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Background: Data regarding the mean resident time (RT) after left main (LM) bifurcation stenting are scant. In the present study we performed a patient-specific computational fluid dynamic (CFD) analysis to investigate the different post-stenting mean RT values in LM patients treated with single-or double stenting techniques., Methods: Patients were identified after reviewing the local Optical Coherence Tomography (OCT) scans database. Overall, 27 patients (mean age 65.5 ± 12.4, 21 males) [10 patients treated with provisional cross-over stenting, 7 with the double kissing crush (DK crush) and 10 with the nano-inverted T (NIT) technique, respectively] with isolated and significant LM bifurcation disease were analyzed., Results: After LM bifurcation stenting, the NIT showed a higher averages WSS values at all bifurcation sites compared to DK crush and provisional cross-over stenting. Moreover, the mean RT resulted lower after NIT compared to provisional or DK crush. During the diastolic phase, the average RT of the entire LM bifurcation was 0.46 s, 0.38 s and 0.33 s after using the provisional stenting, DK crush and NIT, respectively. Moreover, the average RT in the LM bifurcation decreased by 17.1 % using the DK crush and by 28.2 % using the NIT compared to the Provisional., Conclusion: The present OCT-derived CFD analysis revealed that, in patients with complex bifurcation LM disease, the provisional approach resulted in lower WSS values, while double stenting techniques, especially the NIT technique, resulted in a marked reduction of average RT compared to the provisional approach., Condensed Abstract: In the present study we performed a patient-specific Optical coherence tomography (OCT)-based computational fluid dynamic (CFD) analysis to investigate the different post-stenting mean RT values in 27 patients treated with provisional cross-over stenting, DK crush and Nano-inverted-T (NIT) stenting. The NIT showed a higher averages WSS values at all bifurcation sites compared to DK crush and Provisional. The mean RT resulted lower in NIT compared to Provisional or DK crush. During the entire diastolic phase, the average RT of the entire LM bifurcation was 0.46 s, 0.38 s and 0.33 s after using the provisional stenting, DK crush and NIT, respectively. Moreover, the average RT in the entire LM bifurcation decreased by 17.1 % using the DK crush and by 28.2 % using the NIT compared to the Provisional., Competing Interests: Declaration of competing interest None of the authors have conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is common in current clinical practice. Cardiac magnetic resonance (CMR) plays an important role in its management and is increasingly recommended by all the current guidelines. However, the prognostic value of CMR in patients with MINOCA is still undetermined., Objectives: The purpose of this study was to determine the diagnostic and prognostic value of CMR in the management of patients with MINOCA., Methods: A systematic review was performed to identify studies reporting the results of CMR findings in patients with MINOCA. Random effects models were used to determine the prevalence of different disease entities: myocarditis, myocardial infarction (MI), or takotsubo syndrome. Pooled odds ratios (ORs) and 95% CIs were calculated to evaluate the prognostic value of CMR diagnosis in the subgroup of studies that reported clinical outcomes., Results: A total of 26 studies comprising 3,624 patients were included. The mean age was 54.2 ± 5.3 years, and 56% were men. MINOCA was confirmed in only 22% (95% CI: 0.17-0.26) of the cases and 68% of patients with initial MINOCA were reclassified after the CMR assessment. The pooled prevalence of myocarditis was 31% (95% CI: 0.25-0.39), and takotsubo syndrome 10% (95% CI: 0.06-0.12). In a subgroup analysis of 5 studies (770 patients) that reported clinical outcomes, CMR diagnosis of confirmed MI was associated with an increased risk of major adverse cardiovascular events (pooled OR: 2.40; 95% CI: 1.60-3.59)., Conclusions: In patients with MINOCA, CMR has been demonstrated to add an important diagnostic and prognostic value, proving to be crucial for the diagnosis of this condition. Sixty-eight percent of patients with initial MINOCA were reclassified after the CMR evaluation. CMR-confirmed diagnosis of MINOCA was associated with an increased risk of major adverse cardiovascular events at follow-up., Competing Interests: Funding Support and Author Disclosures Dr Mileva has received speaker fees from Abbott. Drs Paolisso, Fabbricatore, and Munhoz have received research grants provided by the Cardiopath PhD program. Dr Andreini has received research grants from GE Healthcare and Bracco. Dr Marta Belmonte has received a research grant from the Cardiopath PhD program. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: To investigate in-hospital and long-term prognosis in T2DM patients presenting with acute myocardial infarction (AMI) treated with SGLT2-I versus other oral anti-diabetic agents (non-SGLT2-I users)., Methods: In this multicenter international registry all consecutive diabetic AMI patients undergoing percutaneous coronary intervention between 2018 and 2021 were enrolled and, based on the admission anti-diabetic therapy, divided into SGLT-I users versus non-SGLT2-I users. The primary endpoint was defined as a composite of cardiovascular death, recurrent AMI, and hospitalization for HF (MACE). Secondary outcomes included i) in-hospital cardiovascular death, recurrent AMI, occurrence of arrhythmias, and contrast-induced acute kidney injury (CI-AKI); ii) long-term cardiovascular mortality, recurrent AMI, heart failure (HF) hospitalization., Results: The study population consisted of 646 AMI patients (with or without ST-segment elevation): 111 SGLT2-I users and 535 non-SGLT-I users. The use of SGLT2-I was associated with a significantly lower in-hospital cardiovascular death, arrhythmic burden, and occurrence of CI-AKI (all p < 0.05). During a median follow-up of 24 ± 13 months, the primary composite endpoint, as well as cardiovascular mortality and HF hospitalization were lower for SGLT2-I users compared to non-SGLT2-I patients (p < 0.04 for all). After adjusting for confounding factors, the use of SGLT2-I was identified as independent predictor of reduced MACE occurrence (HR=0.57; 95%CI:0.33-0.99; p = 0.039) and HF hospitalization (HR=0.46; 95%CI:0.21-0.98; p = 0.041)., Conclusions: In T2DM AMI patients, the use of SGLT2-I was associated with a lower risk of adverse cardiovascular outcomes during index hospitalization and long-term follow-up. Our findings provide new insights into the cardioprotective effects of SGLT2-I in the setting of AMI., Registration: Data are part of the observational international registry: SGLT2-I AMI PROTECT., Clinicaltrials: gov Identifier: NCT05261867., Competing Interests: Competing interests The authors declare that they have no competing interests., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Data regarding the optimal dual antiplatelet therapy (DAPT) duration in patients treated with a 1- versus a 2-stent strategy in LM bifurcation PCI are scant. A literature search based on Cochrane Library, Embase, PubMed and Google Scholar was performed to locate articles published between January 2015 and January 2020. The following MeSH terms were used for the search: "Left Main" AND "DAPT Duration" AND "stent" OR "stenting". The analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Occurrence of major adverse cardiovascular events (MACEs) according to length of DAPT and stenting strategy was analysed. A total of 256 articles were retrieved and after evaluation, 3 articles evaluating the results of 8 large registries were included into the analysis including a final population of 4117 patients [mean age 65.7 years, 3133 (76.0%) males]. A short-term DAPT resulted in a lower risk of MACEs in patients treated with a single stent strategy (OR: 0.49, 95% CI [0.33-0.67], p < 0.001, I2 = 0%), whereas a DAPT >12 months resulted in a significant higher risk of MACEs in the same group (OR: 7.39, 95% CI [5.09-10.7], p < 0.001, I2 = 61%) compared to double stent strategy. The available data support the use of short DAPT in single cross-over LM stenting whereas a long DAPT seems to be more appropriate after a double stenting strategy in LM bifurcation PCI., Competing Interests: Declaration of competing interest None of the authors have conflicts of interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to compare clinical outcomes of different bifurcation percutaneous coronary intervention (PCI) techniques., Background: Despite several randomized trials, the optimal PCI technique for bifurcation lesions remains a matter of debate. Provisional stenting has been recommended as the default technique for most bifurcation lesions. Emerging data support double-kissing crush (DK-crush) as a 2-stent technique., Methods: PubMed and Scopus were searched for randomized controlled trials comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE). Secondary outcomes of interest were cardiac death, myocardial infarction, target vessel or lesion revascularization, and stent thrombosis. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis., Results: Twenty-one randomized controlled trials including 5,711 patients treated using 5 bifurcation PCI techniques were included. Investigated techniques were provisional stenting, T stenting/T and protrusion, crush, culotte, and DK-crush. Median follow-up duration was 12 months (interquartile range: 9 to 36 months). When all techniques were considered, patients treated using the DK-crush technique had less occurrence of MACE (OR: 0.39; 95% credible interval: 0.26 to 0.55) compared with those treated using provisional stenting, driven by a reduction in target lesion revascularization (OR: 0.36; 95% credible interval: 0.22 to 0.57). No differences were found in cardiac death, myocardial infarction, or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed among provisional stenting, culotte, T stenting/T and protrusion, and crush. In non-left main bifurcations, DK-crush reduced MACE (OR: 0.42; 95% credible interval: 0.24 to 0.66)., Conclusions: In this network meta-analysis, DK-crush was associated with fewer MACE, driven by lower rates of repeat revascularization, whereas no significant differences among techniques were observed for cardiac death, myocardial infarction, and stent thrombosis. A clinical benefit of 2-stent techniques was observed over provisional stenting in bifurcation with side branch lesion length ≥10 mm., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The optimal final optimization technique to be used in patients after Cross Over Left main stenting remainsdebatable., Aim: We evaluate the impact of the post-optimization technique (POT), kissing balloon (KB) and the POT-side-POT techniques on both cardiovascular mortality and event-free survival in patients receiving left main (LM) cross-over stenting for an isolated/distal bifurcation LM disease., Methods: Clinical and instrumental records of 128 consecutive patients (102 males, mean age 73.39 ± 9.54 years old) with isolated distal/bifurcation LM disease and bypass surgery contraindications or refusal enrolled to receive LM cross-over stenting between the 1st January 2012 and the 1st January 2017 at two institutions: the Rovigo General Hospital (Rovigo, Italy) and the Alexandrovka Hospital University School of Medicine (Sofia, Bulgaria). Patients has been divided into three groups (POT, KB and POT-side-POT) according the optimal final optimization technique used while the 5-year cardiovascular mortality has been evaluated using the log-rank (Mantel-Cox) analysis., Results: Baseline angiographic characteristics of the LM disease were mostly equivalent among the three groups. Over a global follow-up of 61.03 ± 0.92 months, the rates of target vessel revascularization, acute myocardial infarction, and stent thrombosis, were not different among groups. Patients treated with POT had a slightly better long-term survival., Conclusions: None of these optimization techniques appeared to have clearly better long-term outcomes after LM Cross-over stenting in our retrospective study. POT resulted in a slightly better survival compared to Pot-sid-POT and KB., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background/purpose: Computational fluid dynamics (CFD) have been recently adopted in many fields of cardiovascular medicine and in interventional cardiology. Using CFD analysis we compared the use of different PCI procedures, with and without the utilization of a proximal optimization technique (POT), on a complex coronary artery bifurcation., Methods/materials: For the analysis, we considered a hypothetic model of a left anterior descending artery-diagonal Medina 1,1,1 bifurcation type with a diameter of the proximal main branch (MB) and the side branch (SB) set at 3.5mm and 2.5mm, respectively. The bifurcation angle has been set to 50°. For the stent simulation, we reconstructed a third-generation, ultra-thin strut everolimus-eluting stent (ORSIRO stent, Biotronik IC, Bulack, Switzerland)., Results: The Nano-crush and the modified T techniques seem able to restore the most physiologic fluid dynamic profile. Conversely, the DK-crush and the culotte demonstrated an intermediate and worst effect, respectively. The addition of a final POT resulted favorably for both Nano-crush and reverse modified T techniques, whereas a neutral and lack of significant effects have been observed for the DK-crush and culotte technique, respectively., Conclusion: Different double-stenting techniques (DST) have a different impact on coronary flow physiology. Both Nano-crush and modified T techniques achieved the most physiologic profile. The addition of a final POT appears to be a favourable step for both Nano-crush and modified T., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Results of regular drug-eluting stents (rDESs) in bifurcation treatment are not optimal. The aim of the Polish Bifurcation Optimal Stenting I (POLBOS I) trial was to compare bifurcation treatment with any rDES vs the dedicated bifurcation paclitaxel-eluting stent BiOSS Expert (Balton, Poland). The second aim was to study the effect of final kissing balloon (FKB) inflation on clinical outcomes., Methods: Between October 2010 and January 2013 patients with stable coronary artery disease or non-ST-elevation acute coronary syndrome were assigned 1:1 to 1 of 2 treatment strategies: BiOSS Expert stent or rDES implantation. Coronary angiography was performed at 12 months. The primary end point was a composite of cardiac-related death, myocardial infarction (MI), and target lesion revascularization (TLR) at 12 months., Results: The BiOSS Expert was implanted in 120 patients (49.4%), and an rDES was implanted in 123 patients. The target vessel was the left anterior descending (LAD) artery (52% vs 70%) followed by the left main stem (LMS) coronary artery (22% vs 15%). In the rDES group, 38.2% received paclitaxel-eluting stents. There were 3 stent implantation failures (2 in the rDES group and 1 in the BiOSS Expert group). Side branch treatment with an rDES was required in 10% of cases in both groups. At 12 months, the incidence of cumulative major adverse cardiovascular events (MACE) was similar in both groups: 13.3% vs 12.2% (P = 0.7). The TLR rate was significantly higher in the BiOSS Expert group compared with the rDES group (11.5% vs 7.3%; P = 0.02). Significantly lower rates of restenosis were observed in FKB subgroups of both the BiOSS Expert (8.1% vs 13.2%; P < 0.05) and rDES groups (4.9% vs 9.5%; P < 0.05)., Conclusions: MACE rates were comparable between the 2 groups; however, the TLR rate was higher in the BiOSS Expert group. A more aggressive protocol yielded better angiographic and clinical outcomes., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The best treatment strategy for below the knee bifurcation disease is not known. We present first two cases with successful implantation of dedicated coronary bifurcation sirolimus eluting stent BiOSS Lim (Balton, Poland) in complex bifurcation and trifurcation lesions of tibioperoneal trunk. Both implantations were uncomplicated with sustained short-term result at 30-day control Duplex ultrasound and remarkable clinical improvement. Our report demonstrates feasibility and short-term effectiveness of implantation of dedicated coronary bifurcation stent in below-the-knee bi- and tri-furcations., (© 2014.)

Objectives: Restenosis after drug eluting stent (DES) implantation in the distal/bifurcation left main (DBLM) remains challenging to manage. The aim of this study was to assess the in-stent restenosis (ISR) after DES implantation in DLM and to evaluate current management strategy., Methods: The medical records of patients referred for LM distal/bifurcation percutaneous coronary interventions (PCI) from the same Cardiology Unit in the January 2007 to December 2012 period were reviewed for PCI technique, stent type, restenosis type, restenosis treatment and management (CABG, balloon angioplasty only, alternative DES implant, drug eluting balloon angioplasty)., Results: Fourteen patients (5 females, mean age 75.1±8.3years) out of 89 (15.7%) having undergone a percutaneous coronary interventions on DBLM with DES, developed restenosis (everolimus stents in 10 patients, zotarolimus stents in 4 patients). Technique used at the first implant included stenting of the main branch in 4 patients, culottes stenting in 6 patients and T-stent in 4 patients. The mean time elapsed from the first angioplasty and ISR intervention was 7.6±3.6months. Restenosis treatments included: implantation of a different DES (in 3 patients), implantation of a bare-metal stent (in 2 patients), simple balloon angioplasty (in 4 patients), and drug-eluting balloon (5 patients). At 6-month angiographic control second restenosis rate was 14.2%. After a mean follow-up of 38.5±24.4months the target vessel revascularization was 14.3%: surgery was the final choice in two patients due to recurrent restenosis. Incidence of major adverse cardiac event was 28.5%., Conclusions: The occurrence of restenosis after DBLM following DES implantation is not frequent but remains difficult to manage. In our small anecdotal series, all the different strategies including implantation of different DES, balloon angioplasty, bare-metal stent implantation and drug-eluting balloon angioplasty appeared equally effective in maintaining arterial patency., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: This study sought to investigate the clinical, electrocardiographic, and physiological relevance of main and side branches in coronary bifurcation lesions., Background: Discrepancy exists between stenosis severity and clinical outcomes in bifurcation lesions. However, its mechanism has not been fully evaluated yet., Methods: Sixty-five patients with left anterior descending coronary artery (LAD) bifurcation lesions were prospectively enrolled. Chest pain and 12-lead electrocardiogram were assessed after 1-min occlusion of coronary flow and coronary wedge pressure (Pw) was measured using a pressure wire., Results: ST-segment elevation was more frequent during LAD occlusion (92%) than during diagonal branch occlusion (37%) (p < 0.001). Pain score was also higher with the occlusion of LAD than with the diagonal branch (p < 0.001). However, both Pw and Pw/aortic pressure (Pa) were lower in the LAD than in diagonal branches (Pw: 21.0 ± 6.5 vs. 26.7 ± 9.4, p < 0.0001; Pw/Pa: 0.22 ± 0.07 vs. 0.27 ± 0.08, p = 0.001). The corrected QT interval was prolonged with LAD occlusion (435.0 ± 39.6 ms to 454.0 ± 45.4 ms, p < 0.0001) but not with diagonal branch occlusion. There was no difference in vessel size between the diagonal branches with and without ST-segment elevation during occlusion. Positive and negative predictive values of vessel size (≥2.5 mm) to determine the presence of ST-segment elevation were 48% and 72%, respectively., Conclusions: Diagonal branch occlusion caused fewer anginas, less electrocardiogram change, less arrhythmogenic potential, and higher Pw than did a LAD occlusion. These differences seem to be the main mechanism explaining why aggressive treatment for side branches has not translated into clinical benefit in coronary bifurcation lesions. (Comparison Between Main Branch and Side Branch Vessels; NCT01046409)., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The correlation between the structure and the spectroscopic properties of N-methylcodeinium iodide (1) has been studied, using the methods of single crystal X-ray diffraction, IR-LD spectroscopy of oriented samples as a suspension in nematic liquid crystals, UV-vis spectroscopy and 1H and 13C NMR spectroscopy. HPLC tandem mass spectrometry (HPLC ESI MS/MS) and thermal methods were also employed. Quantum chemical calculations have been performed with a view to obtaining the electronic structure and vibrational properties of the title compound. Compound (1) crystallizes in the space group P2(1)2(1)2(1) and its cations and anions are joined by moderate intermolecular OH...I- interaction of length 3.442A. The codeine molecule exhibits the classical T-shape for opiates. A dihedral angle value of 86.4(5) degrees between the A/B/C and D/E planes is obtained. Rings A and B are effectively coplanar with an interplanar angle of 3.6(3) degrees.