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Heavily calcified coronary lesions increase the complexity of percutaneous coronary interventions (PCI) and represent a challenge for interventional cardiologists. They are an important cause of stent underexpansion and poor clinical outcome. Nowadays, there are different dedicated devices which enhance the chances of success. Rotational atherectomy is the first-line modality which permits to cross balloons or stents through severe calcified lesions. However, when circumferential deep calcium plaques exist may not be enough to achieve adequate expansion of these devices. In these cases, the complementary use of intracoronary lithotripsy ("RotaTripsy") can be an effective approach that further modifies the calcified plaque and enables optimal stent implantation. We present the first case series undergoing PCI using "RotaTripsy" technique.

Introduction and objectives Aortic self-expandable (SE) transcatheter aortic valve implantation (TAVI) devices are particularly useful for patients with aortic stenosis and small/tortuous vessels, small aortic annuli, or low coronary ostia. However, it is unclear whether the growing range of SE devices shows comparable hemodynamic and clinical outcomes. We aimed to determine the differential hemodynamic (residual valve area and regurgitation) and clinical outcomes of these devices in comparable scenarios. Methods All patients were enrolled from 4 institutions and were managed with 4 different SE TAVI devices. Baseline and follow-up clinical data were collected and echocardiographic tests blindly and centrally analyzed. Patients were compared according to valve type and a 1:1 matched comparison was performed according to degree of calcification, aortic annulus dimensions, left ventricular ejection fraction, and body surface area. Results In total, 514 patients were included (Evolut R/PRO, 217; ACURATE neo, 107; ALLEGRA, 102; Portico, 88). Surgical risk scores were comparable in the unmatched population. No differences were observed in the post-TAVI regurgitation rate and in in-hospital mortality (2.7%). The rate of pacemaker implantation at discharge was significantly different among devices (P=.049), with Portico showing the highest rate (23%) and ACURATE neo the lowest (9.5%); Evolut R/PRO and ALLEGRA had rates of 15.9% and 21.2%, respectively. The adjusted comparison showed worse residual TAVI gradients and aortic valve area with ACURATE neo vs ALLEGRA (P=.001) but the latter had higher risk of valve embolization and a tendency for more cerebrovascular events. Conclusions A matched comparison of 4 SE TAVI devices showed no differences regarding residual aortic regurgitation and in-hospital mortality.

espanolIntroduccion y objetivos: El objetivo del estudio fue investigar si la evaluacion no invasiva del indice de calcificacion coronaria mediante tomografia computarizada cardiaca multidetector (TCMD) puede predecir la necesidad de una aterectomia rotacional (AR) electiva durante la intervencion coronaria percutanea. Metodos: Se incluyeron pacientes diagnosticados de estenosis coronaria grave con placas moderadamente o gravemente calcificadas durante la angiografia coronaria. Esos pacientes se sometieron a la cuantificacion del indice de calcificacion coronaria con la escala de Agatston utilizando TCMD y posteriormente a intervencion percutanea. Solo fueron tratadas con AR las lesiones que se consideraba que no era posible cruzar ni dilatar, segun un protocolo de revascularizacion predisenado. Ninguno de los operadores conocia de antemano los resultados de la TCMD. Segun el protocolo del estudio, en el analisis estadistico se incluyeron variables clinicas, angiograficas y relacionadas con la puntuacion Agatston. Durante el seguimiento se estudiaron los resultados a corto y largo plazo en ambos grupos. Resultados: Se analizaron 40 pacientes: 20 que recibieron AR y 20 con intervencion coronaria percutanea convencional. La mayoria se incluyo despues de un sindrome coronario agudo y tenian una anatomia coronaria compleja (puntuacion media de la escala Syntax de 25 puntos). La creatinina y la puntuacion de Agatston por lesion fueron los unicos factores predictivos de la AR. No se observaron diferencias significativas en el pronostico dentro del hospital o a largo plazo. Un nuevo parametro, el indice CAC-Cre, fue util para predecir la necesidad de AR. Conclusiones: El analisis de la calcificacion de las arterias coronarias mediante la puntuacion de Agatston mejora la evaluacion no invasiva de las placas coronarias complejas antes de la intervencion coronaria percutanea. La puntuacion de Agatston por lesion, la creatinina serica y el indice CAC-Cre son parametros utiles para predecir la necesidad de una AR electiva durante la intervencion coronaria percutanea. EnglishIntroduction and objectives: This study aims to investigate if the non-invasive assessment of coronary calcium score using multislice cardiac computerized tomography (MSCT) may anticipate the need for elective rotational atherectomy (RA) during percutaneous coronary intervention. Methods: Patients were considered eligible for the study after receiving a diagnosis of severe coronary stenosis with moderate or severely calcified plaques during index coronary angiography. Those patients underwent the Agatston coronary artery calcium (CAC) score quantification using the MSCT and then underwent percutaneous intervention. Only those lesions considered non-crossable or non-dilatable according to a pre-specified revascularization protocol were treated with RA. All operators were blinded to the MSCT results. According to the study protocol, clinical, angiographic and Agatston-related variables were included in the statistical analysis. Short and long-term outcomes were investigated in both treatment groups during follow-up. Results: A total of 40 patients were included in the analysis: 20 underwent RA and 20 conventional percutaneous coronary interventions. Most patients were included after suffering from an acute coronary syndrome and had complex coronary anatomy (mean Syntax score, 25 points). The logistic regression analysis showed that creatinine levels and the per-lesion Agatston score were the only predictors of RA. No significant differences were observed regarding in-hospital or long-term procedural outcomes. A novel parameter, the CAC-Cre index, was found to be useful to anticipate the need for RA. Conclusions: Coronary artery calcification analysis using the Agatston score is a simple technique that improves the non-invasive assessment of complex coronary plaques prior to percutaneous coronary intervention. The per-lesion Agatston score, serum creatinine levels, and the CAC-Cre index may become useful parameters to anticipate the need for elective RAs during percutaneous coronary intervention.

Background We aimed to compare the performance of the recent CASTLE score to J-CTO, CL and PROGRESS CTO scores in a comprehensive database of percutaneous coronary intervention of chronic total occlusion procedures. Methods Scores were calculated using raw data from 1,342 chronic total occlusion procedures included in REBECO Registry that includes learning and expert operators. Calibration, discrimination and reclassification were evaluated and compared. Results Mean score values were: CASTLE 1.60±1.10, J-CTO 2.15±1.24, PROGRESS 1.68±0.94 and CL 2.52±1.52 points. The overall percutaneous coronary intervention success rate was 77.8%. Calibration was good for CASTLE and CL, but not for J-CTO or PROGRESS scores. Discrimination: the area under the curve (AUC) of CASTLE (0.633) was significantly higher than PROGRESS (0.557) and similar to J-CTO (0.628) and CL (0.652). Reclassification: CASTLE, as assessed by integrated discrimination improvement, was superior to PROGRESS (integrated discrimination improvement +0.036, p Conclusion Procedural percutaneous coronary intervention difficulty is not consistently depicted by available chronic total occlusion scores and is influenced by the characteristics of each chronic total occlusion cohort. In our study population, including expert and learning operators, the CASTLE score had slightly better overall performance along with CL score. However, we found only intermediate performance in the c-statistic predicting chronic total occlusion success among all scores.

Seventy-four-year-old male patient admitted with non-ST-elevation acute myocardial infarction. The coronary angiography performed revealed the presence of right coronary artery stenosis with a giant coronary artery aneurysm (CAA) and high thrombus burden (figure 1A). Dual antiplatelet and anticoagulation therapies were recommended for its exclusion in a staged procedure. After confirmation of thrombus reduction (figure 1B), predilatation was attempted and both the length of the CAA (40 mm) and the landing zone were measured on the intravascular ultrasound (IVUS) (figure 1C). From proximal to distal, two 5 mm x 26 mm-PK-Papyrus covered coronary stents (PCS) (Biotronik, Switzerland) were deployed. The overlapping stent zone was confirmed using the StentBoost imaging modality (Philips Medical Systems, Nederland) (figure 1D) and the stent was deployed under fluoroscopic guidance in the absence of any respiratory movements. The subsequent angiography performed revealed an incomplete CAA exclusion (figure 1E) despite postdilatation with a 5.5 mm noncompliant balloon (NCB). The IVUS confirmed the existence of a gap between both stents due to stent shortening (E2, figure 1E and video 1 of the supplementary data). Another 5 mm × 15 mm PCS was deployed followed by postdilatation with a 5.5 mm NCB. Both the angiography and the IVUS confirmed the...

A 76-year-old patient underwent coronary angiography due to progressive angina. He presented a severely calcified diffuse disease at proximal-mid left anterior descending artery ([Figure 1A][1]). ![Figure 1][2] Figure 1 Initial Angiographic and Intravascular Ultrasound Findings

Introduction and objectives Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy and feasibility of percutaneous balloon pericardiotomy (PBP) as the initial treatment of choice for these effusions. Methods Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of PBP carried out in a single-center in patients with advanced cancer. Results Forty PBPs were performed in 35 patients with a mean age of 61.8years (55% females). Thirty-four patients had pathologically confirmed metastatic neoplastic disease (26 patients with tumoral cells in the pericardial liquid), 7 had previously required pericardiocentesis, and in the remaining patients PBP was the first treatment for the effusion. All patients had a severe circumferential effusion (29mm by mean on transthoracic echocardiography [TTE]), and most presented evidence of hemodynamic compromise on TTE. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up. One patient developed a pseudoaneurysm in the right ventricle, even though no further treatment was required. Eight patients needed a new pericardial procedure: 3 had elective pericardial window surgeries and 5 had a second PBP. Eighty percent of patients died during follow-up (57days by mean from the PBP) regarding their oncological disease. Conclusion PBP is a simple and safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches, since they have a very poor prognosis regarding to their oncological disease.

Background Cangrelor, an intravenous, reversible P2Y12 antagonist, is approved for use in patients undergoing percutaneous coronary intervention (PCI). Objectives This study sought to evaluate the efficacy and safety of cangrelor compared with clopidogrel in subgroups that did and did not receive glycoprotein IIb/IIIa inhibitors (GPIs). Methods This pooled, patient-level analysis of the 3 CHAMPION (Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trials analyzed all randomized patients who underwent PCI and received the study drug (n = 24,902). Only bailout/rescue GPI use was permitted, except in CHAMPION PCI, in which routine or bailout/rescue GPI use was at the site investigator’s discretion. The primary efficacy endpoint was the composite of all-cause mortality, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 h after randomization. Results Overall, 3,173 patients (12.7%) received a GPI, most commonly eptifibatide (69.4%). Despite variation in indications for GPIs, baseline characteristics were well balanced between the cangrelor and clopidogrel arms in subsets receiving and not receiving GPIs. Rates of the primary composite endpoint were lower with cangrelor compared with clopidogrel in patients who did (4.9% vs. 6.5%; odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.55 to 1.01) or did not receive a GPI (3.6% vs. 4.4%; OR: 0.82; 95% CI: 0.72 to 0.94; Pint = 0.55). Cangrelor did not increase the primary safety endpoint, GUSTO-defined severe/life-threatening bleeding, in patients who did (0.4% vs. 0.5%; OR: 0.71; 95% CI: 0.25 to 1.99) or did not receive GPIs (0.2% vs. 0.1%; OR: 1.56; 95% CI: 0.80 to 3.04; Pint = 0.21). GPI use was associated with increased risk of bleeding in both treatment arms. Conclusions Cangrelor’s efficacy in reducing ischemic complications in patients undergoing PCI was maintained irrespective of GPI administration. GPI use was associated with substantially higher bleeding rates, regardless of the randomization to cangrelor or clopidogrel. (A Clinical Trial to Demonstrate the Efficacy of Cangrelor [PCI]: NCT00305162 ; Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition [PLATFORM]: NCT00385138 ; A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention [PCI] [CHAMPION PHOENIX] [CHAMPION]: NCT01156571 )

Introduction and objectives: There is current controversy regarding the benefits of percutaneous recanalization (PCI) of chronic total coronary occlusions (CTO). Our aim was to determine acute and follow-up outcomes in our setting. Methods: Two-year prospective registry of consecutive patients undergoing PCI of CTO in 24 centers. Results: A total of 1000 PCIs of CTO were performed in 952 patients. Most were symptomatic (81.5%), with chronic ischemic heart disease (59.2%). Previous recanalization attempts had been made in 15%. The mean SYNTAX score was 19.5 +/- 10.6 and J-score was > 2 in 17.3%. A retrograde procedure was performed in 92 patients (9.2%). The success rate was 74.9% and was higher in patients without previous attempts (82.2% vs 75.2%; P = .001), those with a J-score 20 mm, and blunt proximal cap were independent predictors of failed recanalization. The rate of procedural complications was 7.1%, including perforation (3%), myocardial infarction (1.3%), and death (0.5%). At 1-year of follow-up, 88.2% of successfully revascularized patients showed clinical improvement (vs 34.8%, P < .001), which was associated with lower mortality. At 1-year of follow-up, the mortality rate was 1.5%. Conclusions: Compared with other national registries, patients in the Iberian registry undergoing PCI of a CTO showed similar complexity, success rate, and complications. Successful recanalization was strongly associated with functional improvement, which was related to lower mortality. (C) 2018 Published by Elsevier Espana, S.L.U. on behalf of Sociedad Espanola de Cardiologia.

Objective: To analyze long-term survival and predictors of mortality in patients evaluated for transcatheter aortic valve implantation (TAVI) depending on the decision taken by the heart team. Methods: All patients with severe aortic stenosis and high surgical risk evaluated for TAVI between June 2008 and June 2012 were included. Patients were grouped according to the therapeutic strategy decided by the heart team. Mean follow-up was 16.6 months (maximum 55.3). Results: A total of 149 patients were evaluated: 79 were accepted for TAVI, 12 had no current indication for valve replacement and were deferred, 13 were redirected to conventional surgery and 45 received medical treatment. The evaluated patients had a mean age of 83.7 years and a mean EuroSCORE of 19.8±12.3. Median survival free from all-cause death was 34.7 months (95% CI 27.1–42.3) in the TAVI group, 47.4 months (95% CI 0–97.4) in the deferred intervention group, not available in the surgery group and 8.2 months (95% CI 5.6–10.9) in the medical treatment group (log-rank p

Introduction and Objectives: The aim of this study was to analyze the incidence of drug-eluting stent thrombosis (sirolimus or everolimus) in patients with chronic total coronary occlusions (CTO) and to determine its clinical implications and related factors. Methods: Data from the 12-month follow-up of the 207 patients included in the CIBELES trial with CTO were analyzed. Results: Stent thrombosis occurred in three patients, two definite and one probable (overall thrombosis rate: 1.4%). However, there were no cases of death or Q-wave myocardial infarction. In univariate analysis, patients with a higher incidence of stent thrombosis were those in whom the target vessel was the left anterior descending, who had single-vessel disease, were assigned to treatment with sirolimus-eluting stents, and those with smaller minimum luminal diameter immediately after the procedure. In multivariate analysis, the only independent predictor of stent thrombosis was minimal luminal diameter immediately after the procedure. Conclusions: The rate of drug-eluting stent thrombosis in patients with CTO is relatively low (1.4%). The only independent predictor of stent thrombosis in this context was minimal luminal diameter after the procedure and the clinical presentation was in all cases relatively benign. Resumo: Introdução e objetivos: o objetivo do nosso estudo foi analisar a incidência de trombose de stent com eluição de fármaco (sirolimus ou everolimus) em pacientes com oclusões coronárias crónicas e identificar as suas implicações clínicas e fatores relacionados. Métodos: 12 meses de acompanhamento dos 207 pacientes incluídos no ensaio Cibeles com oclusão total coronária crónica. Resultados: a trombose de stent ocorreu em três doentes: duas definitivas e uma provável (taxa global de trombose 1,4%). No entanto, não surgiu nenhum caso de morte ou enfarte do miocárdio com onda Q. Na análise univariada, os doentes com maior incidência de trombose de stent foram aqueles em que o vaso-alvo foi a descendente anterior, os que tinham a doença de um vaso, os que foram considerados para tratamento com stent com sirolimus, e aqueles com diâmetro luminal mínimo menor imediatamente após o procedimento. Na análise multivariada, o único preditor independente de trombose do stent foi o diâmetro luminal mínimo imediatamente após o procedimento. Conclusões: a taxa de trombose de stent farmacológico em pacientes com oclusão coronária crónica foi relativamente baixa (1,4%).O único preditor independente de trombose de stent neste contexto foi o diâmetro luminal mínimo após o procedimento, tendo a apresentação clínica em todos os casos sido relativamente benigna. Keywords: Stent, Thrombosis, Everolimus, Sirolimus, Chronic total coronary occlusion, Palavras-chave: Stent, Trombose, Everolimus, Sirolimus, Oclusão coronária crónica total

Introduction and objectives Percutaneous closure of paravalvular leakage is an alternative to surgery in high-risk patients, but its use has been limited by a lack of specific devices. More appropriate devices—like the Amplatzer Vascular Plug III —have recently been developed, but information about their efficacy and safety is still scarce. The objective of the present study was to assess the mid-term results of paravalvular leakage closure with this device. Methods We analyzed the clinical and echocardiographic course both in-hospital and mid-term (13 [9] months) in a series of 20 consecutive patients (age, 68 years; logistic EuroSCORE, 29) with paravalvular leakage and attempted percutaneous closure. Results Closure was attempted for 23 leaks (17 mitral and 6 aortic) during 22 procedures in 20 patients. Implantation was successful in 87% of the leaks and the procedure was successful in 83%—with success being defined as a reduction in regurgitation of ≥ 1 degree. Survival at 1 year was 64.7% and survival free of the composite event of death/surgery was 58.8%. The degree of residual regurgitation was not associated with mortality but was associated with functional status. Survivors showed significant improvement in functional class. Conclusions Percutaneous closure of leakage with the Amplatzer Vascular Plug III is safe and efficient in the mid-term. However, mortality among high-risk patients is high independently of the degree of residual regurgitation, indicating that these procedures are performed when heart disease has reached an advanced stage.

A 75-year-old man admitted with unstable angina underwent coronary angiography demonstrating tandem in-stent restenosis in the proximal-segment of the left anterior descending artery. Optical coherence tomography (OCT) detected underoptimal stent implantation within circumferential atherosclerotic

We report a case of very late bare-metal stent restenosis, in which assessment by two intracoronary imaging techniques (intravascular ultrasound and optical coherence tomography) revealed the underlying mechanism (neoatherosclerosis) and facilitated percutaneous treatment (direct bare-metal stent-in-stent). We also take the opportunity to briefly describe the advantages and limitations of both techniques in this pathology. Resumo: Neste artigo fazemos referência a um caso de reestenose muito tardia de um stent convencional que, através de duas técnicas de diagnóstico intracoronário, ultrassonografia intravascular (IVUS) e tomografia de coerência ótica (OCT), permite dar a conhecer o seu mecanismo subjacente (neoaterosclerose) e facilita o seu tratamento percutâneo (stent convencional direto intrasent). Aproveitamos também a ocasião para fazer uma breve descrição das vantagens e limitações de ambas as técnicas neste tipo de patologia. Keywords: Neoatherosclerosis, Percutaneous coronary intervention, Intravascular ultrasound, Optical coherence tomography, Palavras-chave: Neoaterosclerose, Intervenção coronária percutânea, IVUS, OCT

Introduction: In recent years, various specific techniques and materials have been developed for the treatment of coronary chronic total occlusions (CTO). Objective: To evaluate the current situation in the treatment of CTO (techniques and material) in our setting. Methods: We evaluated data on techniques and material used in the CIBELES (ChronIc coronary occlusion treated By EveroLimus Eluting Stent) trial, a randomized comparison of sirolimus- and everolimus-eluting stents in 207 patients with CTO in 13 centers in Spain and Portugal. Results: A radial approach was used in 23% of patients, and retrograde techniques were used in only 5%. A high number of balloons were used (2.2 ± 0.9 per patient). Microcatheters were used in 33% of patients, and post-dilatation balloons in only 25%. The mean number of stents implanted per patient was 2.1 ± 1.0, with a mean total stent length of 49 ± 24 mm. Other devices and techniques used were: Tornus penetration catheter in 4% of patients, rotational atherectomy in 2%, and cutting balloon in 1%. Intracoronary ultrasound was used in only 6% of patients. In 34% of cases, operators used guidewires that were not specifically for CTO. Considerable variability between centers was detected in the use of different techniques, the highest and lowest variability being observed in the use of intracoronary ultrasound and the use of CTO guidewires, respectively. Conclusions: In the CIBELES trial, techniques and devices specifically designed for the treatment of CTO were used in a relatively low proportion of patients. Considerable variability between centers was detected. Resumo: Introdução: Durante os últimos anos foram desenvolvidos materiais e técnicas específicos para o tratamento de oclusões totais crónicas (OTC). Objetivo: Avaliar a situação atual no tratamento de OTC (técnicas e material) na nossa realidade. Métodos: Avaliámos os dados relacionados com as técnicas e material usados no estudo CIBELES (ChronIc coronary occlusion treated By EveroLimus Eluting Stent) que comparou de forma aleatororizada stents eluidores de sirolimus e everolimus em 207 doentes com OTC em 13 centros de Espanha e Portugal. Resultados: A abordagem radial foi usada em 23% dos doentes e as técnicas retrógradas foram usadas em apenas 5%. Foi usado um elevado número de balões (2,2 ± 0,9 por doente). Microcatéteres foram usados em 33% e balões de pós-dilatação apenas em 25% dos doentes. O número médio de stents implantados por doente foi de 2,1 ± 1,0, com um comprimento total médio de 49 ± 24 mm. Outro material foi: tornus 4%, aterectomia rotacional 2% e cutting balloon em 1% dos doentes. Ecografia intra-coronária foi usada em apenas 6% dos doentes. Em 34% dos casos os operadores usaram fios-guia que não eram específicos de OTC. Uma alta variabilidade entre centros foi detetada no uso de diferentes técnicas, sendo a variabilidade observada mais alta e mais baixa no uso de ecografia intra-coronária e no uso de guias de OTC, respetivamente. Conclusões: No estudo CIBELES, técnicas e material especificamente desenvolvidos para o tratamento de OTC foram usados numa proporção relativamente baixa dos doentes. Foi detetada uma alta variabilidade entre centros. Keywords: Coronary stents, Coronary angioplasty, Chronic occlusion, Coronary artery disease, Palavras-chave: Stents coronários, Angioplastia coronária, Oclusões crónicas, Doença coronária

The no-reflow phenomenon (NRP) is defined as the lack of adequate myocardial tissue perfusion despite a patent epicardial coronary artery. The incidence of NRP varies between 2-5% of elective percutaneous coronary interventions (PCI) and 30% in primary PCI. Clinically, it is an independent predictor of myocardial infarction, in-hospital mortality, and long-term mortality. It may be categorized in interventional (after PCI, especially in saphenous venous grafts) or reperfusion NRP (after re-opening of a totally occluded coronary artery, usually during primary PCI or thrombolysis). There are many physiopathological factors implicated: distal microembolization, interstitial and intracellular edema, coronary spasm and capillary plugging. Although reperfusion and no reflow is a field of intense research, no single mechanical or pharmacological therapy has demonstrated a clear efficacy against NRP, probably due to its multifactorial nature. Once established, the treatment of NRP is based on vasodilators like adenosine, verapamil, nitroprusside or nicorandil. However, the efficacy of these measures is poor, so every effort should be made to prevent the apparition of NRP. The objective of this report is to provide an update of the pharmacological armamentarium available for the prevention and treatment of NRP, and suggest a systematic approach of the management of NRP according to the different possible clinical scenarios.

Introduction: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in patients with severe aortic stenosis (AS) and unacceptably high surgical risk. Methods: We present our first two years’ experience with TAVI. A total of 76 AS patients were evaluated for TAVI and 23 of them underwent a TAVI procedure. These patients had a mean EuroSCORE of 22.4% and a mean age of 81.5 years, and were prospectively followed for a mean of 12.9±11 months. Results: The percutaneous aortic valve was successfully implanted in 100% of the patients. Mortality at 30 days was 4%. The most common complications were access site-related bleeding and transfusion (22%), followed by new permanent pacemaker implantation (9%). After a mean follow-up of 12.9 months, survival was 87%. In a maximum follow-up of 30 months there were no cases of prosthesis dysfunction or cardiovascular death. Conclusions: Two years after the introduction of a TAVI program in our center, the procedure has established itself as a safe and effective alternative for patients with severe AS and unacceptably high surgical risk. Resumo: Introdução: A implantação da válvula aórtica transcateter (TAVI) é uma alternativa à substituição valvular aórtica cirúrgica convencional para doentes com estenose aórtica (EA) grave e risco cirúrgico inaceitável. Métodos: Apresentamos a experiência com TAVI no nosso centro durante os primeiros anos, desde o seu início. De 76 doentes com EA avaliados para eventual TAVI, realizou-se o procedimento em 23 dos mesmos, que apresentavam um Euroscore médio de 22,4% e uma idade média de 81,5 anos. Estes 23 doentes foram seguidos de modo prospectivo durante 12,9±11 meses. Resultados: A prótese foi implantada com êxito em todos os doentes. A mortalidade aos 30 dias foi de 4%. As complicações mais frequentes foram as vasculares e a necessidade de transfusão (22%) seguida de colocação de pace-maker definitivo (9%). Após um follow-up médio de 30 meses não se registou nenhum caso de disfunção protésica nem de morte cardiovascular. Conclusões: Dois anos após o início de um programa de TAVI no nosso centro, a TAVI evidencia-se como uma alternativa eficaz para doentes com EA grave inoperáveis por risco cirúrgico elevado. Keywords: Aortic valve stenosis, Heart valve prosthesis, Transcatheter aortic valve implantation, Non-coronary intervention, Aortic valve replacement, Palavras-chave: Estenose aórtica grave, Prótese valvular cardíaca, Prótese aórtica transcateter, Intervenção cardíaca não coronária, Substituição valvular aórtica

Of 12 patients with sudden death and a high probability of coronary artery disease who underwent cardiac catheterization, 4 (25%) showed coronary arteries without significant obstructive lesions or angiographic signs of instability. The study protocol included an invasive study of coronary vasoreactivity and an intracoronary imaging study with intravascular ultrasound. The coronary reactivity study showed coronary vasospasm in 1 patient. Intravascular ultrasound showed active coronary plaques with images suggesting intraluminal thrombus in all patients. The diagnosis reached was sudden death secondary to ventricular arrhythmias in the context of acute coronary syndrome; the use of an implantable cardioverter-defibrillator was therefore not indicated. In conclusion, in patients with sudden death with a high probability of coronary artery disease but with coronary arteries lacking significant lesions, intracoronary imaging (eg, by intravascular ultrasound) may be essential to establish a diagnosis and appropriate treatment, even in patients with induced coronary vasospasm.

The use of drug-eluting stents (DES) in unfavourable patients has been associated with higher rates of clinical complications and stent thrombosis, and because of that concerns about the use of DES in high-risk settings have been raised.This study sought to demonstrate that the clinical benefit of DES increases as the risk profile of the patients increases.A meta-regression analysis from 31 randomized trials that compared DES and bare-metal stents, including overall 12,035 patients, was performed. The relationship between the clinical benefit of using DES (number of patients to treat [NNT] to prevent one episode of target lesion revascularization [TLR]), and the risk profile of the population (rate of TLR in patients allocated to bare-metal stents) in each trial was evaluated.The clinical benefit of DES increased as the risk profile of each study population increased: NNT for TLR=31.1-1.2 (TLR for bare-metal stents); p0.001. The use of DES was safe regardless of the risk profile of each study population, since the effect of DES in mortality, myocardial infarction, and stent thrombosis, was not adversely affected by the risk profile of each study population (95% confidence interval for β value 0.09 to 0.11, -0.12 to 0.19, and -0.03 to-0.15 for mortality, myocardial infarction, and stent thrombosis, respectively).The clinical benefit of DES increases as the risk profile of the patients increases, without affecting safety.

AIMS Data on primary percutaneous coronary intervention for ST-segment elevation in nonagenarian patients are very limited. Our aim was to evaluate the results of primary percutaneous coronary intervention in patients ≥ 90 years old with ST-segment elevation acute myocardial infarction. METHODS AND RESULTS We conducted a multicentre registry focused on nonagenarians treated with percutaneous coronary interventions, gathering data from five tertiary centres in Spain. We included 38 patients with ST-segment elevation acute myocardial infarction who presented within 12 hours after symptoms onset and who were treated with primary percutaneous intervention. Mean age was 91.5 (90-98). Angiographic success was achieved in 90%, and TIMI 3 flow in 76% of cases. In-hospital mortality was 34.2%, concentrated in patients with major bleeding (100% vs. 31.4%), final TIMI flow grade I at admission (53.3% vs. 21.7%). CONCLUSIONS Primary percutaneous coronary intervention in nonagenarians with ST-segment elevation acute myocardial infarction is associated with high rate of successful recanalisation of the infarct-related artery. Mortality is concentrated in patients with severe bleeding during hospitalisation, heart failure at admission, and final TIMI flow

Aims Because of the reduction in the rate events related with in-stent restenosis, most events after drug-eluting stent implantation occur shortly after coronary stenting. Cobalt-chromium alloys allow to reduce strut thickness and improve flexibility and deliverability of coronary stent platforms, and thus could be associated with lower short-term events after stenting. The aim of this study was to test the hypothesis that drug-eluting coronary stents with a cobalt-chromium platform reduce the incidence of periprocedural (30-day) myocardial infarction in comparison with stainless steel drug-eluting coronary stents. Methods and results A meta-analysis from nine randomised trials comparing cobalt-chromium and stainless steel drug-eluting coronary stents that overall included 11,313 patients was performed. The incidence of myocardial infarction, stent thrombosis, and cardiac death at 30 days was compared between both types of stents. At 30 days, the incidence of acute myocardial infarction was significantly lower in patients allocated to cobalt-chromium drug-eluting stents (2.3% vs. 3.9%, respectively; p=0.006; odds ratio 0.72, 95% confidence interval 0.58-0.91), due to a significant reduction in the rate of non-Q-wave myocardial infarction (odds ratio 0.67, 95% confidence interval 0.51-0.88). The incidence of stent thrombosis was similar between both groups of patients, (0.5% vs. 0.5%, p=0.76; odds ratio 1.09, 95% confidence interval 0.63-1.89). Conclusions Drug-eluting coronary stents that use cobalt-chromium stent platforms have a better safety profile at 30 days in comparison with stainless steel drug-eluting stents, due to a significant reduction in the rate of myocardial infarction.

Chronic total coronary occlusions constitute a sub-group of lesions at very high risk of restenosis after successful percutaneous coronary intervention. The sirolimus-eluting coronary stent is the only drugeluting stent that has demonstrated to reduce angiographic restenosis and the need for new revascularisation procedures in comparison with bare-metal stents in randomised clinical trials focusing on these lesions. Everolimus-eluting stents have shown to offer optimal angiographic and clinical outcomes in comparison with bare-metal stents and paclitaxel-eluting stents, but no randomised trials have tested the device in chronic total occlusions. The CIBELES (non-acute Coronary occlusIon treated By EveroLimus- Eluting Stent) will randomise 208 patients with chronic total coronary occlusions in 13 centres from Portugal and Spain to receive everolimus- or sirolimus-eluting coronary stents. The primary endpoint will be angiographic in-stent late loss.

Very late thrombosis in an implanted bare-metal stent is a very uncommon event outside the context of brachytherapy and few data about its pathophysiology are available. We performed an intravascular ultrasound study during primary angioplasty in five patients with very late bare-metal stent thrombosis and carried out a histological analysis of the material removed by manual thrombectomy. The mean time from the index procedure was 7 ± 4 years. Intravascular ultrasound findings were: calcified atherosclerosis with in-stent plaque rupture, complex plaque in the distal segment of the stent, in-stent neointimal proliferation associated with underexpansion, and severe in-stent proliferation. Histological findings were consistent with the intravascular ultrasound images: recent thrombus with areas of old thrombosis in all cases and remnant atheromatous plaque and endothelium. Consequently, in-stent or distal stent atherosclerosis progression and progressive neointimal proliferation were the likely pathophysiological mechanisms.

Aims The aim of this study was to evaluate whether there is any relationship between in-stent late loss (ISLL) and the risk of stent thrombosis (ST) in patients treated with drug eluting stents (DES). The benefit of DES in reducing binary angiographic restenosis and the need for new revascularisation procedures is due to a reduction on ISLL. It has been hypothesised, however, that neointimal hyperplasia could preclude ST, and thus a very low ISLL could increase the risk of ST. Methods and results We selected 26 randomised clinical trials comparing bare metal stents and DES or different DES types, and including clinical and angiographic follow-up. In order to evaluate the association between risk of ST and ISLL, meta-regression analyses were conducted, weighting for the number of patients of each study. Twenty-six studies were included, retrieving 36 subgroups for analysis and 8,971 patients treated with DES. The incidence for ST and LST was 0.81% and 0.17%. Using meta-regression techniques, neither the risk of ST nor the risk of LST were found to be significantly associated with ISLL, accounting for -0.82 and -0.002 meta-regression estimates respectively (IC 95%: -1.92 to 0.28 for ST and -0.008 to 0.003 for LST). Conclusions The risk of ST and LST after DES implantation is not related with ISLL values. A very low mean value of ISLL is nor associated with a higher risk of ST.

The no-reflow phenomenon (NRP) is characterized by an inadequate myocardial tissue perfusion in the presence of a patent epicardial coronary artery. It generally occurs after temporary occlusion of the artery causing myocardial ischemia and necrosis that persist after relief of the vessel occlusion, without evidence of epicardial mechanical obstruction. Currently, the main scenario of NRP is the setting of percutaneous coronary interventions (PCI), especially in patients with acute myocardial infarction or saphenous vein graft disease, and its occurrence is associated with adverse clinical outcomes. Pathophysiology of NRP is not fully understood but it seems to be related with microvascular damage. Several mechanisms have been involved, such as distal microembolization, interstitial and intracellular edema, coronary spasm and capillary plugging. Diagnosis of NRP is generally based on clinical and angiographic data. Several methods have been proposed for the assessment of NRP, such as electrocardiography, myocardial contrast echocardiography, contrast-enhanced magnetic resonance imaging, nuclear imaging or positron emission tomography, that have demonstrated additional prognostic value over angiography. There are different pharmacological and mechanical approaches for the prevention of NRP but none of them have demonstrated a clear efficacy. The treatment of established NRP is mainly based on the administration of coronary vasodilators, like adenosine, verapamil or nitroprusside, but clinical results are frequently disappointing. The objective of this review is to describe the state of the art of the pathophysiology, diagnosis and pharmacological management of NRP.

Percutaneous implantation of aortic valve prostheses has recently emerged as a therapeutic option for patients with severe symptomatic aortic stenosis for whom surgical valve replacement is not suitable. We describe our initial experience with this technique at our institution. Percutaneous implantation of an Edwards Sapiens aortic prosthesis was performed using the transfemoral approach in 4 patients with severe symptomatic aortic stenosis for whom surgery was not suitable (mean EuroSCORE, 23%). The procedure was successful in all patients, with optimal implantation of the prosthesis and no complications. By 1 month of follow-up, no patient had experienced an event and all had improved their functional class.

Introduction and objectives Transcatheter aortic valve implantation is used as an alternative to surgical valve replacement in patients with severe aortic stenosis who are considered high-surgical-risk or inoperable. Two of the main areas of uncertainty in this field are valve durability and long-term survival. Methods This prospective single-center registry study from a tertiary hospital included all consecutive patients who underwent percutaneous aortic valve implantation between 2008 and 2012. Clinical follow-up lasted a minimum of 2.5 years and a maximum of 6.5 years. Valve Academic Research Consortium-2 definitions were used. Results Seventy-nine patients were included, with an immediate success rate of 94.9%. The median survival was 47.6 months (95% confidence intervals, 37.4-57.9 months), ie, 4 years. One quarter of deaths occurred in the first month, and most were of cardiovascular cause. After the first month, most deaths were due to noncardiovascular causes. The mean values of valve gradients did not increase during follow-up. The cumulative rate of prosthetic valve dysfunction was 15.3%, with no cases of repeat valve replacement. Conclusions Half of the patients with aortic stenosis who underwent transcatheter aortic valve implantation were alive 4 years after the procedure. There was a 15.3% prosthetic valve dysfunction rate in cumulative follow-up, with no cases of repeat valve replacement.

An 83-year-old woman with chronic atrial fibrillation and hypertension underwent left atrial appendage occlusion at another center with a 22-mm Amplatzer cardiac plug (St. Jude Medical, Minneapolis, Minnesota) after embolic central retinal artery occlusion while receiving treatment with dabigatran.

Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy and feasibility of percutaneous balloon pericardiotomy (PBP) as the initial treatment of choice for these effusions. Retrospective analysis of the clinical, echocardiographic, and

Clinical trials have shown that functional assessment of coronary stenosis by fractional flow reserve (FFR) improves clinical outcomes. Intravascular ultrasound (IVUS) complements conventional angiography, and is a powerful tool to assess atherosclerotic plaques and to guide percutaneous coronary intervention (PCI). Computational fluid dynamics (CFD) simulation represents a novel method for the functional assessment of coronary flow. A CFD simulation can be calculated from the data normally acquired by IVUS images. A case of coronary heart disease studied with FFR and IVUS, before and after PCI, is presented. A three-dimensional model was constructed based on IVUS images, to which CFD was applied. A discussion of the literature concerning the clinical utility of CFD simulation is provided. Resumo: Estudos clínicos demonstraram que a avaliação funcional da doença coronária com fio de pressão e determinação da reserva fracionada de fluxo (fractional flow reserve - FFR) melhora a evolução clínica. O estudo por ultra-som intravascular (IVUS) complementa a angiografia convencional, e é uma ferramenta poderosa para a avaliação das placas ateroscleróticas orientando a intervenção coronária percutânea (ICP). A simulação computorizada da dinâmica de fluidos (CFD), representa um novo método que permite avaliar funcionalmente o fluxo coronário. A CFD pode ser calculada a partir dos dados normalmente obtidos por IVUS. É apresentado um caso de doença coronária estudada com FFR e IVUS, antes e após a ICP. Foi construído um modelo tridimensional com base nas imagens obtidas por IVUS e avaliado com a técnica de CFD. É apresentada uma discussão bibliográfica sobre a utilidade clínica da simulação com CFD. Keywords: Coronary artery disease, Myocardial fractional flow reserve, Intravascular ultrasound, Fluid dynamics, Computer simulation, Palavras-chave: Doença cardíaca coronária, Reserva fracionada de fluxo miocárdico, Ultra-sonografia intravascular, Dinâmica de fluidos, Simulação computorizada

Both sirolimus (SES) and paclitaxel eluting stents (PES) have been shown to reduce significantly both the incidence of binary angiographic restenosis and the need for new revascularization procedures [1]. We read with great interest the paper by Sidhu et al., in which the better angiographic behaviour of SES in comparison with PES was not translated into significant differences in terms of clinical events [2]. As paclitaxel is cytotoxic, whereas sirolimus is cytostatic, the risk of stent thrombosis between the two types of drug-eluting stents could be different. In fact, in a recent work, a trend to an increased risk of stent thrombosis after PES implantation was found, whereas the risk of stent thrombosis was similar with SES and bare-metal stents [3]. Stent thrombosis is an infrequent complication. Because of that, data from single trials are not sufficient to compare the incidence of stent thrombosis between two different types of stent. For the evaluation of such an infrequent entity, meta-analysis may increase increase power and precision and provides an overall estimate and range of effect. In order to help to clarify whether the risk of stent thrombosis is different between SES and PES, we have performed a meta-analysis from nine randomized trials that have compared SES and PES, including 5024 patients (2514 allocated to SES, 2510 allocated to PES). The trials included in the meta-analysis were: TAXI (n = 202), REALITY (n = 1353), SIRTAX (n = 1012), ISAR-DIABETES (n = 250), ISAR-DESIRE (n = 200), CORPAL (n = 652), ISAR-SMART-3 (n = 360), BASKET (n = 545) and ISAR-TEST (n = 450) [4–12]. Follow-up ranged from 6 to 12 months. In most trials, the Cypher stent (Cordis Corp., Miami Lakes, FL, USA) and the Taxus stent (Boston Sci., Natick, MA, USA), with polymeric-release of sirolimus and paclitaxel, respectively, were randomly compared in patients with native de novo lesions. In the ISAR-DESIRE study, only patients with in-stent restenosis after bare-metal stent implantation were included. In the ISAR-TEST, the Yukon stent, with nonpolymeric release of sirolimus, was compared with the Taxus stent. The risk ratio for stent thrombosis and its 95% confidence interval (CI) was calculated comparing SES with PES rates using raw data for each study and for the pooled population. The Q-test for heterogeneity and the fixed-effect model were used. There was no heterogeneity among the trials [Q-test for heterogeneity: χ2 = 5.41, d.f. = 6 (P = 0.49); I2 = 0%]. The overall risk of stent thrombosis in the overall population was 0.92% (n = 46 patients): 0.83% (21/2514) and 1.00% (25/2510) in patients allocated to SES and PES, respectively (risk ratio 1.17, 95% CI 0.67, 2.35; P = 0.57) (Figure 1). Figure 1 Comparison of the incidence of stent thrombosis in each of the nine randomized clinical studies included in the meta-analysis, as well as in the pooled population (fixed-effect model) Sirolimus and paclitaxel have different mechanisms of action (sirolimus is cytostatic, whereas paclitaxel is cytotoxic). Moreover, both stent platform and polymer are different in Taxus and Cypher stents, and whereas Taxus releases paclitaxel from a polymer, the Yukon stent has a nonpolymeric release of sirolimus. However, in view of our results, all these differences in stent design, type of polymer and type of drug do not seem to be translated into different risk of stent thrombosis. Given the high number of patients included in our meta-analysis (>5000), the possibility of existing but undetected differences in the risk of stent thrombosis between SES and PES is very low. In a previously published meta-analysis including trials that compared drug-eluting stents and bare-metal stents, we found a similar risk of stent thrombosis in PES and SES trials when the SCORE trial and the patients from the ASPECT study that did not receive thienopyridines were excluded (0.57% vs. 0.58%, P = 1.000) [13]. Drug-eluting stents have revolutionized cardiology worldwide, since they dramatically reduce the need for new revascularization procedures after percutaneous coronary interventions. Because of that, now that more diabetic patients are now being treated percutaneously,with longer lesions and smaller vessels, the absolute incidence of stent thrombosis in the era of drug-eluting stents will probably increase. However, we should bear in mind that the risk of stent thrombosis is related mainly to the appropriateness of antiplatelet therapy and the characteristics of the lesion, more than to the type of coronary stent.

We describe a nonagenarian patient in whom a paclitaxel-eluting stent was lost during an attempt of direct stent implantation at the distal right coronary artery after removal of the guide-wire. The potential usefulness of intravascular ultrasound in the management of this complication is illustrated. The dislodged stent could not be located by fluoroscopy. However, intravascular ultrasound allowed to find the undeployed stent at the proximal segment of the right coronary artery. It showed that the guide-wire was placed outside the lost stent lumen and this undeployed stent was crushed against a previously implanted stent by another stent with optimal intravascular ultrasound-guided implantation.

A 47-year-old man was diagnosed with primary antiphospholipid syndrome and Budd-Chiari syndrome (membranous complete obstruction of the intrahepatic inferior vena cava), with edema and ascites refractory to medical treatment. The inferior vena cava membrane was punctured with a Brockenbrough needle under multidirectional fluoroscopic guidance via a transfemoral approach. The occlusion was dilated with balloons of increasing size and was subsequently stented successfully. At 1-year follow-up venography showed patency of the stent, and the patient remains asymptomatic 2 years after the procedure.

Introduction and objectives Malignant pericardial effusion has a high recurrence rate after pericardiocentesis. We sought to confirm the efficacy of percutaneous balloon pericardiotomy as the initial treatment of choice for these effusions. Methods Retrospective analysis of the clinical, echocardiographic, and follow-up characteristics of a consecutive series of percutaneous balloon pericardiotomies carried out in a single center in patients with advanced cancer. Results Seventeen percutaneous balloon pericardiotomies were performed in 16 patients with a mean age of 66.2 (15.2) years. Fourteen patients had pathologically confirmed metastatic neoplastic disease, 3 had previously required pericardiocentesis, and in the remaining patients percutaneous balloon pericardiotomy was the first treatment for the effusion. All patients had a severe circumferential effusion, and most presented evidence of hemodynamic compromise on echocardiography. In all cases, the procedure was successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications during follow-up (median, 44 [interquartile range, 36-225] days). One patient developed a large pleural effusion that did not require treatment. Three patients needed a new pericardial procedure: 2 had elective pericardial window surgeries and 1 had a second percutaneous balloon pericardiotomy. Conclusions Percutaneous balloon pericardiotomy is a simple, safe technique that can be effective in the prevention of recurrence in many patients with severe malignant pericardial effusion. The characteristics of this procedure make it particularly useful in this group of patients to avoid more aggressive, poorly tolerated approaches.

AIMS Controversy exists about the safety and efficacy of drug-eluting stents (DES) in saphenous vein bypass grafts (SVGs). The aim of this study was to perform a meta-analysis of all published studies comparing DES and bare-metal stents (BMS) in patients with SVGs disease. METHODS AND RESULTS We included 22 studies comparing DES versus BMS in 5,543 patients with SVGs disease. The primary efficacy endpoint was target vessel revascularisation (TVR). The primary safety endpoint was mortality. Other outcomes of interest were cardiac mortality, myocardial infarction, target lesion revascularisation (TLR), stent thrombosis and a combined of major adverse cardiac events (MACE). DES significantly reduced the risk of TVR, OR=0.56 (95% CI, 0.41-0.76, p=0.0003) and TLR, OR=0.58 (95% CI, 0.41-0.81; p=0.001). Total mortality and cardiac mortality were significantly lower in DES versus BMS, OR=0.69 (95% CI, 0.49-0.98, p=0.04) and OR=0.71 (95% CI, 0.51-0.99; p=0.04), respectively. The overall risk of stent thrombosis, and myocardial infarction were not significantly different for patients receiving DES vs. BMS. Total MACE were significantly lower in patients receiving DES, OR=0.55 (95% CI, 0.42-0.71; p

Transcatheter aortic valve implantation is being established as an alternative treatment for some patients with symptomatic severe aortic stenosis who are not considered suitable for surgical aortic valve replacement because of prohibitive surgical risk. 1–3 One of the potential complications is complete atrioventricular block requiring definitive pacemaker implantation. This complication occurs in 4% to 5% with the Edwards-Sapiens prosthesis (Edwards Lifesciences, Irvine, Calif), 1 and in 30% with the CoreValve system (Medtronic CV, Luxembourg),3 but it also occurs in 5% of patients after percutaneous aortic valvuloplasty4 or surgical aortic valve replacement. 5 The cause of complete atrioventricular block after transcatheter aortic valve implantation is unknown. Apart from traumatic lesions produced by aortic valve prosthesis expansion, ischemia of the conduction pathways resulting from insufficient myocardial protection might play a role. Here, necropsy findings in a patient with complete atrioventricular block after transcatheter aortic valve implantation are presented for the first time, showing the physiopathology of this complication. A 79-year-old woman with symptomatic severe aortic stenosis and prohibitive surgical risk was referred for transcatheter aortic valve implantation. A 26-mm EdwardsSapiens prosthetic valve was implanted without complications except complete atrioventricular block requiring transvenous pacemaker stimulation. Three days after transcatheter aortic valve implantation, the patient suffered sudden cardiac death that could not be resolved with resuscitation. Necropsy was performed to evaluate the status of the pros

Restenosis is an important limitation of percutaneous coronary interventions (PCI). In-stent restenosis is mainly due to neointimal hyperplasia, a proliferative process modulated by inflammatory mechanisms. Numerous technical and pharmacological means have been tested to reduce restenosis rates, with frequently disappointing clinical results. Drug-eluting stents (DES) have demonstrated a high efficacy in reducing restenosis, but there are some associated problems that limit its generalized utilization. Glucocorticoids (GC), as potent anti-inflammatory agents, may exert beneficial effects on neointimal proliferation. Clinical studies with oral and intracoronary GC therapy have demonstrated reduction in restenosis rates in selected patients. Although further investigations are warranted, GC might have a potential role for restenosis prevention in selected cases.

Aims Controversy exists about the clinical significance of in-stent late loss (ISLL) after drug-eluting stent (DES) implantation. We sought to clarify whether ISLL after DES implantation is related to a potential clinical impact. Methods and results We included in a meta-regression analysis 21 trials (8641 patients) that randomly compared DES with bare-metal stents (BMS). We evaluated the relationship between angiographic behaviour of DES and the clinical impact of using DES instead of BMS in each trial using meta-regression techniques, weighting by the number of patients included in each trial. Mean ISLL in patients allocated to DES and DISLL (difference in ISLL in patients allocated to BMS and DES) were used as angiographic parameters of efficacy of DES. The number of patients needed to be treated (NNT) to prevent one target lesion revascularization (TLR) was used to quantify the clinical impact of using DES instead of BMS. There was a significant relationship between mean ISLL in patients allocated to DES and the clinical benefit of using DES instead of BMS, as measured with the NNT for TLR: NNT for TLR ¼ 6.2 þ 18.4 [ISLL-DES] (R ¼ 0.62; P ¼ 0.007). Therefore, a 0.1 mm increase in mean ISLL-DES was associated with a 1.8 increase in NNT for TLR. There was also a significant association between the degree of inhibition of neointimal hyperplasia of DES in comparison with BMS with the NNT for TLR: NNT for TLR ¼ 17.1–11.8 [DISLL] (R ¼ 0.61; P ¼ 0.008). Therefore, a 0.1 mm reduction in ISLL by using DES instead of BMS was associated with a 1.2 decrease in mean NNT for TLR. Conclusion There is a strong and significant association between the degree of inhibition of neointimal formation with the use of DES and the clinical impact of using DES instead of BMS.

The only clinical benefit of drug-eluting stents (DESs) over bare metal stents (BMSs) is a significant decrease in the need for new revascularization procedures. We evaluated whether DESs also decrease the incidence of myocardial infarction at midterm. We performed a meta-analysis from 25 randomized trials comparing commercially available DESs with BMSs that included 9,791 patients overall. There was no heterogeneity across the trials included (Q test for heterogeneity, p = 0.68). Of the 9,791 patients included in all the trials, 364 developed an acute myocardial infarction during follow-up (6 to 12 months). The risk of myocardial infarction was significantly lower in patients allocated to DESs (3.3% vs 4.2% in those allocated to BMSs, odds ratio 0.79, 95% confidence interval 0.64 to 0.97, p = 0.03). In conclusion, the significant decrease in angiographic restenosis associated with the use of DESs leads not only to a decreased need for subsequent revascularization procedures but also a decreased incidence of myocardial infarction during the first 12 months after stent implantation.

Purpose: Malignant pericardial effusion (MPE) is associated with adverse outcomes and presents a high rate of recurrence after pericardiocentesis. Various approaches have been reported for prevention of recurrences. However most of them are associated with significant morbidity or even mortality and required unnecessarily prolonged hospital stay. We sought to confirm the efficacy of percutaneous balloon pericardiotomy (PPB) as the initial treatment of choice for MPE. Methods: Retrospective analysis of the clinical, echocardiographic and follow-up characteristics of a consecutive series of PPB carried out in a single center in patients with advanced cancer. Results: Twenty-one PPB were performed in 19 patients with a mean age of 65±15 years. Seventeen patients had pathologically confirmed metastatic neoplastic disease and in another two patients there was a high radiological suspicion of it. Three patients had previously required pericardiocentesis, and in the remaining patients PPB constituted the first treatment for the MPE. All patients had a severe (>20mm) circumferential effusion and only one patient did not have evidence of hemodynamic compromise on echocardiography. In all cases the procedure was initially successful, there were no acute complications, and it was well tolerated at the first attempt. There were no infectious complications, and just one patient developed a large pleural effusion that did not require treatment. During the follow-up (median 74 [IQR 31.5-207.5] days), four patients required a new pericardial procedure: 2 elective pericardial window surgeries and 2 new PPB. Conclusions: PPB is a simple, safe procedure that can be effective in the prevention of recurrences in many patients with MPE. Based on the results and the poor prognosis of these patients we believe that PPB might be considered the initial treatment of choice for most MPE.