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The aim of this review is to highlight the technical details and the scientific data on percutaneous coronary interventions (PCIs) in chronic total occlusion (CTO) performed by transradial approach (TRA). Transfemoral approach (TFA) is commonly regarded as the standard for CTO PCI, but there is a growing number of CTO recanalization procedures performed by TRA. We discuss the relevant technical details to approach a CTO by transradial access, especially the compatibility of various CTO recanalization techniques with specific guiding catheter sizes. Randomized prospective trials in this field are lacking and only data from observational studies are available. We can conclude that transradial access for CTO PCI is feasible and could be very useful in selected patients. In our opinion, transradial access in CTO PCIs should be limited to operators and centers highly experienced in CTO recanaliza¬tion and in TRA.

Background: Chronic total occlusions (CTO) are diagnosed in about 20% of patients with significant coronary artery disease. A disproportion between the high prevalence of CTOs and low rate of invasive treatment still exists. Technical difficulties, clinical uncertainties whether patients benefit from recanalisation, and a lack of knowledge of CTO may be responsible for this fact., Aim: To assess the knowledge of coronary arteries CTO among Polish interventional cardiologists., Methods: A self-designed questionnaire was used during two major Polish invasive cardiology workshops held in 2014., Results: The study included 113 physicians, mostly cardiologists certified as independent operators. Average self-declared efficacy of CTO recanalisation was 63.5%. Most of the respondents agreed that the operator involved in the CTO recanalisation program should perform at least 30-50 procedures per year. Only 67% stated that before CTO revascularisation the evaluation of myocardial viability should be performed with dobutamine stress echocardiography as a preferred test. One third of the physicians agreed that CTO percutaneous coronary intervention (PCI) should not be performed directly after diagnostic angiography, and 51.5% believed that in patients with multi-vessel coronary artery disease PCI of CTO should be performed first. Multi-slice spiral computed tomography during the qualification and planning of the CTO revascularisation, in the opinion of 91% of the responders, should not be used before each procedure but could be useful in selected cases., Conclusions: Polish interventional cardiologists remains in compliance with current opinions about recanalisation of chronic coronary artery occlusions and the consensus of the EuroCTO Club, but there is still an unceasing need for further education and promotion of knowledge about CTOs.

Introduction: Chronic total occlusion (CTO) recanalization is indicated in patients with symptoms and evidence of ischemia, but in most cases those types of lesions are still treated medically. In the last few years CTO angioplasty technique has changed dramatically due to considerable advances in techniques and dedicated equipment., Aim: An attempt to assess the state of knowledge of technical aspects of CTO angioplasty of coronary arteries among Polish interventional cardiologists., Material and Methods: Questionnaire survey performed during two major Polish invasive cardiology workshops., Results: In the study there participated 113 physicians with an average length of work experience of 13 years, most of them cardiologists certified as independent primary operators. The majority of respondents recognized the need of prevention of thrombotic complications through control of activated coagulation time during the CTO procedures. Prevention of renal complications and X-ray protection are also recognized as a significant part of the procedures. The benefits from the use of over-the-wire microcatheters and balloons, the proper choice of dedicated guidewires, contralateral injections and retrograde technique are underestimated., Conclusions: Despite satisfactory knowledge about indications and qualification for the CTO procedure, the awareness of procedural aspects (particularly the retrograde technique) as well as the dedicated CTO equipment among Polish interventional cardiologists is still insufficient.

We present the cases of two patients with hypothermia, with a detailed description of electrocardiographic changes associated with hypothermia. In both cases, J wave was initially misdiagnosed as left bundle branch block (LBBB). We discuss the differentiation of J wave from LBBB.

Background: Antiplatelet drugs currently constitute the basic treatment of coronary artery disease (acute coronary syndrome [ACS], stable angina and patients treated with percutaneous coronary interventions [PCI]). The number of patients with indication for dual antiplatelet therapy with comorbidities with high thrombo-embolic risk (such as atrial fibrillation [AF], venous thrombotic disease, valvular diseases) is increasing. That is why the need for simultaneous administration of dual antiplatelet and oral anticoagulant therapy (triple therapy) has become more common recently. The AF is the most common indication for chronic anticoagulation. Because of the lack of large randomised trials regarding triple therapy, characteristics of this group has not been well established., Aim: To assess the presence of cardiovascular (CV) risk factors and concomitant diseases in patients with ACS requiring triple therapy., Methods: Retrospective analysis included 2279 patients diagnosed with ACS who were admitted to the Departments of Cardiology in Cracow in 2008. In this group, 365 (16%) patients had indications for chronic anticoagulation. Demographic and clinical characteristics of these patients were compared with those of patients included in other published registries., Results: Patients requiring triple therapy were aged 73.2 ± 9.5 years. Hypertension was diagnosed in 80%, hyperlipidaemia in 63%, smoking in 36%, prior myocardial infarction in 33%, prior stroke in 15%, previous treatment with PCI in 13%, coronary artery bypass grafting in 7%, diabetes in 36%, heart failure in 46%, anaemia in 33% and chronic ulcer disease or gastroesophageal reflux disease in 9%. The mean left ventricular ejection fraction was 46 ± 15%. Compared with other registries of patients without indications for triple therapy, our patients had significantly more frequently hypertension, diabetes and were older., Conclusions: Patients after an ACS requiring triple therapy have more often a history of comorbidities and CV risk factors when compared with the group of patients with ACS without indication for triple therapy.

A 14-year follow-up of a 69 year-old male with left ventricular aneurysm and thrombus after antero-septal myocardial infarction is presented. We describe problems with thromboembolic and bleeding complications in the context of changes in the guidelines over the period of treatment.

Background: Dual antiplatelet therapy for 12 months is currently recommended for all patients with acute coronary syndrome (ACS), both for those treated pharmacologically or with percutaneous coronary interventions (PCI). Recently, the need for simultaneous administration of dual antiplatelet and oral anticoagulant therapy (triple therapy) has become more common. However, in addition to intensifying antiplatelet treatment, the risk of haemorrhagic complications is also significantly increased with triple therapy., Aim: To assess the in-hospital use of triple therapy in patients with ACS, who have indications for long-term anticoagulation, and to define the reasons for not administering such a therapy., Methods: The analysis included 298 patients diagnosed with ACS who were admitted to our department. Analysis of recommended treatment was conducted upon discharge from hospital after ACS and during hospitalisation. The reason for discontinuation or non-compliance with oral anticoagulant (OAC) therapy was also assessed., Results: Out of 298 patients diagnosed with ACS, 53 (17.8%) had indications for long-term anticoagulation. The largest group consisted of patients with unstable angina who were treated pharmacologically (51.7%). The most common indication for chronic anticoagulation was paroxysmal atrial fibrillation (AF) (62%). At discharge from hospital, only 15.1% of patients received triple therapy. There was no significant association between the mode of treatment (triple therapy vs. lack of it) and indication for antiplatelet treatment (p = 0.18) or anticoagulation (p = 0.27). Among risk factors for bleeding, only prior episode of bleeding [p = 0.0002; odds ratio (OR) 4.17] and treatment with PCI (p = 0.02; OR impossible to assess because of too small group) were significantly associated with withdrawal of triple therapy., Conclusions: The use of triple therapy in patients presenting with ACS and indications for long-term anticoagulation is insufficient. The reasons for not prescribing triple therapy are not clear. One explanation could be excessive concerns about haemorrhagic complications. There is a lack of equivocal guidelines and large randomised trials which would clearly define the optimal management strategy for patients presenting with ACS and indications for long-term anticoagulation therapy.

Background: Recanalisation for coronary chronic total occlusion (CTO) is associated with high rates of restenosis and reocclusion. The use of intracoronary ultrasound (ICUS) may improve immediate and long-term outcomes following recanalisation. To our knowledge, no study has examined the use of ICUS-guided balloon angioplasty in CTO., Aim: To compare the results of ICUS-guided balloon angioplasty and ICUS-guided angioplasty with stent implantation in patients with CTO., Methods: The study involved 51 CTO patients in whom optimal balloon angioplasty results were achieved according to quantitative coronary angiography (QCA). These patients then underwent ICUS-guided balloon angioplasty with the goal of achieving a minimal luminal cross-sectional area (MLCSA) of > 6.0 mm2 and a residual plaque burden (RPB) of < 65%. Of the 51 patients, the ICUS criteria defining optimal balloon angioplasty were achieved in 23 patients and 7 patients did not undergo stent implantation due to calcification and/or small vessel diameters (group A--30 patients). In 21 patients, the failure to achieve optimal ICUS parameters resulted in stent implantation with the goal of achieving in stent MLCSA > 9 mm2 and > 55% of average total cross-sectional area of the vessel according to distal and proximal reference segments (group B). The two groups were similar in terms of clinical and angiographic characteristics., Results: Balloon angioplasty which was regarded as optimal by QCA, was shown to be non-optimal by ICUS in 41 patients (80.4%). The MLCSA was smaller in group A than group B (6.5 +/- 1.5 vs. 8.9 +/- 2.0 mm2; p < 0.001). Restenosis was found in 8 (26.6%) group A patients and 4 group B patients (19%) (p > 0.05). The restenosis rate in 23 group A patients with optimal ICUS parameters was 8.6% (2 patients). Consecutive ICUS measurements showed a gradual increase in the total vessel area during the PCI procedure and at the 6-month follow-up (p < 0.05)., Conclusions: (1) Achieving an optimal balloon angioplasty result in CTO patients requires confirmation using ICUS. (2) In some patients immediate and long-term outcomes following ICUS-guided optimised balloon angioplasty are comparable to those of ICUS-guided stent implantation. (3) Direct measurement of a chronically occluded coronary artery at pre-intervention, during the intervention and at long-term follow-up may argue in favour of using ICUS in recanalisation of CTO. (4) ICUS-guided balloon angioplasty for CTO could be a method of choice in patients in whom long-term dual antiplatelet therapy is associated with a high probability of bleeding complications.

Dual antiplatelet therapy is currently recommended for all patients with acute coronary syndromes, independent of whether they receive pharmacological treatment or undergo percutaneous coronary intervention. Antiplatelet agents are the cornerstone of pharmacological treatment in interventional cardiology. However, there is a clear need for randomized trials to assess the treatment strategy of dual antiplatelet therapy in patients who also need long-term antithrombotic treatment (such as those with atrial fibrillation, prosthetic heart valve, mitral valve regurgitation or stenosis, deep vein thrombosis, pulmonary embolism, or pulmonary hypertension). In this paper we discuss trials and analyses on the use of dual antiplatelet treatment in combination with antithrombotic therapy in particular diseases, with a focus on the risk of hemorrhagic events connected with this treatment, as well as recent guidelines of the European Society of Cardiology, the American College of Cardiology, and the American Heart Association.

Objectives: A prospective, open-labeled study to assess the antihypertensive effect of monotherapy with rilmenidine and its impact on quality of life (QoL), as well as on biochemical parameters in perimenopausal women with essential hypertension., Design and Methods: Fifty-five perimenopausal women with mild to moderate essential hypertension (mean age 51.4+/-2.4 years) were enrolled. At baseline and after 12-week monotherapy with rilmenidine, we assessed: systolic (SBP) and diastolic (DBP) blood pressure (BP), heart rate (HR), fasting glucose, serum creatinine and total cholesterol levels. QoL was also assessed at baseline and at 12 weeks by two standardized questionnaires: the Short Form - 36 (SF-36) and the Subjective Symptoms Assessment Profile (SSAP). Statistical analysis was performed using Student's t-test to compare changes in BP, QoL and biochemical parameters during therapy with rilmenidine., Results: After 12 weeks of therapy, there was a significant decrease in BP and HR. Normalization of BP was observed in 46 (84%) women. Rilmenidine did not influence serum creatinine, fasting glucose and lipid profile. Treatment was very well tolerated by the patients and no side-effects were noted. Both the SF-36 and the SSAP demonstrated improvement in general QoL. We observed a significant improvement in all SF-36 subscales. In the SSAP, a similar significant improvement was found, except dizziness subscale. Improvement in QoL was not related to reduction of BP., Conclusions: Monotherapy with rilmenidine is safe and effective in BP treatment and significantly improves QoL in perimenopausal women with essential hypertension.

Background: Over 1/3 of all patients treated for acute myocardial infarction are elderly (over 70 years of age). Blood flow restoration in the infarct-related artery is a fundamental therapeutic strategy, however reperfusion therapy is rarely used in the elderly as compared with younger groups. Mortality and complication rates are much higher in the elderly than in younger patients irrespective of the type of reperfusion therapy. Elderly patients are modestly represented in studies undertaken to analyze the efficacy of various types of reperfusion therapy. For this reason the choice of an optimal therapy in acute myocardial infarction in the elderly remains an open question., Methods: In the I Department of Cardiology PCI has been the strategy of choice in the treatment of acute myocardial infarction. This is a retrospective analysis of early and late outcomes of primary coronary angioplasty in elderly patients with myocardial infarction. Between June 2001 and December 2003 four hundred and five (405) consecutive patients were admitted to our centre due to acute myocardial infarction. A group of 352 patients treated by primary coronary angioplasty was analyzed. Patients were divided into two subgroups one subgroup--over 70 years of age (84 patients) and the second one--below 70 years of age (268 patients) serving as controls. Early (in-hospital) and late (at 30 days, 6 and 12 months) outcomes were assessed., Results: The most important observation was that elderly patients with myocardial infarction may be safely and effectively treated with primary coronary angioplasty. In-hospital mortality (5.9% vs. 2.2%, p < 0.05) and the number of bleeding complications (9.5% vs. 4.1%, p < 0.05) were higher in the elderly than in younger patients, but still lower than in the studies where fibrinolysis was used as a reperfusion strategy. Another important fact was the relatively frequent use of a platelet glycoprotein IIb/IIIa inhibitor (abciximab) in the elderly group (46.4% patients)., Conclusions: Our results prove that these agents may also be safely administered in elderly patients with myocardial infarction. It is probable that the relatively frequent use of platelet glycoprotein IIb/IIIa inhibitors in our elderly patients was one of the reasons for lower early mortality as compared with the findings of other investigators.

In patients following a myocardial infarction, heart rate variability is an important prognostic factor. Decreased heart rate variability is associated with a higher mortality rate. This study evaluated the influence of recanalisation by percutaneous coronary intervention (PCI) in totally occluded coronary arteries on the heart rate variability in patients with myocardial akinesis in the recanalised artery area. The study group included 22 men (average age 52.8 +/- 7.7) after successful PCI recanalization of the totally occluded artery. All patients had akinesis in the recanalised artery area. All patients underwent 24-hour continuous electrocardiographic Holter monitoring with HRV analysis and echocardiographic dobutamine tests both before the PCI and 6 months afterwards. The population was divided into two groups: group A (10 patients) had contractility adjustments in echocardiographic tests that were performed 6 months after the PCI. Group B (12 patients) did not have contractility adjustments. Before the PCI, there were no differences in the wall motion score index (WMI) or the time-domain HRV parameters between the two groups. After 6 months, there was a significant increase in the WMI value in group A, whereas this index remained unchanged in group B. In group A the time-domain HRV parameters had improved 6 months after the PCI, whereas they remained unchanged in group B. Successful percutaneous revascularization of the totally occluded coronary artery in patients with myocardial akinesis in the occluded artery area leads to an increase in HRV parameters. This improvement occurred only in patients that had a contractility adjustment after the PCI in previous akinetic segments of myocardium.

Structural and functional changes of arterial walls are one of the underlying causes of many disorders which modern cardiology deals with. Information about arterial structure and function can be now obtained from various non-invasive vascular imaging tests, such as: measurements of carotid intima media thickness, assessment of biomechanical parameters of blood flow, endothelial function or coronary artery calcification. Despite the development of new diagnostic tools, the diagnosis of cardiovascular risk is still very difficult. This review discusses the role of arterial remodeling in the assessment of cardiovascular risk. Evidences presented in this paper demonstrate that the data about arterial function and structure can be used when deciding about the initiation of therapy and can provide information about the efficacy of treatment.

Unlabelled: The tension of the arterial wall increases the proliferation of the vascular smooth muscle cells which is one of the basic mechanisms of the reocclusion after percutaneous coronary intervention (PCI). The aim of the study was to evaluate the significance of the pulse pressure (PP) in predicting the restenosis after PCI., Methods: We retrospectively studied 84 patients (average age 53.9 +/- 10.1; 69 males and 15 females)--35 patients with angiographically proved restenosis and 49 patients without restenosis matched according to age and gender. The pulse pressure in the ascending aorta was measured before PCI. The standard angiographic measurements took place before PCI and immediately after it. The restenosis was defined as recurrent stenosis > 50% on the follow-up angiogram which was performed up to 9 months after PCI., Results: The mean pulse pressure was significantly higher in patients with restenosis (76.9 +/- 24.2 mmHg vs 61.3 +/- 17.5 mmHg, p < 0.001). The incidence rate of restenosis was 28.6% for the patients with the lowest PP and 55.2% for the patients with the highest PP (p < 0.05). The odds ratio after adjustment for sex, age, smoking status, hypercholesterolemia, diabetes mellitus, the type of lesions that underwent the PCI, maximal inflation pressure, time of inflation, minimal lumen diameter before and after the PCI, reference lumen diameter, stent implantation and mean blood pressure was 1.0, 2.83 (0.59-13.72) and 7.36 (1.12-68.11) for the patients with the lowest, middle and highest PP, respectively. The multiple-adjusted analysis showed that 10 mmHg increase in PP is associated with 72% increase in risk of restenosis (OR 1.72, CI 1.14-2.60, p < 0.01)., Conclusion: Ascending aortic pulse pressure is an independent predictive factor for restenosis after percutaneous coronary intervention.