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Objective To comparatively assess the natural history of patients of different ages undergoing transcatheter aortic valve replacement (TAVR). Patients and Methods For this study, we used the YOUNG TAVR, an international, multicenter registry investigating mortality trends up to 2 years in patients with aortic valve stenosis treated by TAVR, classified according to 3 prespecified age groups: 75 years or younger (n=179), 76 to 86 years (n=602), and older than 86 years (n=221). A total of 1002 patients undergoing TAVR were included. Demographic, clinical, and outcome data in the youngest group were compared with those of patients 76 to 86 years and older than 86 years. Patients were followed up for up to 2 years. Results Compared with patients 75 years or younger (reference group), patients aged 76 to 86 years and older than 86 years had nonsignificantly different 30-day mortality (odds ratio, 0.76; 95% CI, 0.41-1.38; P=.37 and odds ratio, 1.27; 95% CI, 0.62-2.60; P=.51, respectively) and 1-year mortality (hazard ratio (HR), 0.72; 95% CI, 0.48-1.09; P=.12 and HR, 1.11; 95% CI, 0.88-1.40; P=.34, respectively). Mortality at 2 years was significantly lower among patients aged 76 to 86 years (HR, 0.62; 95% CI, 0.42-0.90; P=.01) but not among the older group (HR, 1.06; 95% CI, 0.68-1.67; P=.79). The Society of Thoracic Surgeons 30-day mortality score was lower in younger patients who, however, had a significantly higher prevalence of chronic obstructive pulmonary disease (P=.005 vs the intermediate group and P=.02 vs the older group) and bicuspid aortic valves (P=.02 vs both older groups), larger left ventricles, and lower ejection fractions. Conclusion In the present registry, mortality at 2 years after TAVR among patients 75 years or younger was higher compared with that of patients aged 75 to 86 years and was not markedly different from that of patients older than 86 years. The findings are attributable at least in part to a greater burden of comorbidities in the younger age group that are not entirely captured by current risk assessment tools.

We aim to compare Polymer-Free Biolimus-Eluting Stent (PF-BES) with Durable Polymer Everolimus-Eluting stent (DP-EES) in unselected patients. PF-BES showed a favorable profile in high-bleeding risk patients who underwent percutaneous coronary intervention. Limited data are available on PF-BES compared with second-generation durable polymer-coated drug-eluting stents in patients eligible for standard dual antiplatelet therapy. A total of 848 consecutive patients were enrolled: 306 patients were treated with PF-BES and 542 with DP-EES. Stent performance was tested in a propensity score-matched population and in a Complex Higher-Risk and Indicated Patients (CHIP) subpopulation. A per-lesion analysis on 1,204 lesions (PF-BES = 424 vs DP-EES = 780) was also performed. At a medium follow-up of 18.5 ± 5.0 months, no differences in the matched population were found in terms of major adverse cardiac events (PF-BES 9.0% vs DP-EES 4.5%; p 0.091), myocardial infarction (PF-BES 6.2% vs DP-EES 2.3%; p 0.111), stent restenosis (PF-BES 2.3% vs DP-EES 0.0%; p 0.123), definite or probable stent thrombosis (PF-BES 2.8% vs DP-EES 1.1%; p 0.448). A significant inferior rate of restenosis was observed in the DP-EES arm in the whole (PF-BES 2.3% vs DP-EES 0.6%; p 0.041) and CHIP populations (PF-BES 4.3% vs DP-EES 0.5%; p 0.023), as well as in the per-lesion analysis (DP-EES 0.4% vs PF-BES 1.7%; p 0.039). In conclusion, in a real-world cohort PF-BES performed similarly to DP-EES in terms of restenosis and stent thrombosis in the matched population. Nonetheless, in the whole and CHIP populations, as well as in the per-lesion analysis, restenosis occurrence resulted higher in the PF-BES group.

Tricuspid valve endocarditis (TVE) is not an uncommon finding in intravenous drug addicts [1]. TVE with pulmonary septic embolization, however, is a less common finding [2]. Even more rare is the diagnosis of TVE mainly led by pulmonary signs. We report the case of a 40-year-old man, a former intravenous drug addict, referred to our institution for recurrent episodes of cough and fever mimicking episodes of pneumonitis since a couple of months. The patient was affected by chronic hepatitis C, without history of heart disease. At previous hospitalization, chest radiograph showed 2 parenchyma nodules within left lung (basal and apical). A pneumonitis was therefore hypothesized and the patient was administrated with levofloxacin and ceftriaxone for 2 weeks, without any symptom relief. At present hospitalization, chest X-ray confirmed the presence of a single nodule in the basal segment of the left lung. Physical examination, however, was unremarkable. Rest ECG showed sinus rhythm at 78 bpm without significant ST anomalies (Fig. 1). Systolic blood pressure was 120/80 mm Hg. Troponin was 0.03 ng/ml and N-terminal pro-brain natriuretic peptide 20.6 pg/ml, while C-reactive

Background Surgery for acute aortic dissection (AAD) is frequently complicated by excessive postoperative bleeding and blood product transfusion. Blood flow through the nonendothelialized false lumen is a potential trigger for the activation of the hemostatic system; however, the physiopathology of the aortic dissection induced coagulopathy has never been precisely studied. The aim of the present study is the evaluation of the coagulation and fibrinolytic systems and platelet activation in patients undergoing surgery for AAD. Methods Eighteen patients undergoing emergent surgery for Stanford type A AAD were enrolled in the study. The activation of the coagulation and fibrinolytic systems and platelet activation were evaluated at 6 different time points before, during, and after the operation, measuring prothrombin fragment 1.2 (F1.2), plasmin-antiplasmin complex, and platelet factor 4, respectively. Results All measured biomarkers were increased before, during, and after the operations indicating a systemic activation of coagulation, fibrinolysis, and platelets. These changes were pronounced even preoperatively (T0), and soon after the beginning of cardiopulmonary bypass (T1) when the influence of hypothermia and prolonged cardiopulmonary bypass time were not yet involved. Time from symptom onset to intervention inversely correlated with preoperative F1.2 (r = −0.75; p = 0.002) and plasmin-antiplasmin levels (r = −0.57; p = 0.034). Conclusions Blood flow through the false lumen is a powerful activator of the hemostatic system even before the operation. This remarkable activation may influence postoperative outcome of AAD patients.

Dual antiplatelet therapy improves angiographic results of primary percutaneous coronary intervention (pPCI) in patients with STEMI. The new oral P2Y12 inhibitors (P2Y12-I) prasugrel and ticagrelor are the gold-standard drugs because of a faster and more intense effect when compared to clopidogrel.

Isolated aortic aneurysms in Takayasu arteritis (TA) are rare. Reported operative mortality and operative complication rates seem low, with an infrequent need for surgical revision, even though most reports concern occlusive disease. Treatment of aneurysms in TA requires therapeutic strategies that are different from the ones used for atherosclerotic vessel dilatations because the pathology and the extensive, progressive, relapsing nature of the disease are deeply different from the atherosclerotic process. We report a case of thoracic stent-graft bulging rupture, a device previously implanted to exclude a thoracic aneurysm, associated with two small aneurysms near the distal implantation site. Both were treated with three new-generation stent grafts implanted in a telescope fashion.

Objectives The aim of this trial was to compare cutting balloon angioplasty (CBA) with conventional balloon angioplasty (i.e., percutaneous transluminal coronary angioplasty [PTCA]) for the treatment of patients with coronary in-stent restenosis (ISR). Background Retrospective studies suggest CBA might be superior to conventional PTCA in the treatment of ISR. Methods The Restenosis Cutting Balloon Evaluation Trial (RESCUT) is a multicenter, randomized, prospective European trial including 428 patients with all types of ISR (e.g., focal, multifocal, diffuse, proliferative). Results In both groups, the majority of ISR lesions were shorter than 20 mm. The length of restenotic stents was similar (CBA: 18.6 ± 9.7 mm; PTCA: 18.3 ± 8.7 mm). The number of balloons used to treat ISR was lower in the CBA group: only one balloon was used in 82.3% of CBA cases, compared with 75% of PTCA procedures (p = 0.03). Balloon slippage was less frequent in the CBA group (CBA 6.5%, PTCA 25%; p Conclusions Cutting balloon angioplasty did not reduce recurrent ISR and major adverse cardiac events, as compared with conventional PTCA. However, CBA was associated with some procedural advantages, such as use of fewer balloons, less requirement for additional stenting, and a lower incidence of balloon slippage.

Background: The goal of STEMI treatment is early reperfusion. The new oral P2Y12 inhibitors (P2Y12-I) prasugrel and ticagrelor demonstrated to improve angiographic results of primary percutaneous coronary intervention (pPCI) and clinical prognosis, but their onset of action is significantly impaired

The aim of our study was to investigate the inflammatory response immediately after percutaneous transmyocardial laser revascularization (PTMR) along with the underlying mechanism of angiogenesis.Patients with angina pectoris underwent coronary angiography and were divided into two groups. Group A (n = 10) included patients with obstructed vessels who received PTMR, whereas group B (n = 5) comprised patients who had normal coronary arteries. Blood levels of neutrophils, procalcitonin, troponin-I, myoglobin, and creatine kinase (CK) mass were evaluated in each patient before angiography and monitored up to 48 hours after the procedure. Six patients were injected with 99mTc-leukoscan approximately 60 to 90 minutes after PTMR. During the 240 to 300 minutes after the radionuclide administration, single photon emission tomography (SPET) was performed and compared with conventional 99mTc-sestamibi-SPET.A significant increase in blood levels of neutrophils and procalcitonin was observed in group A only (p0.005). A slight but significant increase of troponin-I was evident in the same group (p0.05), and a distinct myocardial uptake of 99mTc-Leukoscan-SPET was observed in each patient along homologous regions treated by PTMR.The increased amount of neutrophils (both circulating and inside the treated myocardial areas) along with the raised levels of procalcitonin were the immediate reactions to PTMR. This systemic and intramyocardial inflammatory response is the underlying mechanism that gives rise to angiogenesis.

Stent-graft implantation is a very interesting and promising therapeutic option, alternative to conventional open operation, for the treatment of the diseases of the thoracic descending aorta. Several studies demonstrated encouraging results about the effectiveness of this technique both in the chronic settings and in acute scenarios, 1-3 although complications related to this treatment are also well recognized. In particular, complications can arise if great attention is focused on the perigraft leak, which, with an incidence estimated between 2.4% and 45.5%, represents the most common complication. On the other hand, little information is actually available about other rare, but not less important, stent-related findings and about their clinical significance. 4

To report the use of endografts to manage multiple aneurysms due to Cogan syndrome (CS). A 38-year-old woman with descending thoracic aorta and right common carotid artery aneurysms due to CS was treated with endovascular grafts. After 4 years, angio computed tomography scan demonstrated complete exclusion of the aneurysms with no signs of endoleak, whereas echo color Doppler showed patency of the carotid graft, no signs of restenosis, no progression of the disease in the landing zones, and complete aneurysm exclusion. Endovascular repair seems to have favorable long-term outcomes and should be considered a viable alternative to surgery in unfit for open surgery patients, even if they are young, and when the aneurysm size and location would pose a higher risk of perioperative and postoperative complications after an open surgical procedure.

The pressure-length relation in normal and ischemic segments was analyzed with use of left ventriculography and simultaneous micromanometry during supine exercise in 9 normal subjects and 12 patients with effort angina. Segmental analysis was done in the right anterior oblique projection using a long axis with three perpendicular, equidistant chords. The apical segment in the 12 patients with coronary artery disease represented the ischemic region. In 5 of the 12 patients with coronary artery disease, the basal segment that showed no exercise-induced deterioration in wall motion was used as an intrapatient control (nonischemic segment).In the 12 patients with coronary artery disease, left ventricular ejection fraction decreased (from 65% to 50%, p < 0.001), end-diastolic pressure increased (from 24 to 40 mm Hg, p < 0.001) and the lowest diastolic filling pressure increased (from 9 to 22 mm Hg, p < 0.001) during exercise-induced ischemia. In normal subjects, ejection fraction increased (from 64% to 70%, p < 0.01) with unchanged end-diastolic pressure, whereas the lowest diastolic filling pressure decreased during exercise (from 9 to 3 mm Hg, p < 0.01). Global left ventricular diastolic pressure-volume curves showed an upward and rightward shift during exercise-induced ischemia. Regional pressure-length curves of both nonischemic (n = 5) and ischemic (n = 12) segments were shifted upward in early diastole, but moved to a higher portion of the rest pressure-length curve without an upward shift during mid- to end-diastole. In contrast, the apical segment in normal subjects showed a downward shift during exercise. Regional stiffness increased during exercise-induced ischemia in the ischemic but not in the nonischemic segment.In conclusion, the global left ventricular diastolic pressure-volume relation shows an upward and rightward shift during exercise-induced ischemia, whereas the regional pressure-length curves of the nonischemic and ischemic segments show an upward shift only during early, but not during late, diastole. This early diastolic upward shift of the regional pressure-length curve is more pronounced in the nonischemic segment. Regional stiffness is increased only in the ischemic segment. Thus, there is a time-dependent upward shift of the regional pressure-length curve during exercise-induced ischemia that is probably due to delayed relaxation in the ischemic segment and increased viscous forces in the nonischemic segment.

Whether exercise-induced vasoconstriction of coronary artery stenoses is modified by the administration of calcium antagonists was examined in 14 patients with classic angina pectoris. In this group the effect of intracoronary diltiazem (2 to 3 mg) on luminal area was evaluated in normal and stenotic segments of epicardial coronary arteries during symptom-limited supine exercise. The luminal area of a normal and a stenotic coronary artery segment was determined by quantitative coronary arteriography with a computer-assisted system. Patients were studied at rest, 6 min after 2 to 3 mg of intracoronary diltiazem, during supine bicycle exercise (96 W) and 5 min after sublingual administration of 1.6 mg nitroglycerin. Heart rate, mean pulmonary and aortic pressure as well as the percent change of both normal and stenotic luminal area were determined.Intracoronary administration of diltiazem was associated with mild dilation of both normal (19%, p < 0.01) and stenotic coronary luminal area (11%, p < 0.05). During subsequent exercise, luminal area of the stenotic vessel segment increased by 23% (p < 0.001) and that of the normal vessel segment by 24% (p < 0.001), whereas in a previously reported control group, luminal area of the stenotic vessel segment decreased by 29% during exercise. After sublingual administration of nitroglycerin, the luminal area of both the normal and the stenotic vessel segment increased further by 19% (p < 0.01) and 22% (p < 0.01), respectively, compared with the values after intracoronary administration of diltiazem.Thus, intracoronary administration of diltiazem prevents exercise-induced vasoconstriction of stenotic coronary arteries, suggesting a direct vasodilating effect on the coronary artery. Diltiazem and nitroglycerin seem to have an additive effect on coronary vasodilation of stenotic vessel segments probably as a result of restoration of endothelial function of the diseased coronary vessel by diltiazem.

Passive diastolic properties of the left ventricle were determined in 10 control subjects and 12 patients with dilated cardiomyopathy. Simultaneous left ventricular angiography and high fidelity pressure measurements were performed in all patients. Left ventricular chamber stiffness was calculated from left ventricular pressure-volume and myocardial stiffness from left ventricular stress-strain relations with use of a viscoelastic model. Patients with dilated cardiomyopathy were classified into two groups according to the diastolic constant of myocardial stiffness (beta). Group 1 consisted of seven patients with a normal constant of myocardial stiffness less than or equal to 9.6 (normal range 2.2 to 9.6) and group 2 of 5 patients with a beta greater than 9.6. Structural abnormalities (percent interstitial fibrosis, fibrous content) in patients with dilated cardiomyopathy were assessed by morphometry from right ventricular endomyocardial biopsies. Heart rate was similar in the three groups. Left ventricular end-diastolic pressure was significantly greater in patients with cardiomyopathy (18 mm Hg in group 1 and 22 mm Hg in group 2) than in the control patients (10 mm Hg). Left ventricular ejection fraction was significantly lower in groups 1 (37%) and 2 (36%) than in the control patients (66%). Left ventricular muscle mass index was significantly increased in both groups with cardiomyopathy. The constant of chamber stiffness (beta*) was slightly although not significantly greater in groups 1 and 2 (0.58 and 0.58, respectively) than in the control group (0.35). The constant of myocardial stiffness beta was normal in group 1 (7.0; control group 6.9, p = NS) but was significantly increased in group 2 (23.5). Interstitial fibrosis was 19% in group 1 and 43% (p less than 0.001) in group 2 (normal less than or equal to 10%). There was an exponential relation between both diastolic constant of myocardial stiffness (beta) and interstitial fibrosis (IF) (r = 0.95; p less than 0.001) and beta and fibrous content divided by end-diastolic volume index (r = 0.93; p less than 0.001). It is concluded that myocardial stiffness can be normal in patients with dilated cardiomyopathy despite severely depressed systolic function. Structural alterations of the myocardium with increased amounts of fibrous tissues are probably responsible for the observed changes in passive elastic properties of the myocardium in patients with dilated cardiomyopathy. The constant of myocardial stiffness (beta) helps to identify patients with severe structural alterations (group 2), representing possibly a more advanced stage of the disease.