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INTRODUCTION AND OBJECTIVES: Severe calcification is present in>50% of coronary chronic total occlusions (CTOs) undergoing percutaneous intervention. We aimed to describe the contemporary use and outcomes of plaque modification devices (PMDs) in this context. METHODS: Patients were included in the prospective, consecutive Iberian CTO registry (32 centers in Spain and Portugal), from 2015 to 2020. Comparison was performed according to the use of PMDs. RESULTS: Among 2235 patients, wire crossing was achieved in 1900 patients and PMDs were used in 134 patients (7%), requiring more than 1 PMD in 24 patients (1%). The selected PMDs were rotational atherectomy (35.1%), lithotripsy (5.2%), laser (11.2%), cutting/scoring balloons (27.6%), OPN balloons (2.9%), or a combination of PMDs (18%). PMDs were used in older patients, with greater cardiovascular burden, and higher Syntax and J-CTO scores. This greater complexity was associated with longer procedural time but similar total stent length (52 vs 57mm; P=.105). If the wire crossed, the procedural success rate was 87.2% but increased to 96.3% when PMDs were used (P=.001). Conversely, PMDs were not associated with a higher rate of procedural complications (3.7 vs 3.2%; P=.615). Despite the worse baseline profile, at 2 years of follow-up there were no differences in the survival rate (PMDs: 94.3% vs no-PMDs: 94.3%, respectively; P=.967). CONCLUSIONS: Following successful wire crossing in CTOs, PMDs were used in 7% of the lesions with an increased success rate. Mid-term outcomes were comparable despite their worse baseline profile, suggesting that broader use of PMDs in this setting might have potential technical and prognostic benefits.

The use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes.We enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up.Significant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P.001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P=.001; stenting, 0.0% vs 2.6%, P=.104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HRPressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique.

Introduction and objectives Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome. The characteristics and in-hospital clinical course of patients with SCAD in Spain remain unknown. Methods We present data from consecutive patients included in the national prospective SCAD registry. Angiographic analysis was performed in a centralized core laboratory. Results Between June 2015 and April 2019, we included 318 patients with SCAD (358 lesions) from 31 centers. Median age was 53 years, and 88% were women. The most frequent presentation was non–ST-segment elevation acute myocardial infarction (53%). The most frequently involved artery was the left anterior descending coronary artery (44%), predominantly affecting the distal segments (39%) and secondary branches (54%). Most lesions (62%) appeared on angiography as intramural hematoma, without double lumen. Conservative management was selected as the initial approach in most patients (78%). During the index admission, 6% of patients had a major adverse event and 4 patients (1.3%) died. Independent predictors of adverse events were initial management with percutaneous coronary intervention (OR, 5.97; P = .004) and angiographic presentation as intramural hematoma (OR, 4.96; P = .028). Conclusions In Spain, SCAD affects mainly middle-aged women. In most patients, the initial management strategy was conservative with excellent in-hospital survival. Initial management with percutaneous coronary intervention and angiographic presentation as intramural hematoma were related to the presence of in-hospital adverse events. Registered at ClnicalTrials.gov (Identifier: NCT03607981).

Percutaneous coronary intervention (PCI) for aorto-ostial chronic total coronary occlusion (CTO) can be a particularly challenging lesion subset. The aim of this study was to analyze the technical aspects and outcomes of aorto-ostial CTO PCI in a multicenter registry.Patients undergoing aorto-ostial CTO PCI at 4 centers between February 2013 and December 2018 were included. Success rates, as well as procedural aspects and outcomes, were analyzed.A total of 103 patients were included. Mean age was 64±10 years and the mean J-CTO score was 3.1±1.1. Thirty-one lesions (30.4%) were flush ostial CTOs. Technical and procedural success were achieved in 79 (76.7%) and 78 (75.7%) of the patients, respectively. The retrograde approach was the most frequent successful crossing technique (n=49; 62.0%), especially in flush vs nonflush aorto-ostial CTOs (82.6% vs 53.5%; P=.02). The only variable independently associated with technical failure was the absence of interventional collaterals (OR, 12.38; 95%CI, 4.02-38.15; P.001). Coronary perforation occurred in 4 patients (3.9%) requiring covered stent implantation (without subsequent cardiac tamponade) and 2 patients (1.9%) had a stroke (one of which was a transient ischemic attack). During a median follow-up of 31 months, 3 (2.9%) patients died from cardiovascular causes and 13 (12.6%) required repeat target vessel revascularization.Aorto-ostial occlusions represent a challenging subset for PCI. However, an acceptable success rate with favorable outcomes during follow-up can be achieved by experienced operators. The presence of interventional collaterals allowing the use of the retrograde approach is key for achieving procedural success.

Resumen Introduccion y objetivos La Asociacion de Cardiologia Intervencionista de la Sociedad Espanola de Cardiologia (ACI-SEC) presenta su informe anual de actividad de 2019. Metodos Se invito a participar a todos los centros espanoles con laboratorio de hemodinamica. La recogida de datos se realizo telematicamente y una empresa externa, junto con los miembros de la ACI-SEC, llevo a cabo su analisis. Resultados Participaron 119 centros (83 publicos y 36 privados). Se realizaron 165.124 estudios diagnosticos (el 4,7% mas que en 2018). La guia de presion y la ecografia intracoronaria crecieron un 20% y la tomografia de coherencia optica, un 8,4%. El intervencionismo coronario aumento un 4,5%, con 75.819 procedimientos. De ellos, 22.529 en el infarto agudo de miocardio, con el 91,8% de angioplastias primarias (el 6,3% mas que en 2018). La media de angioplastias primarias por millon de habitantes crecio a 439. El acceso fue radial en el 88,3% de los procedimientos intervencionistas. Se practicaron 4.281 implantes percutaneos de valvula aortica (el 21,0% mas que en 2018), con una media de 90,9 por millon de habitantes. La reparacion percutanea mitral tambien crecio un 17,4% (385 procedimientos); el cierre de orejuela, un 43,0% (n = 921) y el foramen oval permeable, un 38,1% (n = 710). Conclusiones En 2019 se produjo un incremento del uso de tecnicas de diagnostico intracoronarias y prodecimientos diagnosticos y terapeuticos coronarios, fundamentalmente en la angioplastia primaria. En intervencionismo estructural, destaca el fuerte ascenso del numero de implantes percutaneos de valvula aortica, asi como de procedimientos de reparacion mitral, cierre de orejuela y foramen oval permeable.

Adequate, updated and functional technology is essential in cardiology. In Spain, the economic scenario has strongly impacted technology renewal programs and obsolescence is a growing problem. The current report attempts to describe the current situation and the conditions that must concur to update, replace or adopt new technologies in the field of cardiology.

Introduction and objectives: There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry. Methods: Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch >= 2 mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n = 201) or complex strategy (n = 37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization. Results: Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P = .48 and 85.6% vs 81.1%; P = .49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P = .58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P = .08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results. Conclusions: Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies. (C) 2017 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Introduction and objectives Bioresorbable vascular scaffolds (BVS) have the potential to restore vasomotion but the clinical implications are unknown. We sought to evaluate angina and ischemia in the long-term in patients treated with BVS and metallic drug-eluting stents (mDES). Methods Multicenter study including patients with 24 ± 6 months of uneventful follow-up, in which stress echocardiography was performed and functional status was assessed by the Seattle Angina Questionnaire (SAQ). The primary endpoint was a positive result in stress echocardiography. Results The study included 102 patients treated with BVS and 106 with mDES. There were no differences in the patients’ baseline characteristics. Recurrent angina was found in 18 patients (17.6%) in the BVS group vs 25 (23.5%) in the mDES group ( P = .37), but SAQ results were significantly better in the BVS group (angina frequency 96.0 ± 8.0 vs 89.2 ± 29.7; P = .02). Stress echocardiography was positive in 11/92 (11.9%) of BVS patients vs 9/96 (9.4%) of mDES patients in the ( P = .71) and angina was induced in 2/102 (1.9%) vs 7/106 (6.6%) ( P = .18), respectively, but exercise performance was better in the BVS group even in those with positive tests (exercise duration 9.0 ± 2.0 minutes vs 7.7 ± 1.8 minutes; P = .02). A propensity score matching analysis yielded similar results. Conclusions The primary endpoint was similar in both groups. In addition, recurrent angina was similar in patients with BVS and mDES. The better functional status, assessed by means of SAQ and exercise performance, detected in patients receiving BVS should be confirmed in further studies.

Introduction and objectives Coronary restenosis after bioresorbable vascular scaffold (BVS) implantation is infrequent and little information is available on the main characteristics of these lesions. The aim of this study was to assess restenotic lesions by using optical coherence tomography (OCT). Methods We studied 330 patients with coronary artery disease who received 398 BVS to treat 380 lesions. These patients were clinically and angiographically evaluated at follow-up and OCT was carried out on detection of restenosis. Results After a follow-up of 19 ± 10 months, 18 restenotic lesions were detected in 17 patients (5.4%). Depending on the time of presentation, most cases of restenosis were late or very late (9 ± 4 months). The most frequent angiographic pattern was focal restenosis in 12 (67%) patients, which was mainly located at the proximal border in 9 (75%) whether involving the scaffold or not. The homogeneous pattern was infrequent, occurring in 3 (25%) lesions and was only visualized in 3 out of 6 cases of restenosis located at the margin. When the focal restenosis was located in the platform, OCT showed a heterogeneous or layered pattern. Finally, diffuse restenosis was observed in 6 patients (33%). In diffuse restenosis, OCT revealed a lipid-laden or layered tissue structure and the presence of microvessels or microcalcification, potentially suggesting a neoatherosclerotic process. Conclusions After a mean follow-up of 19 months, the restenosis rate was 5.4%. Most restenotic lesions were focal, located at the proximal border. Diffuse restenosis mostly occurred late or very late and most showed signs suggestive of neoatherosclerosis.

Conduction disturbances often occur after CoreValve transcatheter aortic valve implantation. The aim was to analyze which cardiac conduction changes occur in patients with aortic stenosis treated with this type of prosthesis.A total of 181 patients with severe aortic stenosis treated with this prosthesis and studied by electrocardiography between April 2008 and December 2013 were selected. A subgroup of 137 (75.7%) consecutive patients was studied by intracardiac electrocardiogram before and after prosthesis implantation. The primary endpoint of the study was the need for a permanent pacemaker within 72 hours after prosthesis implantation. Numerous variables to predict this possibility were analyzed.Following implantation, PR and QRS intervals were increased from 173±47 ms to 190±52ms (P.01) and from 98±22ms to 129±24 ms (P.01), whereas the A-H and H-V intervals were prolonged from 95±39ms to 108±41ms (P.01) and from 54±10ms to 66±23ms (P.01). A total of 89 (49%) patients had new-onset left bundle-branch block, and 33 (25%) required a pacemaker within the first 72hours. The independent predictors for a pacemaker were baseline right bundle-branch block and prosthetic depth. Intracardiac intervals had no predictive value. In addition, 13 patients required a pacemaker after 72 hours.CoreValve prosthesis implantation has a high incidence of conduction disturbance, with left bundle-branch block being the most common. A total of 25% of patients required a permanent pacemaker. The need for a pacemaker was related to baseline right bundle-branch block and prosthetic depth.

Introduction and objectives The use of the jailed guidewire technique is highly useful when treating bifurcation lesions by provisional stenting. However, at the time of withdrawal, the guidewire can suffer damage and even fracture. The aim of this study was to evaluate structural damage in both polymer-coated and nonpolymer-coated jailed guidewires. Methods Between January 2011 and December 2012, an observational study was conducted using stereoscopic microscopy to evaluate 135 jailed guidewires (45 nonpolymer-coated and 90 polymer-coated) previously used in the percutaneous treatment of bifurcation lesions. Damage after withdrawal was classified as mild, moderate, or severe. Results Age and sex distributions were similar in both groups of patients treated with polymer-coated and nonpolymer-coated guidewires. However, operators selected polymer-coated guidewires more frequently when treating more complex bifurcations and in diabetic patients. Some type of microscopic damage was observed in 25 of the guidewires analyzed (18%). Paradoxically, damage was more common in nonpolymer-coated guidewires (53.0% vs 1.1%; P Conclusions Coronary guidewires that are jailed during the treatment of bifurcations using provisional stenting often suffer nonsevere microscopic damage. Although polymer-coated guidewires were used in more complex bifurcation lesions, paradoxically, they were damaged less frequently.

Different studies have shown improvement in patients with idiopathic nonischemic dilated cardiomyopathy treated with cell-therapy. However, factors influencing responsiveness are not well known. This trial investigates functional changes and factors influencing the 6-month gain in ejection fraction in 27 patients with dilated cardiomiopathy treated with intracoronary cell-therapy.Patients received intracoronary infusion of autologous bone-marrow mononuclear cells (mean infused, 10.2 [2.9]×10(8)). Flow cytometry and functional analyses of the cells were also performed.The 6-month angiographic gain in ejection fraction ranged from -9% to 34% (mean, 9%). These changes were distinguished into 2 groups: 21 patients (78%) with a significant improvement at the 6-month evaluation (mean gain, 14 [7]%), and 6 patients who had no response (mean gain, -5 [3]%). The responders were younger as compared to the nonresponders (50 [12] years vs 62 [9] years; P.04). There was an inverse correlation (r=-0.41; P.003) between the gain in ejection fraction and the high density lipoprotein level, suggesting higher functional gain with low high density lipoprotein levels. The 24 h migratory capability of the infused cells was significantly reduced in the responders' group (5.4 [1.7]×10(8) vs 8.1 [2.3]×10(8); P.009 for vascular endothelial growth factor and 5.8 [1.7]×10(8) vs 8.4 [2.9]×10(8); P.002 for stromal cell-derived factor-1).Younger patients with dilated cardiomiopathy and lower plasma high density lipoprotein levels gain greater benefit from intracoronary cell-therapy. Functional improvement also seems to be enhanced by a lower migratory capacity of the infused cells.

We report our experience with the Venture wire-control catheter in 20 patients with bifurcation lesions in which it was impossible to access the side branch using conventional techniques. This device was always used as a last resort and was employed during different stages in the treatment of the bifurcation lesions (i.e. initially, after stenting of the main vessel or both). In 17 patients (85%), use of the Venture catheter resulted in the success of the procedure. Only one complication associated with a monorail catheter was recorded. It was resolved successfully. One patient died from heart failure 10 days after the procedure and two patients, in whom it was impossible to access the side branch, had non-Q-wave myocardial infarctions. In conclusion, the Venture catheter was effective and safe, and enabled the side branches of complex bifurcation lesions to be accessed.

It is difficult to distinguish the effects early revascularization and regenerative therapy have on left ventricular function in patients with acute myocardial infarction (AMI). This study was an investigation into three groups of patients who had a revascularized anterior wall AMI and depressed left ventricular function (i.e., ejection fraction45%). The aim was to compare changes in left ventricular function between patients who received regenerative therapy and those who did not.Patients were randomly assigned to receive either an intracoronary infusion of autologous mononuclear bone marrow cells (Group I; n=10) or systemic administration of granulocyte colony-stimulating factor (G-CSF) (Group II; n=10), or to a control group (Group III; n=10). In Group I, intracoronary infusion was carried out 7(2) days after AMI. Group-II patients received a 10-day course of subcutaneous G-CSF injections, 10 .g/kg per day starting 5 days after AMI. Ventricular function was assessed at baseline and 3-month follow-up.A 20% increase in mean ejection fraction was observed in Group I, compared with increases of 4% (P.01) and 6% (P.05) in Groups II and III, respectively.Intracoronary infusion of mononuclear bone marrow cells in patients with AMI and poor ventricular function was associated with better short-term functional recovery than previously reported. However, mobilization of stem cells by G-CSF did not have a significant influence on functional recovery.

INTRODUCTION AND OBJECTIVES In vitro studies show that stents deform when dilated laterally to access a side branch. This phenomenon may be avoided by use of a kissing balloon at the end of the procedure. However, to date, no in vivo data are available. Our objectives were to investigate the main vessel stent using intravascular ultrasound (IVUS) at six-month follow-up in 55 patients with bifurcation lesions treated using rapamycin-eluting stents and to examine the effect of technical factors. PATIENTS AND METHOD All patients were treated using provisional or T stents. At 6 months, IVUS measurements were made in the main vessel at both proximal and distal ends of the stent, in reference segments, immediately below the side branch ostium, and at the points where the lumen was smallest and where stent expansion was greatest. RESULTS The lumen area immediately below the side branch ostium was significantly smaller than that at the point of maximum stent expansion (6.7 [1.8] vs 5.1 [1.3] mm2; P

This article summarizes 20 years of percutaneous interventional cardiology for coronary angioplasty. During this period, interventional cardiology has evolved faster than any other type of treatment in the field of cardiovascular diseases. We describe the early results of interventional cardiology, the increase in primary success rates and the reduction in complication rates for percutaneous techniques during this period, which coincided with the introduction of technological advances. In the early 1990s, primary success rates for the treatment of coronary lesions stood at 86%-88%, with a restenosis rate of 30%-40% at 6-month follow-up. Current primary success rates have risen to over 95% with a restenosis rate of under 10%, even for many types of lesions classically considered complex. Currently the main limitations in interventional cardiology remain coronary segments that cannot be accessed due to chronic total occlusion, or severe proximal tortuosity or calcification. Rapid improvements have led to broader clinical indications for percutaneous revascularization procedures, and have made frequent updates of clinical practice guidelines necessary. Meanwhile, comparative studies involving other modes of surgical revascularization have become extremely difficult because percutaneous methods used in long-term studies begun 5 to 10 years have become obsolete.

This study reports the findings in a group of 13 patients aged 53+/-8 years with anterior wall acute myocardial infarction who were revascularized with stents and treated with recombinant human granulocyte colony stimulating factor (G-CSF).Patients were initially treated with intravenous thrombolytics. The first cardiac catheterization was performed between days 0 and 5 after acute myocardial infarction, when the left anterior descending artery was stented. A 10-day course of 10 .g/kg/day G-CSF was started 5 days after acute myocardial infarction. Blood cell counts and immunophenotyping were done to assess the total number of circulating CD34+ cells and their subpopulations in serial fashion. At 3-month follow-up, cardiac catheterization was repeated. Functional recovery was defined as an increase in ejection fraction.All patients did well initially, but 1 had spontaneous spleen rupture on day 8 of G-CSF administration, which required emergency splenectomy. The gain in ejection fraction varied among patients from -22 to +18 (mean, 6.2%+/-12%), and correlated directly with the total number of circulating CD34+ CD38- cells/microL on the fifth day of G-CSF treatment (r=0.78; P.003). The gain in ejection fraction correlated inversely with peak MB fraction creatine kinase (r=-0.82; P.002).Stem-cell mobilization with G-CSF is a feasible and safe treatment for patients with revascularized acute myocardial infarction. However, because of the possibility of acute splenitis induced by massive cell mobilization, future studies should be designed with due caution to take this eventuality into account.