as a reference; relatively lower vs. higher implantations correlated with a higher frequency of any new onset electrical conduction defect (ECD). The mean corresponding distance from valve inferior edge below the virtual aortic annulus line was 3.0 ± 1.6 mm vs. 1.2 ± 1.3 mm in patients with (38.5%) vs. without any new onset ECD, respectively (P = 0.05). The use of C-THV navigation seemed to correlate with higher valve implants but it had no impact on the occurrence of postprocedural paravalvular leaks.Self-expandable valve implants guided by C-THV navigation seems to be associated with more precise implants and lower risk for postprocedural electrical conduction defects, due to higher location in relation to the target line.

The study sought to assess the clinical profile, outcome, and predictors for mortality of "real-world" high-risk severe aortic stenosis patients according to the mode of treatment assigned.Patients were referred to a dedicated clinic for meticulous screening and multidisciplinary team assessment and 343 were finally assigned treatment (age 81.3 ± 7.2 years, 42.3% men): transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN or CoreValve device, 100 (29.2%); surgical aortic valve replacement (SAVR), 61 (17.8%); balloon valvuloplasty (as definitive therapy), 27 (7.9%); medication only, 155 (45.2%). No patient was lost to follow-up.The balloon valvuloplasty group had a significantly higher 1-month mortality rate (18.5%) than the TAVR group (3%, P = 0.006) and medical therapy group (3.9%; P = 0.004), without significant difference from the SAVR group (11.5%, P = 0.5). One-year cumulative survival was significantly higher in the TAVR group (92%) than in the other groups (SAVR 71%, balloon valvuloplasty 61.5%, medication 65%; all P0.001). Among survivors, 1-year rates of high functional class (NYHA I/II) were as follows: TAVR, 84.6%; SAVR, 63.3%; balloon valvuloplasty, 18.2%; medication, 21.4% (TAVR vs. SAVR, P = 0.04; SAVR vs. balloon valvuloplasty or medical therapy, P = 0.01). On multivariate regression analysis, renal failure (hazard ratio [HR] = 5.3, P0.001), not performing TAVR (HR = 4.9, P0.001), and pulmonary pressure (10 mm Hg, HR = 1.2, P = 0.02) were independent predictors of 1-year mortality.TAVR, performed in carefully selected high-risk patients, is associated with an excellent survival rate and high functional class. Patients treated with another of the available modalities, including SAVR, had a worse outcome, regardless of which alternative treatment they receive.

Objectives: To explore the long-term results following implantation of drug-eluting stents (DES) in bifurcation lesions according to contemporary “real world” practice. Background: Limited information is available on the long-term outcomes of patients with bifurcation lesions who are treated using DES. A systematic approach for bifurcation lesion management was applied, using either a “provisional” single stent technique or a dedicated two stents strategy according to the side-branch diameter and severity of its ostial stenosis. Methods: Four hundred one consecutive patients underwent bifurcation percutaneous coronary intervention (PCI) using DES and were included in our prospective registry. All adverse events were recorded up to 2 years and distinguished according to the planned PCI strategy (e.g., one versus two stents technique). Results: A planned two stents strategy was used in 141 patients (35% of patients). In 260 patients (65%), the planned treatment involved stenting of the main branch only with “provisional” stenting of the side-branch according to procedural course. Thus, 24 patients (9.2%) needed additional stenting at the side-branch to complete the PCI. Cumulative major adverse cardiac event rate at 1 and 2 years was similar for both groups (11.4% vs. 14.8% at 1 year and 19.4% vs. 25.7% at 2 years for the single vs. two stents groups, accordingly, P = NS for both). Likewise, there was no difference in mortality, cardiac mortality, myocardial infarction, need for target lesions or target vessel revascularization, or definite stent thrombosis rate between the two groups at 6, 12, and 2 years follow-up. The rate of angiographically confirmed (i.e., definite) stent thrombosis did not differ between the two groups during follow-up. Conclusions: Our study revealed favorable long-term clinical results following DES implantation using a systematic, rather simplified approach towards bifurcation stenting and using either a single or double stenting technique. © 2011 Wiley Periodicals, Inc.

Background: Stent thrombosis (ST) risk may persist long after a successful drug eluting stents (DES) implantation. Objective:We evaluated the incidence, timing, and clinical outcomes of patients with early (≤30 days), late (>30–365 days), and very late (>365 days) angiographically proven ST related to DES. Methods: Between 2004 and 2009, 4,396 patients underwent percutaneous coronary interventions (PCI) with DES implantations. This 5-year follow-up study included 38 patients (mean age 60 ± 12 years; 76% males) who were readmitted with confirmed ST diagnoses. Clopidogrel therapy was prescribed for 3–12 months. Clinical follow-ups were conducted at 1 and 6 months following ST events. Results:The overall ST rate was 0.9% (38/4,396); the late ST rate was 0.7%. There were four (11%) early and 34 (89%) late events; the time interval to thrombosis was 21 ± 14 months (range 0.13–60 months). Two patients had stent fractures associated with ST, 37% had diabetes, and 68% presented with ST-elevation myocardial infarctions (MI). One third was treated with clopidogrel at the ST event. Three patients (8%) had recurrent late ST events and two died within 1 month after the ST event (5%). At 6 months, we observed a 26% major adverse cardiac event rate, and the overall cardiac mortality rate was 8%. Conclusions: In our series, ST occurred infrequently (0.9%), mostly between 1 and 3 years after the period recommended for dual anti-platelet pharmacotherapy, and it is associated with substantial clinical consequences. © 2010 Wiley-Liss, Inc.

To assess the value of the ratio between contrast medium volume and glomerular filtration rate (CMGFRr) for prediction of development of contrast-induced nephropathy (CIN) and mortality in patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).Renal function is a strong predictor of outcome in patients with STEMI. CIN may complicate the course of primary PCI in these patients.The study population included all 871 consecutive patients with STEMI without cardiogenic shock who underwent primary PCI at our center from January 1, 2001, to October 30, 2006. CIN was defined as an absolute increase in serum creatinine0.5 mg/dL or a relative increase25% within 48 hr after PCI.In-hospital CIN developed in 72 (8.3%) patients. On linear regression analysis, the following variables were independently associated with CIN: male sex (odds ratio [OR] = 0.42, 95% confidence interval [CI], 0.18-0.97, P = 0.04), GFR60 (OR = 3.6, 95% CI, 2.79-4.78, P0.0001), multivessel coronary artery disease (OR = 1.67, 95% CI, 1.08-2.58, P = 0.02), CMGFRr (OR = 1.53, 95% CI, 1.01-2.31, P = 0.04, for upper tertile vs. lower two tertiles), and Killip class1 (OR = 1.35, 95% CI, 1.03-1.76, P = 0.03). CMGFRr3.7 was a strong independent predictor of CIN (OR = 3.87, 95% CI, 1.72-8.68, P = 0.001). Twenty-six (2.9%) patients died at 1 month after PCI. The following variables were independently predictive of 1-month mortality: CMGFRr3.7 (OR = 3.3, 95% CI, 1.22-9.04, P = 0.018) and multivessel coronary artery disease (OR = 2.3, 95% CI, 1.28-4.07, P = 0.005).The contrast medium-to-GFR ratio is a strong predictor of CIN and of 1-month mortality in patients undergoing primary PCI for STEMI.

The MGuard stent has been designed as a plaque trapping device to treat athero-thrombotic lesions in saphenous vein grafts and native coronary lesions. It was utilized in seven coronary bypass patients to treat eight vein grafts. The average graft age was 15 years. Procedural success was 100% without any intraprocedural, in-hospital, and/or 30-day major adverse cardiac events (e.g. death, myocardial infarction, and need for repeat graft revascularization). No patient experienced distal embolization and/or procedure-related CK enzymatic rise. This strategy seems to be a promising approach in percutaneous vascular management of vein graft lesions. © 2009 Wiley-Liss, Inc.

The objective of this study was to compare two techniques to treat bifurcation lesions: a single drug-eluting stent (DES) implanted in the main branch combined with balloon dilatation for the side branch vs. stenting of both branches (double stent).Percutaneous coronary intervention in coronary bifurcation lesions remains challenging. Although DES reduce restenosis in lesions, the double stent procedure has not shown clear advantages over a single stent with balloon dilation.Fifty-three symptomatic patients with true bifurcation lesions were treated using either the double stent technique (n = 25) or one stent in the parent vessel plus balloon angioplasty of the side branch (n = 28). Procedural results and major adverse cardiac event rates (MACE: cardiac death, myocardial infarction, target vessel revascularization (TVR)) were compared.Angiographic procedural success (residual stenosis30% in both branches) was 75% in the single stent group and 100% in the double stent group (P = 0.01). All differences were due to residual stenosis of the side branch. Clinical follow-up (6-18 months) was available for all patients; 90.5% of patients had a coronary angiography or nuclear stress test. Three patients (11%) in the single stent group and two (8%) in the double stent group had ischemia-driven TVR (P = NS). Asymptomatic angiographic restenosis (50% diameter stenosis) in the ostium of the side branch was seen in two patients in the double-stent group. At 6 months, MACE-free was comparable between groups (89.3% vs. 88%, P = 0.7).When treating bifurcation lesions with sirolimus-eluting stents, restenosis following a single stent procedure is comparable to stenting both parent and side branch vessels. Thus, stenting the main-branch lesion, coupled with balloon angioplasty in the side branch, produces a high success rate and good clinical outcomes at 6 months.

Objectives: We investigated the impact of primary coronary angioplasty performed during night and compared to the impact of that performed during day-time on outcomes of patients with acute ST elevation anterior wall myocardial infarction (AMI). Methods: We prospectively followed 273 consecutive patients of whom 160 (58.6%) were treated during day time (8:00 a.m. to 6 p.m.) and 113 (41.4%) were treated “off hours”/at night (6 p.m. to 8 a.m.). Baseline demographics, angiographic factors, and clinical outcomes (death, recurrent AMI, and need for repeat revascularization) were compared between the groups. Results: Baseline clinical characteristics were similar between the two groups. Unadjusted mortality at one-month was significantly higher among patients who were treated during night compared with those treated at day-time (9.7% vs. 3.1% P = 0.03), as was adverse cardiac event rate (15.9% vs. 6.9%; P = 0.02). Multiple logistic regression analysis adjusted for the CADILLAC risk score demonstrated that this score, which includes baseline LVEF, renal failure, Killip class, final TIMI flow, age>65 years, anemia, and the number of coronary vessel diseases, is a significant predictor of one-month mortality, while the effect of time of treatment was borderline (night vs. day; odds ratio 2.7; 95% confidence interval, 0.8–9.4; P = 0.095). Conclusions: The results of this study indicate that patients with anterior myocardial infarction treated during night time have worse unadjusted short-term clinical outcomes despite no delay from onset of symptoms to actual treatment. Larger studies are needed in order to identify potential contributors to this phenomenon. © 2006 Wiley-Liss, Inc.