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Incomplete stent apposition (ISA) is an unusual finding of intravascular ultrasound (IVUS) that may occur both after drug-eluting stent (DES) or bare-metal stent (BMS) implantation and could be associated with late stent thrombosis. Controversy still remains about whether the risk of late-acquired ISA is increased after DES implantation. This meta-analysis aimed to clarify whether DES implantation is associated with an increased risk of late-acquired ISA.We performed a meta-analysis from 12 randomized trials that compared DES and BMS and included IVUS follow up: TAXUS II (n = 469), TAXUS IV (n = 187), TAXUS V (n = 213) and VI (n = 147), ASPECT (n = 81), DELIVER (n = 65), SIRIUS (n = 141), DIABETES (n = 140), ENDEAVOR II (n = 250), FUTURE I and II (n = 83), and SPIRIT-I (n = 58). In these trials, 1,834 patients (972 DES, and 862 BMS) underwent immediate and follow-up IVUS examination.There was no heterogeneity among the trials (Q-test for heterogeneity: Chi2: 7.69; (p = 0.26), I2: 22%. Out of the 1,834 patients undergoing serial IVUS examination, 85 developed late-acquired ISA (4.6%). This incidence was significantly higher in DES compared with BMS (6.5% vs. 2.6%, respectively; odds ratio [OR] 2.48, 95% confidence interval [CI] 1.26 to 4.87; p = 0.008). That means that the risk of developing late-acquired ISA is 2.5 times higher after DES versus BMS implantation. No stent thrombosis occurred in the patients diagnosed with ISA over a period up to 12 months.DES implantation could be associated with an increased risk of late ISA in comparison with BMS. The clinical implication of late ISA in the long term remains to be clarified.

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.

Complete left coronary system abolition due to thrombotic occlusion of the left main coronary ostium is an unusual presentation of myocardial infarction. Delays in reaching hospital and restoring coronary blood flow are major predictors of survival in cardiogenic shock. This rare case highlights the high mortality rate of cardiogenic shock due to thrombotic occlusion of the left main coronary ostium in spite of all efforts using innovative devices to remove thrombus and achieve adequate coronary and myocardial perfusion.

We report a case of a 58-year-old woman with rheumatic mitral stenosis scheduled for percutaneous valvuloplasty. Prior left and right ventricular angiograms showed multiple diverticula at left ventricular apical and diaphragmatic walls and right ventricular diaphragmatic wall. Chest x-ray and echocardiogram were normal. Magnetic resonance imaging was concordant with catheterization findings and ruled out other cardiac malformations. The risk of ventricular perforation changed our indication of percutaneous valvuloplasty in favor of open heart commissurotomy.

We read with interest the paper by Amat-Santos et al. ([1][1]) describing the importance of new-onset atrial fibrillation (NOAF) after transcatheter aortic valve implantation (TAVI). They describe an association between NOAF and embolic events (EE), suggesting that NOAF may be a mechanism for late

The cumulative experience gleaned from the NICE trials suggests that adjunctive enoxaparin therapy for percutaneous transluminal coronary angioplasty (PTCA), with or without concomitant abciximab therapy, is both safe and effective. However, no randomized studies have been conducted to compare the two strategies. The aim of this study was to evaluate the safety of combined enoxaparin-abciximab compared with standard therapy using unfractionated heparin and abciximab.Ninety-nine patients undergoing PTCA were randomly assigned to receive either enoxaparin (enoxaparin group, 50 patients, 0.75 mg/kg) or unfractionated heparin (UH group, 49 patients, 70 U/kg) in an intravenous bolus. Both groups received standard abciximab treatment. The aPTT, creatine kinase (CPK), MB, troponin I, hemoglobin, and platelet count were determined 5 h and 17 h after PTCA. Endpoints were major bleeding and clinical or biochemical in-hospital events.There was less major bleeding in the enoxaparin group than in the UH group (1 vs 4) but the difference was not statistically significant. There were no significant differences in the frequency of in-hospital clinical events. There was a lower increase in aPTT at 5 h in the enoxaparin vs UH group (p = 0.02). It was impossible to remove the introducer in 7 of the UH group patients due to aPTT60 s as opposed to 1 patient in the enoxaparin group. Post-procedural CK elevation occurred in 8.0% of the enoxaparin group and in 6.1% of the UH group (p = NS). No thrombocytopenia was observed in either group.Combined enoxaparin-abciximab as an adjuvant therapy during PTCA was safe and associated with a low incidence of major bleeding, major ischemic in-hospital events, and post-procedural CPK elevation.

We read with interest the report by Holmes et al. ([1][1]), in which the current knowledge about stent thrombosis is revisited, and the possibility that biodegradable polymers improve the long-term safety of drug-eluting stents is mentioned. Durable polymers are associated with persistent arterial

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.

To study a cohort of consecutive patients undergoing transcatheter aortic valve implantation (TAVI) and compare the outcomes of atrial fibrillation (AF) patients vs patients in sinus rhythm (SR).All consecutive patients undergoing TAVI in our hospital were included. The AF group comprised patients in AF at the time of TAVI or with history of AF, and were compared with the SR group. Procedural, echocardiographic and follow-up variables were compared. Likewise, the CHA(2)DS(2)-VASC stroke risk score and HAS-BLED bleeding risk score and antithrombotic treatment at discharge in AF patients were compared with that in SR patients.From a total of 34 patients undergoing TAVI, 17 (50%) were allocated to the AF group, of whom 15 (88%) were under chronic oral anticoagulation. Patients in the AF group were similar to those in the SR group except for a trend (P = 0.07) for a higher logistic EuroSCORE (28% vs 19%), and a higher prevalence of hypertension (82% vs 53%) and chronic renal failure (17% vs 0%). Risk of both stroke and bleeding was high in the AF group (mean CHA(2)DS(2)-VASC 4.3, mean HAS-BLED 2.9). In the AF group, treatment at discharge included chronic oral anticoagulation in all except one case, and in association with an antiplatelet drug in 57% of patients. During a mean follow-up of 11 mo (maximum 32), there were only two strokes, none of them during the peri-procedural period: one in the AF group at 30 mo and one in the SR group at 3 mo. There were no statistical differences in procedural success, and clinical outcome (survival at 1 year 81% vs 74% in AF and SR groups, respectively, P = NS).Patients in AF undergoing TAVI show a trend to a higher surgical risk. However, in our cohort, patients in AF did not have a higher stroke rate compared to the SR group, and the prognosis was similar in both groups.