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Introduction: The efficacy and safety of switching P2Y 12 receptor antagonists in patients admitted for acute coronary syndrome (ACS) remain unclear. We assessed the short-term clinical outcomes (in-hospital and within 30 days) of switching P2Y 12 inhibitor (P2Y 12 I) drugs versus maintaining the same regimen by performing a comprehensive review and meta-analysis of available data., Methods: MEDLINE/PubMed/SCOPUS/Cochrane databases were screened for studies regarding switching of P2Y 12 I in patients with ACS that reported 30 days follow-up. Major cardiac events (MACE) and bleeding were compared between patients who were switched/not switched., Results: 22,500 patients from 14 studies were included. Unstable angina/non-ST elevation myocardial infarction (62.0%, interquartile range, 52.8%-68.0%) was the most common clinical presentation. The total number switched was 4294 (19.1%); escalation in 3416 (79.5%) patients (from clopidogrel to prasugrel, 62.9%) and de-escalation in 18.5%. Pooled analysis revealed no significant differences in MACE for any comparison; risk of bleeding was significantly increased among switched patients overall (odds ratio [OR], 1.60; 95% confidence interval [CI] 1.22-2.10) and increased in the escalation group (OR, 1.51; 95% CI, 1.06-2.16)., Conclusions: Among patients presenting with ACS, switching from one P2Y 12 I agent to another in the acute phase seems associated with a short-term increased risk of bleeding. Accurate upfront selection and prescription of a P2Y 12 I based on ischemic and bleeding risks is paramount to avoid adverse events switching-related during hospitalization and in the first 30 days.

Background: Chronic kidney disease (CKD) is associated with increased risk of mortality. We examined the impact of moderate and severe CKD at presentation on short- and long-term mortality among unselected patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI)., Methods: The study cohort consists of 501 patients (pts), enrolled from October 2005 to December 2012. The median follow-up was 46.52±25.58 months (range 8-99). A severe CKD (estimated Glomerular Filtration Rate [eGFR] <30 mL/min/1.73 m2) was detected in 16 pts (3.19%), a moderate CKD (eGFR 30-59 mL/min/1.73 m2) in 110 (21.96%) and a normal kidney function (eGFR >60 mL/min/1.73 m2) in 375 (74.85%)., Results: The crude in-hospital mortality rate resulted significantly higher in pts with severe and moderate CKD compared to pts with normal renal function (50% and 19.08% versus 2.93%, P<0.0001), as well as the long-term mortality rate (57.14% and 46.34% versus 8.77%, P<0.0001). After adjustment for confounding variables, severe and moderate CKD resulted the main independent predictors of in-hospital (odds ratio [OR]=21.815, P<0.0001 for severe CKD and OR= 4.203, P=0.002 for moderate CKD) and long-term (hazard ratio [HR]= 5.272, P=0.001; HR= 1.978, P=0.006) mortality., Conclusions: CKD is a frequent condition in patients with STEMI treated with PPCI and it is associated to an excess of mortality, resulting the main independent negative prognostic predictor.

Background: Few clinical data about indications and prognoses of patients undergoing balloon aortic valvuloplasty (BAV) in the transcatheter aortic valve implantation (TAVI) era have been reported., Methods: Data from all consecutive patients undergoing BAV in seven European centers from 2006 to 2013 were collected. Acute results and long-term outcomes were assessed., Results: A total of 811 patients aged 82 ± 9 years were included; 416 patients (51%) underwent BAV as palliative destination therapy, 320 patients (40%) as bridge to TAVI, and 75 patients (9%) as bridge to surgical aortic valve replacement (SAVR). Patients undergoing BAV as destination therapy had a higher risk profile (logistic EuroSCORE, 20 ± 17 vs 22 ± 14 vs 11 ± 8, respectively; P<.001). Post procedure, peak gradient decreased from 87 ± 22 mm Hg to 66 ± 22 mm Hg (P<.001) and aortic valve area increased from 0.61 ± 0.2 cm2 to 0.8 ± 0.2 cm2 (P<.001). At 30 days, the all-cause death rate (6.5% vs 6.2% vs 7.4%, respectively; P=.56) and the rate of life-threatening and major bleedings (8.0% vs 5.7% vs 6.0%, respectively) did not differ between groups. After a mean follow-up of 318 days (range, 116-500 days), rates of all-cause death were similar (30% vs 34% vs 31%, respectively; P>.99), although patients undergoing BAV as bridge to SAVR showed a lower cardiovascular death rate (11% vs 11% vs 3%, respectively; P=.04)., Conclusion: In the TAVI era, BAV may represent a reasonable option for patients with severe aortic stenosis and temporary contraindications to definite therapy. Given the mortality rates at 30 days, patients should be carefully selected, while events at follow-up are deeply influenced by the decision of whether or not subsequent interventions are performed.

Transvenous lead extraction (TLE) of the Starfix coronary sinus (CS) active-fixation lead may be challenging, due to undeployment of fixation lobes and venous occlusion. We report our experience in Starfix TLE, in comparison with previous data. A 78-year-old male, implanted in 2009 with Starfix lead, was referred to our institution for TLE, due to infective endocarditis with lead-associated vegetations. The tip of Starfix lead was located in distant, anterior position, in the great cardiac vein, close to patent left internal mammary artery-to-left anterior descending artery anastomosis, and first-choice surgical removal had a prohibitive operative risk. Conventional dilatation beyond CS ostium, as well as the use of a standard delivery catheter, was ineffective. An off-label modification of the delivery, by cutting the distal soft tip, was successful. However, the tip of the lead fragmented and was trapped in the innominate vein. Then a gooseneck snare grasped the fragment, allowing complete retrieval. TLE of Starfix leads may be particularly challenging, especially when its tip is located in a distant anterior location. In these cases, important help may be obtained by dilatation within the CS, by means of conventional or modified delivery catheters. Only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads. < Learning objective: TLE of Starfix leads may be challenging, particularly when the tip is located in a distant anterior position. Dilatation with conventional tools may be precluded. In these cases modifications of the delivery catheters may be useful. Surgery should be avoided as first-choice procedure; only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads.>.