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To assess the effect of the duration of stent inflation on stent expansion using digital stent enhancement (DSE).Optimal stent expansion and apposition to the vessel wall are of critical importance to optimize the results of percutaneous coronary intervention (PCI). However, it is not known if stent inflation duration impacts on stent expansion.We performed a prospective cohort study in patients undergoing PCI. Quantitative coronary angiography and DSE data were analyzed. DSE was performed at 5, 15, and 25 sec during stent implantation, after target balloon inflation pressure was achieved.One hundred and four consecutive patients (150 lesions) were enrolled. The mean age was 66.9 ± 11.1 years. Complex lesions (ACC/AHA B2/C) occurred in 26.9%. Stents used: Cypher Select (54.1%), Xience V (30.6%), and Taxus Liberté (15.3%). The minimal stent diameter increased significantly with the duration of stent inflation: 2.60 ± 0.51, 2.76 ± 0.51, and 2.82 ± 0.52 mm at 5, 15, and 25 sec (P0.0001). Similarly, maximal stent diameter increased with the duration of stent inflation: 3.21 ± 0.51, 3.32 ± 0.52, and 3.36 ± 0.54 mm (P0.0001). The average stent diameter also increased with longer stent inflation (P0.0001). Using MUSIC criteria 24.0, 53.3, and 68.0% of stents were appropriately expanded at 5, 15, and 25 sec (P0.0001).The duration of stent balloon inflation has a significant impact on stent expansion. Stent deployment for25 sec is recommended.

See also Lordkipanidze M, Harrison P. Beware of being caught on the rebound. This issue, pp 21–3. Summary. Aims: Antiplatelet therapy with aspirin and clopidogrel is recommended for 1 year after drug-eluting stent (DES) implantation or myocardial infarction. However, the discontinuation of antiplatelet therapy has become an important issue as recent studies have suggested a clustering of ischemic events within 90 days of clopidogrel withdrawal. The objective of this investigation was to explore the hypothesis that there is a transient ‘rebound’ increase in platelet reactivity within 3 months of clopidogrel discontinuation. Methods and Results: In this prospective study, platelet function was assessed in patients taking aspirin and clopidogrel for at least 1 year following DES implantation. Platelet aggregation was measured using a modification of light transmission aggregometry in response to multiple concentrations of adenosine diphosphate (ADP), epinephrine, arachidonic acid, thrombin receptor activating peptide and collagen. Clopidogrel was stopped and platelet function was reassessed 1 week, 1 month and 3 months later. Thirty-two patients on dual antiplatelet therapy were recruited. Discontinuation of clopidogrel increased platelet aggregation to all agonists, except arachidonic acid. Platelet aggregation in response to ADP (2.5, 5, 10, and 20 μm) and epinephrine (5 and 20 μm) was significantly increased at 1 month compared with 3 months following clopidogrel withdrawal. Thus, a transient period of increased platelet reactivity to both ADP and epinephrine was observed 1 month after clopidogrel discontinuation. Conclusions: This study demonstrates a transient increase in platelet reactivity 1 month after clopidogrel withdrawal. This phenomenon may, in part, explain the known clustering of thrombotic events observed after clopidogrel discontinuation. This observation requires confirmation in larger populations.

Platelets play a central role in the regulation of both thrombosis and haemostasis yet tests of platelet function have, until recently, been exclusively used in the diagnosis and management of bleeding disorders. Recent advances have demonstrated the clinical utility of platelet function testing in patients with cardiovascular disease. The ex vivo measurement of response to antiplatelet therapies (aspirin and clopidogrel), by an ever-increasing array of platelet function tests, is, with some assays, predictive of adverse clinical events and thus, represents an emerging area of interest for both the clinician and basic scientist. This review article will describe the advantages and disadvantages of the currently available methods of measuring platelet function and will discuss both the limitations and emerging data supporting the role of platelet function studies in clinical practice.

Right ventricular migration of a systemic venous stent is a rare complication. We present a case of stent migration in a 65-year-old male who underwent palliative intervention for inferior vena cava compression secondary to malignant mesothelioma. Two- and three-dimensional echocardiographic images revealed evidence of a free-stent trapped in the tricuspid valvular apparatus causing severe tricuspid regurgitation.

A 74-year-old male smoker was hospitalized for a transurethral resection of the prostate. A preoperative chest x-ray raised the suspicion of a finding that had been overlooked 6 months earlier.

Thrombolysis is an important reperfusion strategy where primary PCI cannot be offered to STEMI patients within recommended timelines. The National ACS programme recommends the transfer of thrombolysed STEMI patients as soon as possible to a primary PCI centre. In cases of failed thrombolysis the patient should undergo immediate angiography and rescue PCI (RPCI). If thrombolysis is successful a strategy of routine early angiography is recommended. Aim The aim of this study was to determine the number of thrombolysed patients in the West of Ireland that were appropriately deferred for routine early angiography compared to those that were brought for rescue PCI, as determined by TIMI flow at time of coronary angiography and LV function on echo. Methods Data on all Code STEMI patients admitted to UHG is collected prospectively. Using this database we identified all patients who were thrombolysed for STEMI in 2014. Results Of 324 code STEMI admissions to UHG 59 (25.4% female, average age 62, age range 30–95) had received thrombolysis in an outside hospital. 27 (45.7%) were brought immediately to the lab on arrival at UHG; 14 (51.8%) had TIMI 1 or 0 flow, 13 (48.2%) had TIMI 2–3 flow. The main indication for immediate angiography was ongoing pain and STEMI. 30 (53.3%) patients had routine angiography; 4 (13.3%) had TIMI 0 or 1 flow, 26 (86.7%) had TIMI 2 or 3 flow. 2 (3.3%) patients had no angiography, 1 (1.7%) patient was too unstable and did not survive to discharge. The total mortality in the thrombolysed group was 4. Of the group brought for RPCI 24 (89%) proceeded to PCI, no intervention required in 3 (11%) cases, 2 of these being a ‘false call’ (LBBB, pericarditis), 2 patients in this subgroup did not survive. 62% had impaired LV function on initial echo, 38% with severely impaired LV function (EF Conclusion In our cohort of thrombolyed patients from the West of Ireland we found that the appropriate patients are being identified as successfully thrombolysed and having routine early angiography in keeping with international guidelines. This is demonstrated by the statistically significant difference in TIMI flow and initial LV systolic function between the 2 groups, highlighting that the delayed group are correctly identified as having a smaller ischaemic burden.

We thank Dr. Endo and colleagues for their interest in our study [(1)][1]. They correctly note that the absence of a pre-determined revascularization strategy in this nonrandomized analysis confers the potential for patient selection or treatment bias. This implies that when selecting patients for

Percutaneous left atrial appendage occlusion (LAAO) is a device-based therapy for the prevention of stroke in patients with nonvalvular atrial fibrillation (AF). Recently, the Watchman device (Boston Scientific, St Paul, MN, US) was approved in the US by the Food and Drug Administration (FDA) based on the results of two randomised clinical trials that evaluated LAAO in patients eligible for oral anticoagulation (OAC) therapy. However, in real-word clinical practice LAAO is typically offered to patients ineligible for OAC therapy, as they appear to have limited treatment options and consequently worse prognosis. Although LAAO has shown favourable clinical outcomes in OAC-ineligible patients in single or multicentre observational studies, these results need to be confirmed in randomised clinical trials.

deployment was significantly higher than pre-deployment (16.1 12.5% vs. 33.7 12.5%, p

Purpose: Regional differences in the adoption of transcatheter aortic valve implantation (TAVI) technology have emerged since European CE mark approval in 2007. We sought to identify factors that may influence TAVI adoption and inequitable patient access in Western Europe. Methods: TAVI use was determined across 11 European nations: Germany, France, Italy, United Kingdom (UK), Spain, The Netherlands, Switzerland, Belgium, Portugal, Denmark and Ireland. The following national economic indices and healthcare parameters were assessed in order to establish factors associated with TAVI use: (1) the proportion of gross domestic product (GDP) spent on healthcare; (3) the total healthcare expenditure (US dollars) per capita; (4) the principal source of healthcare funding (social insurance or taxation); and (5) the system of TAVI reimbursement (TAVI-specific or constrained). Results: Between 2007-2011, a cumulative total of 34504 patients underwent TAVI in the 11 study nations. Significant linear correlations were found between TAVI utilisation and healthcare spending as a percentage of GDP (r=0.68, p=0.025), and healthcare spending per capita (r=0.80, p=0.005). There was a trend towards increased TAVI use in those nations where healthcare was funded principally by social insurance (Germany, France, the Netherlands, Switzerland, and Belgium) compared to those principally funded by taxation (Italy, UK, Spain, Portugal, Denmark, Ireland) (571±290 versus 252±192 implants per million ≥75 years, p=0.056). TAVI reimbursement strategies across the study nations were heterogeneous. TAVI-specific national DRG-based reimbursement occurs in Germany, France, Switzerland, and Denmark. Constrained reimbursement systems were noted for the UK, Spain, the Netherlands, Belgium, Portugal and Ireland where the cost of TAVI is borne by a local healthcare trust (UK) or by the hospital budget. TAVI-specific reimbursement systems were associated with a 3.3-fold higher TAVI utilisation than constrained systems (698±232 versus 213±112, p=0.002). Furthermore, TAVI-specific reimbursement systems were associated with 2.5 times more TAVI implants per centre than constrained systems (69±18 vs. 26±20 implants per centre p=0.008). Conclusions: National economic indices and reimbursement strategies are closely linked with TAVI use and may explain the inequitable adoption of TAVI across nations.

Aim Covid-19 has had a dramatic impact on the healthcare systems globally. Despite efforts to maintain systems of cardiovascular care during the pandemic, public health responses to the virus have contributed to adverse cardiovascular outcomes. Herein, we summarize current evidence detailing the impact of Covid-19 on interventional cardiology. Methods According to PRISMA criteria, a systematic review was performed through Medline, Embase, and Cochrane databases, to identify reports on the impact of Covid-19 on interventional cardiovascular procedures. We identified 50 published studies that met the prespecified inclusion and exclusion criteria. Results In the acute setting, several datasets report a reduction of acute coronary syndrome (ACS) admission by 40% globally (−40%, 95% CI 37–43 from the National Health Service hospital trusts in England). Most surveys and registries reported a numerically higher impact on NSTEMI/unstable angina cases compared to STEMI (−42%, 95% CI 38–46 and −23%, 95% CI 16–30 respectively, from the National Health Service hospital trusts in England). In STEMI care pathways, several studies report increased delays between symptom onset and first medical contact (105 min, 95% CI 45–222 during the pandemic vs 71 min, 95% CI 30–180 before it, p Most studies suggest similar in-hospital mortality for STEMI during the pandemic compared to historic controls (1.7% vs 1.8%, p=0.67 from British National Institute of Cardiovascular Outcomes Research database). An increased incidence of mechanical complications were observed (41.2% vs 19.6%, p=0.030, from an Italian monocentric experience). In the United States (New York city), overall mortality from ischemic heart diseases depicted a 2-fold increase during the pandemic (relative change 2.39, 95% CI 1.39–4.09). Of note, in the same city home deaths increased from 35/day in 2013–2017 to 200/day during the pandemic. These data suggest that ACS incidence has not decreased, but more likely patients presenting ischemic symptoms may have not contacted health care services, and have died at home. Conclusions The Covid-19 pandemic has adversely impacted outcomes in patients with ischemic heart disease (IHD). The diagnosis and treatment of IHD should be designated a health system priority that remains intact during pandemic events as the magnitude of harm induced by its interruption is substantial. Funding Acknowledgement Type of funding sources: None.

The degree of device oversizing associated with optimal clinical outcomes differs between current transcatheter heart valve (THV) devices. With limited THV sizes some annuli considered borderline for one device may be within an optimal range for another device. We sought to determine whether

Cardiogenic shock (CS) is the most common cause of death in patients with ST-segment elevation myocardial infarction (STEMI). Multivessel coronary disease (MVD) is common in patients with STEMI and CS and is associated with increased myocardial ischemia in compared to single vessel disease (SVD).