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The aorta is the largest artery in the body, delivering oxygenated blood from the left ventricle to all organs. Dissection of the aorta is a lethal condition caused by a tear in the intimal layer of the aorta, followed by blood loss within the aortic wall and separation of the layers to full dissection. The aorta can be affected by a wide range of causes including acute conditions such as trauma and mechanical damage; and genetic conditions such as arterial hypertension, dyslipidaemia, and connective tissue disorders; all increasing the risk of dissection. Both rapid diagnostic recognition and advanced multidisciplinary treatment are critical in managing aortic dissection patients. The treatment depends on the severity and location of the dissection. Open surgical repair is the gold standard of treatment for dissections located to the proximal part of the aorta and the arch, while endovascular interventions are recommended for most distal or type B aortic dissections. In this review article, we examine the epidemiology, pathophysiology, contemporary diagnoses, and management of aortic dissection.

Giant aneurysm of the left main coronary artery is exceedingly rare and accounts for less than 2% of patients undergoing coronary angiography. The etiology varies depending on the patient's age and geographic area, but half are of atherosclerotic origin. In most cases, coronary aneurysms are asymptomatic, however, symptomatic patients present with symptoms characteristic of coronary artery disease such as chest pain (angina pectoris), myocardial infarction, congestive heart failure, and even sudden death. Coronary angiography is considered the gold standard tool to determine the presence or absence of coronary artery disease, and if present, its size and location. Herein, we report a case of giant aneurysm of the left main coronary artery presenting as syncope and documented nonsustained ventricular tachycardia.

Background Vascular complications (VCs) after transfemoral transcatheter aortic valve implantation (TAVI) have an increased mortality risk, and vascular closure device (VCD) use is mandatory. The percutaneous MANTA VCD (Teleflex) is a novel collagen-based technology for closure of large-bore arteriotomies. We compared the MANTA VCD with the suture-based ProGlide VCD (Abbott Vascular). Methods A retrospective review was performed on all consecutive patients who underwent transfemoral TAVI in our center from January 1, 2015, to February 28, 2021, and 30-day outcomes were recorded. Major adverse cardiovascular events (MACE) were cardiac death, disabling stroke, and/or major VCs. Access site–related VCs were VCs related to the access site vessel from which the transcatheter valve was introduced and advanced. Results The MANTA VCD was used in 99 patients and the ProGlide in 224. There was 4.0% MACE in the MANTA group and 4.9% in the ProGlide group (P = .999). Overall VCs were 10.1% vs 7.6%, major VCs were 3.0% vs 2.2%, and minor VCs 7.1% vs 5.4%(P = .753). Access site–related VCs were 5.1% vs 5.8% in the (P = .999), and periprocedural vascular surgical intervention was needed in 6.1% of the MANTA group vs 2.2% of the ProGlide group (P = .099). Conclusion There was no significant difference in MACE, mortality, cardiovascular mortality, VCs, access site–related VCs, periprocedural vascular surgical interventions, bleeding, or transfusion rate between the 2 groups. The MANTA VCD group had more periprocedural vascular surgical interventions which did not reach statistical significance.

The ongoing coronavirus disease 2019 (COVID-19) has caused a global health crisis. This prospective, observational, single-centre, cohort study investigated the influence of the second wave of the pandemic on the treatment of ST-segment elevation myocardial infarction (STEMI) patients admitted to the largest tertiary centre in Nicosia, Cyprus. We measured onset-to-door (O2D) time, door-to-balloon (D2B) time, onset-to-balloon (O2B) time, and 30-day mortality for 250 consecutive patients who presented directly or were transferred to Nicosia General Hospital from 1 January 2021, to 31 December 2021, during the second wave of the pandemic in Cyprus. We compared a control group of patients with similar clinical characteristics admitted before the COVID-19 outbreak. Median O2D time was increased from 89 min to 120 min (p-value=0.094). D2B time was not increased significantly (85.5 vs. 87 min, p-value=0.137). The total ischemic time (O2B time) was increased from 173.5 min to 232.5 min, respectively (173.5 vs. 232.5, p=0.001). During the pandemic, more patients presented with cardiogenic shock (3.94 vs. 13.6, p=0.001) and with cardiac arrest (9.85 vs. 17.2, p=0.035,) while there was an increase in 30-day mortality (4.43% vs. 8.8%, p-value=0.100). Patients with STEMI during the second wave of the COVID-19 pandemic seem to have presentation delays with increased total ischaemic times, presented more commonly in cardiogenic shock or cardiac arrest, increasing 30-day mortality.

A continuous discussion regarding the predictors for permanent pacemaker implantation (PPI) following transcatheter aortic valve implantation (TAVI) is ongoing, especially in the era of low and medium risk patients. The aim of this article is to review the data so far regarding the pathophysiology, risk factors, and the indications for permanent pacemaker implantation after TAVI. The factors that contribute to rhythm abnormalities post TAVI can be divided into pre-existing conduction abnormalities, patient-related anatomical factors, and peri-procedural technical factors. The latter components are potentially modifiable, and this is where attention should be directed, particularly now that in an era of TAVI expansion towards lower-risk patients.

Adrenergic overstimulation in long term can lead to a hyperdynamic myocardium and give rise to hypertrophy and ultimately to heart failure. Amphetamine use is a common cause of neurohormonal activation, which gives rise to such adverse cardiovascular events. However, hypertrophy of myocardium in young patients, even due to apparently obvious causes, should always be considered as a red flag and a further diagnostic downstream should take place, in order to exclude genetic causes. We present a case of a young man with chronic use of amphetamine and an incidental finding of hypertrophic cardiomyopathy.

Open surgery remains the mainstay of treatment for acute type A aortic dissection and should be offered to most patients. However, there are elderly patients in which surgical treatment may be deemed extremely high risk or futile. Endovascular treatment approaches have been applied to a small number of these patients and data are limited to case reports and small series. The application of endovascular therapies to ascending aorta is currently limited by anatomical and technical challenges posed by the dynamic motion of the ascending aorta and the proximity of vital structures to intended landing zones (aortic valve, coronary arteries, and supra-aortic branches) and lack of specially designed endografts to address these issues. While thoracic endovascular aortic repair (TEVAR) has replaced open aortic repair for a suitable lesion in distal aortic dissection, some selected patients with type A aortic dissection at high surgical may be candidates. Hence, there is potential because, in proximal (Stanford type A) dissections, 10–30% of patients are not accepted for surgery, and 30–50% are technically amenable for TEVAR. Recent experience has shown that carefully selected patients with favorable anatomical characteristics may be subject to endovascular stent-graft treatment as a last resort with mixed results. Technical improvement is necessary to offer. satisfactory endovascular options in non-surgical candidates.

Endografting for atretic coarctation is technically feasible to avoid the risks of open surgery. It requires a strategic and structured endovascular approach such as the “Railway” technique for safe and successful restructuring of complete aortic atresia and avoiding rupture or bleeding.

Aortic pathologies in general require a multidisciplinary approach and decision-making to integrate elements of clinical acuity, vascular pathology, individual comorbidity, and risk assessment; thus, ideally it is a center with access to multiple imaging modalities and expertise in all treatment options. Besides classic open surgical options, endovascular procedures have been accepted for a variety of aortic pathologies. More recently, novel transcatheter interventions even to the proximal aorta have been introduced, particularly for patients unfit for open surgery. Nevertheless, the role of transesophageal echocardiography to guide percutaneous aortic interventions is not well established, notwithstanding the growing potential as an ancillary tool to guide the procedure and document success.

The optimal approach for Transcatheter aortic valve implantation (TAVI) is the transfemoral access but alternative TAVI approaches offer the possibility of valve replacement in patients who are not eligible to the transfemoral route. This review paper intends to compare the current available alternative approaches for TAVI in terms of their safety and efficacy, based on the current literature. The transapical, transaortic, transsubclavian, transcarotid, transcaval and suprasternal approaches have been analyzed. The choice of the alternative approach dependents on local Heart Team expertise, patient specific characteristics, access specific characteristics and the need or not for general anesthesia. More studies are needed to investigate the impact of each individual approach on long-term outcomes.

Acute coronary syndromes (ACS) remain the most common disease in acute cardiovascular care. Historically, two groups of patients should be differentiated based on initial ECG features: patients with ongoing chest pain and persistent ST-segment elevation and patients with acute chest pain but no persistent ST-segment elevation. The first condition is defined as STEMI and requires immediate reperfusion by primary angioplasty or fibrinolytic therapy. The second condition is defined as NSTE-ACS and consists a big spectrum of cases range from patients free of symptoms at presentation to individuals with ongoing ischaemia, electrical or haemodynamic instability or cardiac arrest. The different types of ACS must be differentiated as their prognosis and therapeutic strategy varies. However, over the last years, the early and broad use of percutaneous coronary intervention (PCI) as well as innovations in the adjunctive antithrombotic medication, including more effective P2Y12-Inhibitors and new generation DES resulted to a dramatic improvement of the prognosis across the whole spectrum of ACS patients.

Acute myocardial infarction (AMI) is one of the major causes of morbidity and mortality worldwide. The inflammation response during and after AMI is common and seems to play a key role in the peri-AMI period, related with ischaemia-reperfusion injury, adverse cardiac remodelling, infarct size and poor prognosis. In this article, we provide an updated and comprehensive overview of the most important cytokines and adipokines involved in the complex pathophysiology mechanisms in AMI, summarizing their prognostic role post-AMI. Data so far support that elevated levels of the major proinflammatory cytokines TNFα, IL-6 and IL-1 and the adipokines adiponectin, visfatin and resistin, are linked to high mortality and morbidity. In contrary, there is evidence that anti-inflammatory cytokines and adipokines as IL-10, omentin-1 and ghrelin can suppress the AMI-induced inflammatory response and are correlated with better prognosis. Mixed data make unclear the role of the novel adipokines leptin and apelin. After all, imbalance of pro-inflammatory and anti-inflammatory cytokines may result in worst AMI prognosis. The incorporation of these inflammation biomarkers in established prognostic models could further improve their prognostic power improving overall the management of AMI patients.

Abstract: Understanding the similarities and differences between myocardial infarction with or without ST-segment elevation is an essential step for proper patients’ management in current practice. Both syndromes are caused by critical stenosis or total occlusion of coronary arteries (mostly due to thrombosis on atherosclerotic plaque), and manifest with a similar clinical presentation. Recent epidemiologic studies show that the relative incidence of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) moves in an opposite fashion (decreasing and increasing respectively), with a prognosis that is worse at short-term follow-up for STEMI but comparable at long-term. Current management differs, as for STEMIs, immediate reperfusion is recommended, while for NSTEMIs, risk stratification is mandatory in order to stratify patients’ risk, and then decide the timing for coronary angiography. Periprocedural and technical aspects of the interventional management, as well as antithrombotic medications, are for the most similarly implemented in the two types of MI, with routine radial access, DES implant, and novel P2Y12 inhibitors representing the standard of care in both cases. The following review article aims to compare the two types of MI, with and without persistent STsegment elevation. The main purpose is to explore their similarities and differences and address areas of uncertainty with regards to clinical presentation, therapeutic management, and prognosis. The identification of high-risk NSTEMI patients is important as they may require an individualised approach that can substantially overlap with current STEMI recommendations, and their mortality remains high if their management is delayed.

AIMS The aim of this meta-analysis was to appraise the burden of cardiovascular mortality and morbidity among patients undergoing percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest (OHCA). METHODS AND RESULTS This was a meta-analysis of studies assessing the cardiovascular mortality or at least one other pre-defined outcome in OHCA patients undergoing PCI. Forty-nine studies with a total of 301,902 patients (73,634 OHCA and 228,268 non-OHCA patients) were included. Compared to non-OHCA patients, all-cause mortality was higher in OHCA patients (29% vs 4%). The cause of 39% of deaths among OHCA patients was cardiovascular: PCI was more frequently unsuccessful (9.2% vs 7.6%) and there were higher rates of stent thrombosis (2.9% vs 0.8%), myocardial infarction (1.7% vs 1.4%), relevant bleeding (10.2% vs 2.1%) and stroke (1.7% vs 0.5%). OHCA patients compared to non-OHCA patients had a higher risk of all-cause mortality (risk ratio [RR] 6.4, 95% CI: 5.5-7.4), cardiovascular death (4.6, 1.1-19), unsuccessful coronary revascularisation (1.4, 1.1-1.7), stent thrombosis (3.8, 0.6-22.7), myocardial infarction (1.4, 1.1-1.7), relevant bleeding (3.2, 2.5-4.1) and stroke (3.1, 2.3-4.3). CONCLUSIONS Almost one third of OHCA patients undergoing PCI die and more than one third of the fatalities are attributable to cardiovascular causes. The burden of ischaemic and bleeding complications was consistently higher and the success rates of PCI lower among OHCA as compared to non-OHCA patients.

The prevalence of heart failure has an increasing tendency in the last years. Either heart failure with reduced ejection fraction (HFrEF) or with preserved ejection fraction, the treatment depends on the severity, cause, and symptoms. In case of HFrEF, careful evaluation of patient is essential for proper diagnosis, risk stratification and treatment, which should always be individualistic. Except from daily measurements, medical treatment and eventually implantation of implantable cardioverter defibrillator or cardiac resynchronization therapy, implantation of left ventricular assist device (LVAD) belongs also to therapeutic armamentarium. Other than invasive procedures, which are required for the evaluation of every patient with HFrEF, Cardiopulmonary exercise test emerges as one of the most effective noninvasive method for diagnosis, risk stratification, and treatment strategy for these patients. Cardiopulmonary exercise test can provide means for a critical evaluation of cardiovascular system. One of the most important variables is the maximal oxygen consumption (peak VO2). Its high predictive and prognostic power makes peak VO2 essential for the evaluation of patients as candidates, not only for LVAD-implantation, but also for explantation. Furthermore, regarding cardiac rehabilitation and exercise protocols, robust literature supports a follow-up of LVAD-patients by means of cardiopulmonary exercise testing.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has changed the management of aortic dissection and enabled the dissected segment to remodel. In this report we describe the concept of dual lumen intervention with both stent-grafts in the true lumen and thrombus promoting interventions to the false lumen in the attempt to remodel dissected aorta regardless of location. METHODS: A total of 10 patients with aortic dissection (5 type A; 5 type B) underwent dual lumen intervention using a combination of patent foramen ovale (PFO) or atrial septal defect (ASD) occluders, coils and glue in addition to endovascular stenting of the true lumen. Patients were followed by computed tomography (CT) angiogram prior to, 6 months and 2 years following discharge to evaluate the status of aortic remodeling. The analysis comprised successful device delivery, completeness of false lumen thrombosis and aortic remodeling and procedure related complications. RESULTS: Dual lumen interventions have induced aortic remodeling in all cases of proximal dissection, with aortic shrinkage from 63.8±7.5 pre-intervention, to 50.2±6.6 mm (P=0.057) and an increase in true lumen area from 5.8±3.6 to 11.4±2.5 cm2 (P=0.006). In distal dissection (after previous TEVAR with residual false lumen flow), false lumen intervention induced false lumen thrombosis in 4 of 5 cases upon first attempt (1 case required additional coiling of the gutter between left subclavian artery and stent-graft for complete thrombosis). While maximal aortic diameter remained unchanged (55.6±9.1 preintervention and 54.4±13.7 mm at 2 years follow-up), true lumen area increased from 7.8±2.3 pre-procedure, to 10.6±1.5 cm2 at follow-up (P=0.016), consistent with stable remodeling. CONCLUSIONS: Interventional false lumen management of both lumens in case of subacute/chronic aortic dissection is feasible, promotes false lumen thrombosis and induces successful remodeling with or without previous endografting.

Introduction: Coronary angioplasty with the use of stents transformed the percutaneous treatment of coronary artery disease. First-generation drug-eluting stents reduced the risk of restenosis but ...

Zusammenfassung Die bikuspide Aortenklappe ist der häufigste kongenitale Herzfehler und gleichzeitig die häufigste angeborene Fehlbildung der Aortenklappe bei Erwachsenen. In dieser Übersichtsarbeit werden die verschiedenen Aspekte der bikuspiden Aortenklappe einschließlich ihrer Komplikationen unter klinischen Gesichtspunkten dargestellt. Abstract The bicuspid aortic valve is the most common congenital heart disease as also the most common congenital malformation of the aortic valve. Due to altered hemodynamics, anatomy and geometry of the valve apparatus there is a high risk of complications, with the most common of them the aortic valve stenosis. Echocardiography is primarily considered as the gold standard for the diagnosis. However computed tomography and magnetic resonance tomography belong to the diagnostic armamentarium for precise diagnosis, risk stratification and defining the therapeutic approaches. Operative aortic valve replacement has been ultimately the gold standard therapy for the bicuspid aortic valve, although in the last years, transaortic valve replacement emerge as an alternative option with excellent results.

Kounis syndrome is defined as the coincidental occurrence of an acute coronary syndrome with hypersensitivity reactions following an allergic event. The three reported variants of Kounis syndrome are vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus. The syndrome is caused by various inflammatory mediators. The pathophysiological characteristics of Kounis syndrome involve coronary artery spasm and/or atheromatous plaque erosion or rupture during an allergic reaction. Several causes have been described to induce Kounis syndrome, and their number is increasing rapidly. The haemodynamic effect of the syndrome complicated by cardiogenic shock seems to combine allergic shock with extensive peripheral vasodilation and myocardial suppression with the characteristics of cardiogenic shock. Treatment of Kounis syndrome is challenging because it needs management of both cardiac and allergic manifestation simultaneously. We present a case report of type I Kounis syndrome, with coronary spasm secondary to cefuroxime injection complicated with cardiogenic shock. A brief review of the literature on the various facets of this condition is also provided.

Hypertrophic cardiomyopathy (HCM) is the most common inherited heart disease and the most common cause of sudden cardiac death in young population, especially in athletes under 35 years old. Mutations occur primarily in the β-myosin heavy chain gene and involve the cardiac myosin-binding protein C gene. In this review we would like to focus on the importance of the examination of mitral valve apparatus and the mitral valve abnormalities in patients with HCM. Abnormalities in mitral valve (elongated mitral leaflets, displacement of papillary muscles, and systolic anterior motion) may be the primary pathognomonic elements, even in the absence of hypertrophy. Echocardiography is the gold standard for the diagnosis of HCM. Magnetic resonance imaging emerges as one of the most important imaging modalities for precise diagnosis, assisting in risk stratification and treatment strategy. Mitral valve abnormalities take part fundamentally in the formation of systolic anterior motion of the mitral valve and, they have substantially been repaired surgically. Although myectomy addresses the septum reduction, obstruction relief should be maximally achieved with a potential combination of myectomy and mitral valve repair.

Diseases of the aorta include a wide spectrum of acute and chronic conditions ranging from aortic aneurysms and malformations to acute aortic syndromes (AAS), including acute aortic dissection (AD), intramural haematoma (IMH), penetrating aortic ulcer (PAU) and even traumatic aortic injury (TAI). Furthermore, pseudoaneurysm, atherosclerotic and inflammatory conditions can affect the aorta at any location. High risk for acute aortic syndrome and for congenital abnormalities including coarctation of the aorta is often associated with syndromic features and hereditary genetic underpinnings. Classic surgical strategies were for many years the gold standard to treat many aortic conditions; the last two decades, however, has seen the emergence of less traumatic endovascular management as an additional or alternative option to classic surgical strategies. In particular scenarios, endovascular management has already replaced open surgery, while the complexity of the underlying vascular disease, the comorbidity and the increasing age of patients render this cohort very special. Therefore, every patient with aortic disease should be discussed by a dedicated aortic team of specialists that normally consists of vascular interventionalists (cardiology or radiology) and surgeons (cardiac or cardiothoracic) and dedicated anaesthesiologists with the idea to offer the individually best approach to a complex problem: the team should at the same time cover screening for aortic disease and follow-up after surgery or intervention at a personal level.

Treatment of patients presenting with a non-ST elevation acute coronary syndrome (NSTE-ACS) aims at immediate relief of ischaemia and the prevention of serious adverse events, including death, myocardial (re)infarction, and life-threatening arrhythmias. In NSTE-ACS, patient management is guided by risk stratification (troponin, electrocardiogram, risk scores, etc.). Treatment options include anti-ischaemic and antithrombotic drugs and coronary revascularization including percutaneous coronary interventions, or coronary artery bypass grafting. While long-term secondary prevention with aspirin monotherapy is currently the gold standard approach for all NSTE-ACS patients who tolerate the drug, additional medications on top of aspirin such as oral P2Y12 inhibitors or oral anticoagulation have been investigated across clinical trials and their long-term use should be guided by the ischaemic versus bleeding risk status of each single individual patient.

Acute aortic syndrome includes a wide spectrum of aortic conditions such as classic acute aortic dissection, intramural haematoma, symptomatic penetrating aortic ulcers and traumatic aortic lesions. These result primarily from disruption of the inner wall layer, and involve thinning of the aortic wall, increased wall stress, progressive dilatation, evolution of intramural haemorrhage and possibly dissection and rupture. Chronic hypertension and connective tissue disorders are often implicated. Echocardiography, contrast-enhanced computed tomography and dynamic magnetic resonance imaging are used to establish the diagnosis. Aortic dissection is primarily classified according to anatomical characteristics: presence or absence of ascending aortic involvement is distinguished for prognostic and therapeutic reasons. In general, open surgery is indicated for dissection involving the ascending aorta, whereas medical management and/or endovascular stent-graft implantation is considered where the ascending aorta is spared. Pathology involving the aortic arch can be treated using a hybrid approach combining debranching with stent-graft implantation or branched or fenestrated stent-grafts. Stent-graft-induced remodelling seems to have long-term benefits in both complicated and uncomplicated distal dissection. In addition, long-term medical therapy to control hypertension and surveillance are paramount in all patients who have survived aortic dissection to reduce late complications, including recurrent dissection, aneurysm formation and rupture.

Background: Type B aortic dissection is a life-threatening acute aortic condition often with acute ischemic signs or symptoms. With initial management focusing on alleviating malperfusion and pain, and avoiding propagation of dissection or rupture both systolic blood and pulse pressure should be reduced initially by an aggressive medical approach. In the setting of persistent signs of complications endovascular strategies have replaced open surgery and led to a fourfold increase in early survival and better long-term outcomes. Methods: An electronic health database search was performed on articles published between January 2006 and July 2017. Publications were included in this review if (I) the index aortic pathology was type B aortic (distal) dissection; (II) when medical management, open surgical replacement or thoracic endovascular aortic repair were among those options; (III) when at least one of all basic outcome criteria such as survival, spinal cord ischemia and cerebrovascular accident was reported; (IV) when ≥15 serial patients were included. A total of 62 studies were eligible and analysed. Results: Our manuscript has summarized data collected over 12 years on management specific outcomes in the setting of distal aortic dissection and provides an up-to-date interpretation of the published evidence. For complicated cases, treated acutely, the 30-day or in-hospital mortality was 7.3% when managed by endovascular means, whereas the pooled rate for 30-day or in-hospital mortality was 19.0% when subjected to open repair. For acute uncomplicated type B dissection usually treated with blood pressure lowering medications, the pooled 30-day or in-hospital mortality rate was 2.4%. Survival rates at 5 years averaged at 60% (40% mortality). Freedom from any aortic event ranged from 34.0% to 83.9%, underlining an inherent risk of progression and late complications. For chronic complicated type B dissection, the rates of stroke, paraplegia and operative mortality following endovascular repair ranged from 5% to 13%, 2% to 13% and 2 to 13%, respectively, while 5-year survival rates after open repair ranged from 60% to 90%. In chronic uncomplicated type B dissection almost 90% of patients survive initial hospitalization and were subjected to medical management with a 5-year survival of 50–80%. However, up to 20–55% of medically treated patients develop aneurysmal degeneration after 5 years with an unknown risk of rupture.59 Conclusions: Currently, the less invasive strategy of endovascular repair (as compared to open surgery) provides improved 30-day or in-hospital survival in the setting of complicated acute type B aortic dissection and may seek broad application. Open surgical aortic reconstruction should be left to experienced aortic centres if endovascular management is not an option.

Objective Thoracic endovascular aortic repair (TEVAR) has changed the management of aortic dissection by induced remodelling. Beyond reconstructing the true lumen, we describe the concept of False Lumen Intervention to promote Remodelling and Thrombosis (FLIRT) in both type A and B aortic dissection. Methods Between 2011 and 2017, 10 patients with aortic dissection (5 type A; 5 type B) underwent FLIRT using a combination of patent foramen ovale (PFO) or atrial septal defect (ASD) occluders, coils and glue. Patients were followed by computed tomography (CT) angiogram prior to, and 6 months following, discharge to evaluate false lumen (FL) thrombosis and aortic remodelling. Outcomes analyzed comprised successful device delivery, completeness of FL thrombosis and aortic remodelling, procedure related complications and mortality. Results FLIRT induced aortic remodelling in all cases of proximal dissection, with aortic shrinkage from 63.8 ± 7.5 pre-FLIRT, to 50.2 ± 6.6 mm (P = 0.057) and an increase in true lumen area from 5.8 ± 3.6 to 11.4 ± 2.5 cm2 (P = 0.006). In distal dissection (after previous TEVAR with residual FL flow), FLIRT successfully induced FL thrombosis in 4 of 5 cases at first attempt (1 case required additional coiling of the gutter between left subclavian artery and stent-graft for complete thrombosis). While maximal aortic diameter remained unchanged (55.6 ± 9.1 pre-FLIRT and 54.4 ± 13.7 mm at follow-up), true lumen area increased from 7.8 ± 2.3 pre-procedure, to 10.6 ± 1.5 cm2 at follow-up (P = 0.016), consistent with remodelling. Conclusion Interventional FL management, using the FLIRT concept, is feasible in selected cases of aortic dissection, promotes FL thrombosis and induces successful remodelling.

Purpose: To present a novel endovascular management option that avoids open surgery in selected patients with subacute type A aortic dissection (DeBakey II). Case Report: A 75-year-old woman with previous infrarenal abdominal aortic aneurysm repaired in 2006 and multiple comorbidities (EURO score II 20.5%) was admitted with chest pain; computed tomography angiography (CTA) showed a new dissection in the ascending aorta just above the right coronary ostium. As the patient was considered unfit to undergo surgery, an endovascular solution was suggested after multidisciplinary team discussion. With a single entry identified, coils were deployed in the false lumen followed by a patent foramen ovale (PFO) occluder placed across the entry tear to seal the cavity. Intraprocedural digital subtraction angiography and transesophageal echocardiography, as well as CTA 3 days postprocedure, confirmed an entirely thrombosed false lumen. The 6-month follow-up CTA demonstrated the PFO occluder firmly in place, shrinkage of the false lumen, and remodeling of the ascending aorta. Conclusion: Interventional management of the false lumen in proximal (type A) dissection is feasible and sustainable. The use of coils and closure devices may present a new, efficient, minimalistic strategy to avoid open surgery in selected cases.

Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates and a long history of challenges to both diagnose and manage this condition successfully. The International Registry of Acute Aortic Dissection (IRAD) was established in 1996 as a global database to understand this old disease better and improve care for dissection. IRAD initially targeted various areas including etiological factors of dissection, modes of presentation, clinical features, physical findings, imaging, management, and outcomes, and is currently branching out in more specific fields such as endovascular intervention, genetic profiling, and functional imaging. Although presenting symptoms and physical findings have not changed significantly over two decades, the widespread use of computed tomography is standard and has improved the diagnostic pathway. Moreover, more patients are managed with appropriate procedures, such as surgery in type A, and endovascular therapy in subsets of type B aortic dissection. With these ongoing improvements in swift diagnostic work-up and therapeutic care, fewer patients are not getting appropriate treatment and more patients survive once they reach hospital.

The aim of this study was to evaluate the effect of fractional flow reserve (FFR)-guided revascularization compared with culprit-only percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) on infarct size, left ventricular (LV), function, LV remodeling, and the presence of nonculprit infarctions.Patients with STEMI with multivessel disease might have improved clinical outcomes after complete revascularization compared with PCI of the infarct-related artery only, but the impact on infarct size, LV function, and remodeling as well as the risk for periprocedural infarction are unknown.In this substudy of the DANAMI-3 (Third Danish Trial in Acute Myocardial Infarction)-PRIMULTI (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization) randomized trial, patients with STEMI with multivessel disease were randomized to receive either complete FFR-guided revascularization or PCI of the culprit vessel only. The patients underwent cardiac magnetic resonance imaging during index admission and at 3-month follow-up.A total of 280 patients (136 patients with infarct-related and 144 with complete FFR-guided revascularization) were included. There were no differences in final infarct size (median 12% [interquartile range: 5% to 19%] vs. 11% [interquartile range: 4% to 18%]; p = 0.62), myocardial salvage index (median 0.71 [interquartile range: 0.54 to 0.89] vs. 0.66 [interquartile range: 0.55 to 0.87]; p = 0.49), LV ejection fraction (mean 58 ± 9% vs. 59 ± 9%; p = 0.39), and LV end-systolic volume remodeling (mean 7 ± 22 ml vs. 7 ± 19 ml; p = 0.63). New nonculprit infarction occurring after the nonculprit intervention was numerically more frequent among patients treated with complete revascularization (6 [4.5%] vs. 1 [0.8%]; p = 0.12).Complete FFR-guided revascularization in patients with STEMI and multivessel disease did not affect final infarct size, LV function, or remodeling compared with culprit-only PCI.

The role of endovascular procedures in Marfan syndrome (MFS) remains an issue of debate. In principle, endovascular techniques are not intended for the treatment of aortic or vascular conditions in patients with genetic connective tissue disease.

Marfan syndrome is a heritable connective tissue disorder affecting skeletal, ocular and cardiovascular systems. Cardiovascular manifestations comprise aneurysmal dilatation of aortic root, aortic dissection and rupture; peripheral arterial aneurysms have been reported in femoral, iliac and subclavian arteries with surgical reconstruction as the first-line therapeutic option. We report a Marfan patient with a symptomatic aneurysm of left subclavian artery in the intrathoracic retro-clavicular space; instead of open surgical resection, an endovascular solution was successfully applied by use of a flexible self-expanding stent-graft (W.L Gore® Viabahn® Endoprosthesis 9 × 100 mm) to exclude the aneurysm. This case exemplifies a modern option to manage vascular pathology even in patients with Marfan syndrome. Follow-up over 1 year proved very reassuring with complete remodelling and resolution of the aneurysm; long-term follow-up is certainly warranted, considering the potential of recurrence or initial reactive hyperplasia.