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Objectives: The purpose of this study is to compare the long‐term outcomes of patent foramen ovale (PFO) closure using angiography or transesophageal echocardiography as procedural guidance. Background: The interventional treatment is emerging as a safe and efficient option for patients with high likelihood of PFO‐related cryptogenic stroke and high risk of recurrence. The “gold‐standard” guidance technique remains an issue. Methods: Two cohorts of patients undergoing PFO closure for cryptogenic stroke in two catheterization laboratories of the same institution, using similar inclusion criteria but different guidance, were compared with propensity score matching. Results: A total of 374 patients were enrolled, 161 in Angio‐group and 213 in Echo‐group. No difference was detected in the procedural complication rate. In Angio‐group, radiological exposure (P = .001) and 6‐month residual shunt (16.8% vs 8.0%, P = .015) were higher. After a mean follow‐up of 41 ± 30 months, 28 patients (7.5%) presented any adverse event (death, recurrent cerebral ischemia, device‐related complications, reintervention), with a higher rate in Angio‐group (13.0% vs 3.3%, P = .001), mainly due to repeated percutaneous intervention (10.6% vs 1.4%, P = .001). The results were confirmed after propensity score matching (118 patients/group). The rate of recurrent cerebral ischemia was 1.9% and was not significantly different in the two groups. Intra‐procedural guidance and atrial septum aneurysm were independent predictors of the composite primary endpoint (OR 1.2, P = .016). Conclusions: The use of intra‐procedural transesophageal echocardiography (TEE) guidance for PFO closure allows lower residual shunt rate, radiological exposure, and adverse events, mainly driven by a significant reduction in percutaneous reintervention. [ABSTRACT FROM AUTHOR]

Introduction: The efficacy and safety of switching P2Y 12 receptor antagonists in patients admitted for acute coronary syndrome (ACS) remain unclear. We assessed the short-term clinical outcomes (in-hospital and within 30 days) of switching P2Y 12 inhibitor (P2Y 12 I) drugs versus maintaining the same regimen by performing a comprehensive review and meta-analysis of available data., Methods: MEDLINE/PubMed/SCOPUS/Cochrane databases were screened for studies regarding switching of P2Y 12 I in patients with ACS that reported 30 days follow-up. Major cardiac events (MACE) and bleeding were compared between patients who were switched/not switched., Results: 22,500 patients from 14 studies were included. Unstable angina/non-ST elevation myocardial infarction (62.0%, interquartile range, 52.8%-68.0%) was the most common clinical presentation. The total number switched was 4294 (19.1%); escalation in 3416 (79.5%) patients (from clopidogrel to prasugrel, 62.9%) and de-escalation in 18.5%. Pooled analysis revealed no significant differences in MACE for any comparison; risk of bleeding was significantly increased among switched patients overall (odds ratio [OR], 1.60; 95% confidence interval [CI] 1.22-2.10) and increased in the escalation group (OR, 1.51; 95% CI, 1.06-2.16)., Conclusions: Among patients presenting with ACS, switching from one P2Y 12 I agent to another in the acute phase seems associated with a short-term increased risk of bleeding. Accurate upfront selection and prescription of a P2Y 12 I based on ischemic and bleeding risks is paramount to avoid adverse events switching-related during hospitalization and in the first 30 days.

Background: Chronic kidney disease (CKD) is associated with increased risk of mortality. We examined the impact of moderate and severe CKD at presentation on short- and long-term mortality among unselected patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI)., Methods: The study cohort consists of 501 patients (pts), enrolled from October 2005 to December 2012. The median follow-up was 46.52±25.58 months (range 8-99). A severe CKD (estimated Glomerular Filtration Rate [eGFR] <30 mL/min/1.73 m2) was detected in 16 pts (3.19%), a moderate CKD (eGFR 30-59 mL/min/1.73 m2) in 110 (21.96%) and a normal kidney function (eGFR >60 mL/min/1.73 m2) in 375 (74.85%)., Results: The crude in-hospital mortality rate resulted significantly higher in pts with severe and moderate CKD compared to pts with normal renal function (50% and 19.08% versus 2.93%, P<0.0001), as well as the long-term mortality rate (57.14% and 46.34% versus 8.77%, P<0.0001). After adjustment for confounding variables, severe and moderate CKD resulted the main independent predictors of in-hospital (odds ratio [OR]=21.815, P<0.0001 for severe CKD and OR= 4.203, P=0.002 for moderate CKD) and long-term (hazard ratio [HR]= 5.272, P=0.001; HR= 1.978, P=0.006) mortality., Conclusions: CKD is a frequent condition in patients with STEMI treated with PPCI and it is associated to an excess of mortality, resulting the main independent negative prognostic predictor.

Background: Few clinical data about indications and prognoses of patients undergoing balloon aortic valvuloplasty (BAV) in the transcatheter aortic valve implantation (TAVI) era have been reported., Methods: Data from all consecutive patients undergoing BAV in seven European centers from 2006 to 2013 were collected. Acute results and long-term outcomes were assessed., Results: A total of 811 patients aged 82 ± 9 years were included; 416 patients (51%) underwent BAV as palliative destination therapy, 320 patients (40%) as bridge to TAVI, and 75 patients (9%) as bridge to surgical aortic valve replacement (SAVR). Patients undergoing BAV as destination therapy had a higher risk profile (logistic EuroSCORE, 20 ± 17 vs 22 ± 14 vs 11 ± 8, respectively; P<.001). Post procedure, peak gradient decreased from 87 ± 22 mm Hg to 66 ± 22 mm Hg (P<.001) and aortic valve area increased from 0.61 ± 0.2 cm2 to 0.8 ± 0.2 cm2 (P<.001). At 30 days, the all-cause death rate (6.5% vs 6.2% vs 7.4%, respectively; P=.56) and the rate of life-threatening and major bleedings (8.0% vs 5.7% vs 6.0%, respectively) did not differ between groups. After a mean follow-up of 318 days (range, 116-500 days), rates of all-cause death were similar (30% vs 34% vs 31%, respectively; P>.99), although patients undergoing BAV as bridge to SAVR showed a lower cardiovascular death rate (11% vs 11% vs 3%, respectively; P=.04)., Conclusion: In the TAVI era, BAV may represent a reasonable option for patients with severe aortic stenosis and temporary contraindications to definite therapy. Given the mortality rates at 30 days, patients should be carefully selected, while events at follow-up are deeply influenced by the decision of whether or not subsequent interventions are performed.

Transvenous lead extraction (TLE) of the Starfix coronary sinus (CS) active-fixation lead may be challenging, due to undeployment of fixation lobes and venous occlusion. We report our experience in Starfix TLE, in comparison with previous data. A 78-year-old male, implanted in 2009 with Starfix lead, was referred to our institution for TLE, due to infective endocarditis with lead-associated vegetations. The tip of Starfix lead was located in distant, anterior position, in the great cardiac vein, close to patent left internal mammary artery-to-left anterior descending artery anastomosis, and first-choice surgical removal had a prohibitive operative risk. Conventional dilatation beyond CS ostium, as well as the use of a standard delivery catheter, was ineffective. An off-label modification of the delivery, by cutting the distal soft tip, was successful. However, the tip of the lead fragmented and was trapped in the innominate vein. Then a gooseneck snare grasped the fragment, allowing complete retrieval. TLE of Starfix leads may be particularly challenging, especially when its tip is located in a distant anterior location. In these cases, important help may be obtained by dilatation within the CS, by means of conventional or modified delivery catheters. Only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads. < Learning objective: TLE of Starfix leads may be challenging, particularly when the tip is located in a distant anterior position. Dilatation with conventional tools may be precluded. In these cases modifications of the delivery catheters may be useful. Surgery should be avoided as first-choice procedure; only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads.>.

Aims: Thirty-day readmission rate after percutaneous coronary intervention (PCI) is used as an index of quality of care, but the complete recovery from any myocardial damage needs 8 weeks. We evaluated the readmission rate 60 days after PCI, defined its predictors, and investigated its relationship with long-term prognosis., Methods and Results: All consecutive patients undergoing PCI in a large volume hospital were enrolled, and their outcomes were explored using an institutional database. The primary outcome was unplanned 60-day readmission. A composite of major adverse cardiovascular events (MACEs) including all-cause death, myocardial infarction, and repeated revascularization were the secondary endpoints. Among the 1193 enrolled patients, 71 (6.0%) underwent unplanned 60-day readmission for unstable angina (35.3%), chest pain (21.1%), heart failure (14.1%), and acute myocardial infarction (11.3%); 40.8% patients underwent repeated PCI. Readmitted patients carried more frequently left main disease (16.9 vs. 8.3%, P = 0.001), proximal left descending artery disease (31.0 vs. 27.4%, P = 0.03), and bifurcation disease (26.8 vs. 20.5%, P = 0.03). The only predictor of readmission was left main disease. After a mean follow-up of 743 ± 334 days, patients with 60-day readmission experienced higher rates of all-cause death (8.5 vs. 3.8%, P = 0.05). General baseline conditions and multivessel disease, but not 60-day readmissions, were predictors of MACE and death at follow-up., Conclusion: Unplanned 60-day readmissions after PCI are mainly related to the extent of coronary artery disease, being associated with left main, proximal left descending artery, and bifurcation disease. Readmissions are associated with higher long-term all-cause mortality.