Search

AIMS: To investigate gender difference in mortality among patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous angioplasty (PPCI). METHODS: We analyzed data from the prospective registries of two hub PPCI centres over a 10-year period to assess the role of female gender as an independent predictor of both all-cause and cardiac death at 30 days and 1 year. To account for all confounding variables, a propensity score (PS)-adjusted multivariable Cox regression model and a PS-matched comparison between the male and female were used. RESULTS: Among 4370 consecutive STEMI patients treated with PPCI at participating centres, 1188 (27.2%) were women. The survival rate at 30 days and 1 year were significantly lower in women (Log-rank P-value

Background Several environmental and seasonal factors are thought to be crucial in the risk of acute coronary syndromes (ACS), including temperature, latitude, longitude, atmospheric air pressure, wind velocity and circadian period. However differences in coronary plaque composition according to season variation is still poorly understood. Purpose Our study aims to analyse the characteristics of non-culprit coronary plaques in patients undergoing optical coherence tomography evaluation (OCT) evaluation of the left anterior descending artery. Methods We included 1848 non-culprit coronary plaques from 1003 patients of the CLIMA registry. The season of OCT pullback acquisition was collected for each patient. Results Overall, median age was 66 years (56-74), with 24.6% of women and 53.4% of ACS. At patient-level analysis, patients admitted in summer were less frequently affected by hypertension (59.8% vs 69.4% in autumn, 68.5% in winter and 72% in spring; p=0.027) and chronic kidney disease (14.8% vs 15.9% in autumn, 10.3% in winter and 19.4% in spring; p=0.037) in. At lesion-level analysis, similar values of fibrous cap thickness, maximum lipid arc, length of plaques and presence of macrophages were observed (Table 1). Summer plaques had a smaller minimum lumen area than spring plaques (5.7±3.1 vs 5.1±239; p=0.044) and also a less frequent superficial macrophage infiltration (23% vs 36.1% in autumn, 30.5% in winter and 30.6% in spring; p=0.030) and presence of cholesterol crystals (16.7% vs 23.8% in autumn, 28.4% in winter and 22.1% in spring; p=0.037 than three other season). Table 1 Conclusions Coronary plaques during summer had less local sign of inflammation such superficial macrophage infiltration and cholesterol crystals. Further studies are needed to confirm these results and investigate clinical implications.

Background Percutaneous coronary intervention (PCI) appears a reasonable alternative to coronary artery bypass graft in selected groups of patients with unprotected left main coronary artery (ULMCA) disease. Despite technological progression, improved operator skills and introduction of drug-eluting stents (DES), in-stent restenosis still remains a major limitation after PCI of ULMCA disease. The prognostic relevance of target lesion revascularization (TLR) after PCI of ULMCA disease is unknown. Objectives This study sought to evaluate the impact of elective, uncomplicated target lesion revascularization on long-term cardiac mortality after PCI of ULMCA disease. Methods Consecutive patients undergoing PCI for ULMCA disease between January 2003 and December 2015 in one interventional center in Italy were included. Patients presenting with cardiogenic shock, ST-segment elevation myocardial infarction (MI), as well as those undergoing urgent or complicated TLR were excluded. The primary endpoint of the study was cardiac mortality. The secondary endpoints of the study were all-cause death, MI, stroke as individual endpoints, or the composite of cardiac death, MI or stroke defined as major adverse cardiac events (MACE). Results Among the 418 patients fulfilling the study criteria, 79 (18.46%) underwent elective, uncomplicated TLR. After a median follow-up of 5.5 years, there were 23 cardiac deaths among patients undergoing elective, uncomplicated TLR versus 50 in patients not undergoing TLR. After adjusting for possible confounders, TLR was an independent predictor of cardiac mortality (Hazard ratio [HR] = 1.92, 95% confidence interval [CI]: 1.05 to 3.49; p = 0.03). Patients undergoing TLR had also significantly higher rates of the composite of cardiac death, MI and stroke compared with the no TLR group (adjusted HR = 1.76, 95% CI 1.14 to 2.72). Conclusion Elective, uncomplicated TLR after PCI of ULMCA disease is associated with increased risk of long-term cardiac mortality. Reducing the risk of TLR after PCI of ULMCA disease may potentially improve the survival of these patients.

A 57-year-old man with severe aortic valve stenosis at high surgical risk underwent transcatheter valve replacement with a 29-mm Edwards Sapien-3 valve (Edwards Lifesciences). The valve was successfully implanted using the right femoral access, but at the end of the deployment the balloon ruptured (Videos 1 and 2) and could not be retrieved from the e-Sheath. The Commander delivery system was then readvanced in the aorta over the wire (Video 3), which was snared and externalized using a 25-mm AndraSnare (Andramed GmbH) inserted through the left femoral artery using a 25-cm-long 22-F Cook sheath (Cook Medical) (Figure 1). Then, the Commander was pushed over the wire, across the aortic bifurcation, making the ruptured balloon get into the Cook sheath (Figure 2). The Commander was then truncated (Figure 3), and the ruptured balloon proximal part attached to the pusher/balloon catheter unit was retrieved through the eSheath (Figure 4). Then, the ruptured balloon distal part attached to the inner balloon shaft was pushed forward such that it could be externalized through the left femoral sheath, cut (Figure 5), and finally pulled back with the wire through the eSheath (Figure 6).

Objectives The aim of this study was to investigate the efficacy and safety of currently used drug-eluting stents (DES). Background Head-to-head comparisons among newer DES have shown conflicting results. Methods For this network meta-analysis, randomized controlled trials comparing different types of currently used DES were searched in PubMed, Scopus, and proceedings of international meetings. The primary endpoint was target lesion failure (TLF) at 1 year and at long-term follow-up. Results Seventy-seven trials with 99,039 patients were selected for this network meta-analysis. Among the 10 DES included in the meta-analysis, 4 received the most extensive investigation: Orsiro, XIENCE, Nobori/BioMatrix, and Resolute. At 1 year, the Orsiro stent was associated with lower rates of TLF compared with XIENCE (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.71 to 0.98; p = 0.03), Resolute (OR: 0.81; 95% CI: 0.68 to 0.95; p = 0.01), and Nobori/BioMatrix (OR: 0.81; 95% CI: 0.67 to 0.98; p = 0.03). Orsiro had the highest probability to be the best (70.8%), with a surface under the cumulative ranking curve value of 95.9%. However, after a median follow-up period of 50 months (range: 24 to 60 months), no significant difference was apparent in the rates of TLF between any DES, although Orsiro still ranked as the best stent (58.6% probability to be the best). In addition, Orsiro had a lower rate of long-term definite stent thrombosis compared with Nobori/BioMatrix (OR: 0.60; 95% CI: 0.36 to 0.98; p = 0.04) and lower rates of definite and probable stent thrombosis compared with Resolute (OR: 0.66; 95% CI: 0.45 to 0.99; p = 0.04). No differences in cardiac mortality between any DES were observed. Conclusions Orsiro is associated with a lower 1-year rate of TLF compared with XIENCE, Resolute, and Nobori/BioMatrix but with an attenuation of the efficacy signal at long-term follow-up.

Background Incidence and long-term clinical consequences of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) are still unclear. Methods We enrolled 710 consecutive patients who underwent TAVR. PPM was defined as absent if the index orifice area (iEOA) was >0.85 cm2/m2, moderate if the iEOA was between 0.65 and 0.85 cm2/m2 or severe if the iEOA was Results Among the 566 patients fulfilling the study criteria, the distribution of PPM was as follows: 50.5% none (n = 286), 43% moderate PPM (n = 243) and 6.5% severe PPM (n = 37). At 5-year follow-up, patients with severe PPM had a significantly higher incidence of the combined endpoint of cardiovascular death, acute myocardial infarction and stroke (p = .025) compared with the other patients. After adjusting the results for possible confounders, severe PPM remained an independent predictor of long-term adverse outcome (HR: 2.46; 95% Confidence Interval: 1.10–5.53). The independent predictors of severe PPM were valve-in-valve procedure and body mass index. Balloon-expandable valves were not associated with higher rates of severe PPM in comparison with self-expandable valves (8% vs. 5%, respectively, p = .245). Conclusions In our study severe PPM emerged as a risk factor for long-term major adverse cardiac and cerebrovascular events.

Percutaneous coronary intervention (PCI) in coronary artery ectasia is technically challenging, particularly regarding appropriate stent sizing, and it is associated with a higher incidence of adverse events. In this case report, a 63-year-old male patient, heart transplant recipient, underwent elective follow-up coronary angiography in the absence of clinical symptoms. Five years previously the patient was treated with coronary angioplasty and drug-eluting stent implantation for critical lesions of the left anterior descending coronary artery. Angiographic images showed a focal in-stent haziness at the level of an ectatic segment. To elucidate this finding, optical coherence tomography (OCT) was performed. Intracoronary imaging showed severe malapposition of the proximal end of the stent, with an intraluminal signal-rich structure, suggestive of organized stent thrombosis. Stent dilation was performed to maximal recommended diameter, with significant reduction of the malapposed area, as shown by repeated OCT pullbacks. Intracoronary imaging is particularly valuable in PCI of ectatic vessels to guide appropriate stent sizing and avoid stent malapposition. OCT, thanks to its superior spatial resolution in comparison with other intravascular imaging techniques, provides advantages for stent optimization and evaluation of stent failure causes. However, its limited imaging area and possible incomplete blood clearance may limit its usefulness in severely ectatic vessels.

BACKGROUND: Aortic aneurysms are associated with coronary artery ectasia (CAE). However, the relation between the extent of CAE and the severity of aortic dilatation is not understood. This study was undertaken to investigate the relationship between angiographic extension of CAE and aortic dimension. PATIENTS AND METHODS: We retrospectively include 135 patients with angiographic diagnosis of CAE defined as dilatation of coronary segment more than 1.5 times than an adjacent healthy one. Study population was divided in four groups according to the maximum diameter of ascending aorta beyond sinus of Valsalva obtained in the parasternal long-axis view (group 1: 55 mm or previous surgery because of aortic aneurysm/dissection). The relationship between aortic dimension and the extension of CAE was investigated by means of multivariable linear regression, including variables selected at univariable analysis (P < 0.1). The total estimated ectatic area (EEA total) was used as dependent variable. RESULTS: Baseline characteristics of study groups were well balanced. Patients in group 4 were more likely to have both higher neutrophil count and neutrophil to lymphocyte ratio. On univariable analysis ascending aorta diameter [Coef. = 0.075; 95% confidence interval (CI) 0.052-0.103, P < 0.01] and c-reactive protein (CRP) values [Coef. = 0.033, 95% CI 0.003-0.174, P = 0.04] showed a linear association with total EEA. After adjustment for CRP values only the ascending aorta diameter was still associated with the extent of CAE (95% CI 0.025-0.063, P < 0.01). CONCLUSION: In patients with diagnosis of CAE, a strong linear association between aortic dimension and coronary ectasia extent exists.

This study sought to investigate the impact of elective, uncomplicated target lesion revascularization (TLR) on long-term cardiac mortality after percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) disease. Consecutive patients undergoing PCI for ULMCA disease between January 2003 and December 2015 in 1 interventional center in Northern Italy were included. Patients presenting with cardiogenic shock, ST-segment elevation myocardial infarction (MI), as well as those undergoing urgent or complicated TLR were excluded. The primary endpoint of the study was cardiac mortality. Among the 418 patients fulfilling the study criteria, 79 (18.46%) underwent elective, uncomplicated TLR. After a median follow-up of 5.5 years, there were 23 cardiac deaths among patients undergoing elective, uncomplicated TLR versus 50 in patients not undergoing TLR. After adjusting for possible confounders, TLR was an independent predictor of cardiac mortality (Hazard ratio [HZ] = 1.92, 95% confidence interval [CI]: 1.05 to 3.49; p = 0.03). Patients undergoing TLR had also significantly higher rates of the composite of cardiac death, MI and stroke compared with the no TLR group (adjusted HR = 1.76, 95% CI 1.14 to 2.72). In conclusion, elective, uncomplicated TLR after PCI of ULMCA disease is associated with increased risk of long-term cardiac mortality. Reducing the risk of TLR after PCI of ULMCA disease may potentially improve the survival of these patients.

Background To assess whether coronary bypass (CABG) or stenting reduce the risk of mortality and myocardial infarction (MI) compared with optimal medical therapy (OMT) in stable coronary artery disease (CAD). Methods We performed a systematic review and network meta-analysis of contemporary randomized controlled trials comparing OMT, CABG and different stent types in stable CAD. All-comer trials were included if the rate of patients with acute myocardial infarction (AMI) was≤20%. Endpoints were all-cause mortality and MI. Results Ninety-seven trials including 75,754 patients were analyzed at a weighted mean follow up of 42.5 months. Compared to OMT, CABG was associated with a lower risk of death (OR = 0.84; 95%CI:0.71–0.97). After exclusion of trials in left main and/or multivessel disease(LM/MVD) this benefit was not statistically significant (OR = 0.89; 95%CI:0.74–1.06). CABG was associated with a lower risk of MI (OR = 0.67;95%CI: 0.49–0.91) showing, however, a certain degree of inconsistency (p=0.10). None of the stent types included was associated with a lower risk of death. However, durable-polymer-CoCr-everolimus-eluting stent, by mixed evidence, after exclusion of either LM/MVD (OR = 0.73;95%CI: 0.54–0.98) or all-comer/post-MI trials (OR = 0.62;95%CI:0.39–0.98) was associated with a lower risk of MI than OMT. Similar findings, by indirect evidence, were confirmed for bio-absorbable-polymer-CoCr-sirolimus eluting stent (LMV/MVD trials excluded OR = 0.46; 95%CI = 0.29–0.74, all-comer/post-MI trials excluded: OR = 0.41;95%CI:0.22–0.79). Conclusions In stable CAD, CABG reduces the risk of mortality and MI compared to OMT, especially in patients with higher extent of CAD. Our study suggests that some of second and latest-generation drug-eluting stents may reduce the risk of MI. Future research should confirm these latter findings.

Objectives The aim of this study was to investigate the safety and efficacy of coronary protection by preventive coronary wiring and stenting across the coronary ostia in patients at high risk for coronary obstruction after transcatheter aortic valve replacement (TAVR). Background Coronary obstruction following TAVR is a life-threatening complication with high procedural and short-term mortality. Methods Data were collected retrospectively from a multicenter international registry between April 2011 and February 2019. Results Among 236 patients undergoing coronary protection with preventive coronary wiring, 143 had eventually stents implanted across the coronary ostia after valve deployment. At 3-year follow-up, rates of cardiac death were 7.8% in patients receiving stents and 15.7% in those not receiving stents (adjusted hazard ratio: 0.42; 95% confidence interval: 0.14 to 1.28; p = 0.13). There were 2 definite stent thromboses (0.9%) in patients receiving stents, both occurring after TAVR in “valve-in-valve” procedures. In patients not receiving stents, there were 4 delayed coronary occlusions (DCOs) (4.3%), occurring from 5 min to 6 h after wire removal. Three cases occurred in valve-in-valve procedures and 1 in a native aortic valve procedure. Distance between the virtual transcatheter valve and the protected coronary ostia Conclusions In patients undergoing TAVR at high risk for coronary obstruction, preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis. Patients undergoing coronary protection with wire only have a considerable risk for DCO.

BACKGROUND The ability of optical coherence tomography (OCT) to recognize intraplaque macrophage infiltration is now well acknowledged. This post-hoc analysis of the CLIMA study aimed to address the clinical impact of the circumferential extension of OCT-defined macrophages and their location at one year follow-up. METHODS The multicentre CLIMA study enrolled 1003 patients undergoing OCT evaluation of the untreated proximal left anterior descending (LAD) coronary artery. Measurements of circumferential extension of macrophages and measurements of the distance from intima-lumen contour to macrophages string were performed at the plaque cross-section judged as containing the greatest amount of macrophages. The main study endpoint was a composite of cardiac death, myocardial infarction (MI) and/or target vessel revascularization (TVR). RESULTS Patients with large macrophage arc (p = 0.001) and superficial macrophage arc (p

ObjectivesTo evaluate the role of the ECG in the differential diagnosis between Anderson-Fabry disease (AFD) and hypertrophic cardiomyopathy (HCM).MethodsIn this multicentre retrospective study, 111 AFD patients with left ventricular hypertrophy were compared with 111 patients with HCM, matched for sex, age and maximal wall thickness by propensity score. Independent ECG predictors of AFD were identified by multivariate analysis, and a multiparametric ECG score-based algorithm for differential diagnosis was developed.ResultsShort PR interval, prolonged QRS duration, right bundle branch block (RBBB), R in augmented vector left (aVL) ≥1.1 mV and inferior ST depression independently predicted AFD diagnosis. A point-by-point ECG score was then derived with the following diagnostic performances: c-statistic 0.80 (95% CI 0.74 to 0.86) for discrimination, the Hosmel-Lemeshow χ2 6.14 (p=0.189) for calibration, sensitivity 69%, specificity 84%, positive predictive value 82% and negative predictive value 72%. After bootstrap resampling, the mean optimism was 0.025, and the internal validated c-statistic for the score was 0.78.ConclusionsStandard ECG can help to differentiate AFD from HCM while investigating unexplained left ventricular hypertrophy. Short PR interval, prolonged QRS duration, RBBB, R in aVL ≥1.1 mV and inferior ST depression independently predicted AFD. Their systematic evaluation and the integration in a multiparametric ECG score can support AFD diagnosis.

Aims Balloon pulmonary angioplasty (BPA) has recently been developed as a treatment strategy for chronic thromboembolic pulmonary hypertension (CTEPH) but efficacy and technical safety have to be established. We examine the effects of BPA on patients with inoperable disease or residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). Methods and results From 2015 to 2020 we enrolled symptomatic inoperable CTEPH patients and patients with residual PH after PEA. At baseline and 3 months after last BPA session patients underwent clinical evaluation, 6-min walking distance (6MWD), and right heart catheterization. Friedman test with Bonferroni post-hoc pairwise analysis was used. Fifty patients [male 42%, median age 68 (51–74) years, 42 inoperable, and 8 with residual PH after PEA] were treated for a total of 156 sessions (median 2 sessions/patient); during each session we treated 2.3 (2.2–2.7) vessels. Results are shown in the Table. Forty-nine patients were treated with medical therapy before BPA (19 with combination therapy). Five pulmonary artery dissection and two haemoptysis with clinical impairment were documented during the procedures; 37 patients had lung injury (radiographic opacity with/without haemoptysis and/or hypoxaemia), none had renal dysfunction, 7 patients had access site complications. Seven patients died during follow-up (none within 30 days from the procedure) because of sepsis (1), heart failure (1), cancer (2), arrhythmic storm (2), and sudden death in patients with severe coronary atherosclerosis (1). Conclusions BPA is a safe and effective treatment able to improve symptoms and haemodynamic profile. 45 Table 16MWD, six minute walking distanceCI, cardiac index; mPAP, mean pulmonary arterial pressure; PAC, pulmonary arterial compliance; PVR, pulmonary vascular resistance; RAP, right atrial pressure; SvO2, mixed venous oxygen saturation; WHO-FC, World Health Organization functional class.

Aims Coronary artery ectasia (CAE) is not a rare finding in coronary angiography with a prevalence ranging from 1% to 20% according to clinical setting. The aim of this study was to analyse the angiographic differences of coronary ectasia based on admitting diagnosis. Methods and results A cohort study was conducted including patients with angiographic evidence of CAE between January 2016 and December 2020. The study population was divided into two groups according to the clinical presentation: stable coronary artery disease (SCAD) and acute coronary syndrome (ACS). Markis classification, basal thrombolysis in myocardial infarction (TIMI) flow of each coronary artery, associated coronary artery obstruction (CAO), and respective Gensini score were reported. A total of 144 patients were included in this study. No difference were found concerning age or the traditional cardiovascular risk factors. Compared to general population, higher rates of myocardial infarction with non-obstructive coronary arteries (MINOCA) and ischaemia with non-obstructive coronary arteries (INOCA) (31% of the entire ACS cohort and 42% the SCAD group, respectively) were observed. Furthermore, irrespective of lower Gensini score values, MINOCA patients showed significantly more widespread CAE and a more severe impairment of coronary flow compared to SCAD and obstructive ACS patients. Conclusions CAE patients show a surprisingly high rate of acute coronary syndromes with non-obstructive coronary arteries. The extent of the ectatic involvement and its consequences on coronary blood flow could be the base of the higher rate of ACS events observed in this population, recognizing mechanisms other than plaque rupture.

Background Uncertainty exists over the optimal treatment strategy for patients presenting with acutely decompensated severe aortic stenosis (AS). The available options include a bridging balloon aortic valvuloplasty (BAV) or a direct transcatheter aortic valve implantation (TAVI). Purpose Our study compares TAVI outcomes in patients treated with two different strategies in acutely decompensated severe AS: bridged TAVI vs direct TAVI. Methods In this observational study all patients admitted with decompensated severe AS who underwent balloon aortic balloon valvuloplasty (BAV) and/or TAVI on the index admission were included. Comparison was made between bridged TAVI group (defined as initial BAV followed by TAVI) and direct TAVI group (TAVI on the index admission without bridging BAV). For this analysis we excluded patients in cardiogenic shock. Baseline characteristics, echocardiographic and periprocedural data were recorded in hospital database. Major adverse cardiovascular events (MACE) were defined as death, major bleeding, rehospitalisation for heart failure, or stroke). The follow-up data was obtained by outpatient visits and/or telephone calls. Results 178 patients with acutely decompensated AS were analysed: 58 bridged TAVI, 23 direct TAVI, 9 bridged SAVR and 88 destination BAV (defined as BAV non followed by a definite treatment). There was no statistically significant difference between bridged TAVI and direct TAVI group in mean age (83.6±6.6 vs 80.4±8.3 years), the prevalence major comorbidities (coronary, respiratory, neurological or peripheral vascular disease), renal function (eGFR 43.4±18.9 vs 45.2±20.9 ml/min/m2), the mean LV ejection fraction (53.4±13.8 vs 48.6±14.6%) or aortic valve gradient (39.4±13.0 vs 34.1±12.3mmHg), respectively. Direct TAVI patients had a higher mean surgical risk scores (STS 6.1±3.7 vs 9.1±7.0%, logES 18.8±11.5 vs 30.8±20.9%, p=0.01) and higher prevalence of significant aortic regurgitation (5% vs 43%, p=0.0001). The femoral TAVI access was used in 98% of bridged and 78% of direct TAVI patients (p=0.006). The estimated 1-year survival and 1-year MACE-free survival did not differ significantly between the bridged TAVI and direct TAVI groups (86.8% vs 78.3%, p=0.20 and 79.7% vs 64.2%, p=0.11, respectively). Conclusions A large proportion of patients admitted with acutely decompensated AS were not eligible for definite treatment. There is no difference in procedural success, 1-year all-cause mortality and 1-year major adverse cardiovascular events between the bridged TAVI or direct TAVI strategies in acute decompensated aortic stenosis allowing to personalize treatment strategy for individual patient. Funding Acknowledgement Type of funding sources: None. Table 1. Clinical and procedural data

Chronic thromboembolic pulmonary hypertension (CTEPH) is a complex disease where organized pulmonary thrombi and progressive vascular remodeling of the pulmonary arterial tree act synergistically to increase pulmonary vascular resistance and cause pulmonary hypertension. Balloon pulmonary angioplasty (BPA) has gained a renewed interest for the treatment of patients with CTEPH who are not undergoing surgery with pulmonary endarterectomy (PEA) or with persistent/recurrent pulmonary hypertension after PEA and has shown promising results in several observational studies conducted to date. We describe the case of a 42-year-old man with inoperable CTEPH in NYHA functional class III who normalized functional capacity, hemodynamic profile and main hemodynamic parameters after three BPA sessions.

Balloon pulmonary angioplasty (BPA) represents a therapeutic option for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) in patients who are not eligible for surgical pulmonary endarterectomy (PEA) or with persistent/recurrent symptomatic pulmonary arterial hypertension after PEA. This study evaluated the safety of BPA during 5 years of experience of the only Italian center systematically performing this procedure.The BPA program was activated at the S. Orsola Polyclinic in Bologna in June 2015. Life-threatening periprocedural complications were defined as: death30 days, need for cardiopulmonary support, hemoptysis with the need for endotracheal intubation. Serious complications were vascular complications requiring surgical or percutaneous intervention. Other endpoints of interest were: hemoptysis, pulmonary vascular damage with or without hemoptysis, and pulmonary reperfusion injury with high-resolution computed tomography lung scan at 24 h.From June 2015 to September 2020, 50 patients (45% male, median age 68 years), 42 inoperable and 8 with persistent/recurrent pulmonary hypertension after PEA, underwent 156 BPA procedures at our institution. There was one life-threatening complication (2% of patients, 0.06% of the procedures), i.e. severe hemoptysis requiring endotracheal intubation, and four serious complications (8% of the patients, 2.6% of the procedures), i.e. one pulmonary artery perforation requiring percutaneous treatment and three access-site vascular complications requiring surgery. There were no deaths30 days. Pulmonary reperfusion injury occurred in 37 patients (74%) for a total of 96 sessions (62%). However, reperfusion injury was limited and with subclinical course in most cases.This study confirmed the relative safety of BPA in patients with CTEPH who are not candidates for heart surgery or with persistent pulmonary hypertension after PEA in the first large Italian experience.

BACKGROUND: Coronary artery ectasia (CAE) is associated with ascending aortic (AA) ectasia. The purpose of this study is to evaluate the diagnostic performance of different echocardiographic parameters (EP) in predicting the presence of CAE. METHODS: Four hundred-eighteen patients with AA ectasia candidate to coronary angiography were identified and divided in two groups in respect of the presence of CAE. Receiver-operating characteristic curves areas (AUC) were used to assess the discrimination power of the following EP: aortic annulus diameter, sinuses of Valsalva (SV) diameter, sino-tubular junction (STJ) diameter, AA diameter, STJ to SV ratio (STJ-to-SV) and STJ to AA ratio (STJ-to-AA). All these parameters were indexed by body surface area. The relationship between the best EP and the presence of CAE was investigated by means of multivariable logistic regression. RESULTS: The rate of CAE in the study population was 32%. On univariable logistic regression, aortic annulus, STJ, STJ-to-SV and STJ-to-AA were associated with the presence of CAE after Bonferroni correction. STJ-to-SV emerged as the parameter with the best discrimination power (AUC=0.81) compared to STJ (AUC=0.69), STJ-to-AA (AUC=0.68), aortic annulus (AUC=0.59), AA (AUC=0.56) and SV (AUC=0.55); (p for comparison

Although optical coherence tomography (OCT) proved to be able to identify macrophage clusters, there are no available data on the possibility to obtain reproducible measurements of their circumferential extension and location. The purpose of the present post-hoc analysis of the CLIMA study was to revise the clinical and demographic variables of patients having coronary plaques with macrophages and to investigate the reproducibility of their quantitative assessment. A total of 577 patients out of 1003 undergoing OCT showed macrophage accumulation. Three groups were identified; group 1 (426 patients) without macrophages, group 2 (296) patients with low macrophage content (less than median value [67°] of circumferential arc) and group 3 (281) with high macrophage content arc [> 67°]. Patients with macrophages (groups 2 and 3) showed a higher prevalence of family history for coronary artery disease and hypercholesterolemia and had a significantly larger body mass index. Furthermore, group 3 had more commonly triple vessel disease and higher value of LDL cholesterol levels compared to the two other groups. The inter-observer agreement for macrophage interpretation was good: R values were 0.97 for the circumferential arc extension, 0.95 for the minimum distance and 0.98 for the mean distance. A non-significant correlation between circumferential extension of macrophages and hsCRP values was found (R = 0.013). Quantitative assessment of macrophage accumulations can be obtained with high reproducibility by OCT. The presence and amount of macrophages are poorly correlated with hsCRP and identify patients with more advanced atherosclerosis and higher LDL cholesterol levels.

n.d

Purpose Near infrared spectroscopy-Intravascular ultrasound (NIRS-IVUS) provide a fully automated Lipid Core Burden Index (LCBI). Optical coherence tomography (OCT) is potentially capable of measuring lipid longitudinal extension in a dedicated two-dimensional LCBI spread-out plot. The present study has been designed to validate an automated approach to assess OCT images, able of providing a dedicated LCBI spread-out plot. Methods We compared results obtained with conventional (manual) OCT, with those obtained with a novel automated OCT algorithm and with NIRS-IVUS in consecutive 40 patients. Our goal was to calculate the lipid core longitudinal extension in a dedicated two-dimensional LCBI spread-out plot. Three groups were identified according to the studied lesions: (1) culprit lesions in ACS patients (n = 16), (2) non-culprit lesions in ACS patients (n = 12) and (3) lesions in stable patients (n = 12). OCT (either manual and automated) and NIRS-IVUS assessment showed for culprit ACS plaques a more complex anatomy. Results A strong trend for increased LCBI was found in the culprit ACS group, regardless of the adopted imaging modality (either NIRS-IVUS or automated OCT). A fair correlation was obtained for the maximum 4 mm LCBI measured by NIRS-IVUS and automated OCT (r = 0.75). The sensitivity and specificity of automated OCT to detect significant LCBI (> 400) were 90.5 and 84.2 respectively. Conclusion We developed an OCT automated approach that can provide a dedicated lipid plaque spread-out plot to address plaque vulnerability. The automated OCT software can promote and improve OCT clinical applications for the identification of patients at risk of hard events.

BACKGROUND: Although a 1-year duration of dual antiplatelet therapy (DAPT) is used in many patients after drug-eluting stent (DES) implantation, the evidence supporting this duration is uncertain. OBJECTIVES: The authors investigated the risk-benefit profile of 1-year vs≤6-month DAPT after DES using 2 novel scores to risk stratify bleeding and ischemic events. METHODS: Ischemic and bleeding risk scores were generated from ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents), a multicenter, international, "all-comers" registry that enrolled 8,665 patients treated with DES. The risk-benefit profile of 1-year vs≤6-month DAPT was then investigated across risk strata from an individual patient data pooled dataset of 7 randomized trials that enrolled 15,083 patients treated with DES. RESULTS: In the derivation cohort, the ischemic score and the bleeding score had c-indexes of 0.76 and 0.66, respectively, and both were well calibrated. In the pooled dataset, no significant difference was apparent in any ischemic endpoint between 1-year and≤6-month DAPT, regardless of the risk strata. In the overall dataset, there was no significant difference in the risk of clinically relevant bleeding between 1-year and≤6-month DAPT; however, among 2,508 patients at increased risk of bleeding, 1-year compared with≤6-month DAPT was associated with greater bleeding (HR: 2.80; 95%CI: 1.12-7.13) without a reduced risk of ischemic events in any risk strata, including those with acute coronary syndromes. These results were consistent in a network meta-analysis. CONCLUSIONS: In the present large-scale study, compared with≤6-month DAPT, a 1-year duration of DAPT was not associated with reduced adverse ischemic events in any risk strata (including acute coronary syndromes) but was associated with greater bleeding in patients at increased risk of bleeding.

Funder: Alma Mater Studiorum - Università di Bologna, STUDY DESIGN: To compare arterial inflammation (AI) between people living with HIV (PLWH) and uninfected people as assessed by 18F-Fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET). METHODS: We prospectively enrolled 20 PLWH and 20 uninfected people with no known cardiovascular disease and at least 3 traditional cardiovascular risk factors. All patients underwent 18F-FDG-PET/computed tomography (CT) of the thorax and neck. Biomarkers linked to inflammation and atherosclerosis were also determined. The primary outcome was AI in ascending aorta (AA) measured as mean maximum target-to-background ratio (TBRmax). The independent relationships between HIV status and both TBRmax and biomarkers were evaluated by multivariable linear regression adjusted for body mass index, creatinine, statin therapy, and atherosclerotic cardiovascular 10-year estimated risk (ASCVD). RESULTS: Unadjusted mean TBRmax in AA was slightly higher but not statistically different (P = .18) in PLWH (2.07; IQR 1.97, 2.32]) than uninfected people (2.01; IQR 1.85, 2.16]). On multivariable analysis, PLWH had an independent risk of increased mean log-TBRmax in AA (coef = 0.12; 95%CI 0.01,0.22; P = .032). HIV infection was independently associated with higher values of interleukin-10 (coef = 0.83; 95%CI 0.34, 1.32; P = .001), interferon-γ (coef. = 0.90; 95%CI 0.32, 1.47; P = .003), and vascular cell adhesion molecule-1 (VCAM-1) (coef. = 0.75; 95%CI: 0.42, 1.08, P < .001). CONCLUSIONS: In patients with high cardiovascular risk, HIV status was an independent predictor of increased TBRmax in AA. PLWH also had an increased independent risk of IFN-γ, IL-10, and VCAM-1 levels.

Background In the acute coronary syndromes (ACS) setting, despite the extensive use of coronary revascularization and P2Y12 inhibitors such as prasugrel and ticagrelor, with a more pronounced inhibitory effect on platelets than clopidogrel, the rate of death and recurrent myocardial infarction (MI) at 1 year is still high. In this clinical setting the development of a risk score which takes into account patient's and procedural characteristics could represent a useful tool to identify patients at high risk for ischaemic events at 1 year who could take advantage from more aggressive secondary prevention strategies. Purpose The aim of our study was to develop a risk score to predict 1-year probability of after discharge cardiac events (recurrent MI and cardiac death) in patients with acute MI treated with percutaneous coronary intervention (PCI). Methods We prospectively enrolled all consecutive patients hospitalized for acute MI between 2003 and 2017 treated with PCI with/without stent placement at our center. We excluded patients who died in-hospital or who experienced in-hospital recurrent MI and patients undergoing surgical revascularization by coronary artery bypass graft (CABG). The patients of the final study cohort were therefore randomly assigned to either a derivation sample (60%) or a validation sample (40%). Based on the multivariate analysis we developed a point system according to the “Framingham Risk Score” method. Results The final study cohort, represented by 4922 patients, was split in a derivation sample of 2972 patients and in a validation sample of 1950 patients: in both groups the median age was around 70 years; the male prevalence was 73%; 65% of patients were dagnosed with ST-segment elevation MI. The clinical prediction score underlined as risk factors for recurrent cardiac events older age, diabetes mellitus, peripheral arterial disease, prior MI, Killip class >2 at presentation, higher platelet count and creatinine values, lower left ventricular ejection fraction; radial access and the use of second generation drug eluting stents resulted to be protective. This model showed a good discrimination power in both the derivation and the validation samples with an area under the curve (AUC) of 0.75 and 0.71, respectively. The calibration showed a good concordance between predicted and observed events in both the derivation and the validation samples. Same results were observed in patients with/without ST-segment elevation MI and in gender subgroups. Conclusions The present study, conducted retrospectively on a large population of patients with acute MI treated with PCI enrolled prospectively, enabled us to derivate and validate a risk score of cardiac death and recurrent MI at 1 year which took into account both clinical and procedural characteristics and which demonstrated a good predictive performance. After-discharge events by risk subgroups Funding Acknowledgement Type of funding source: None

Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinically entity and represents 5% to 10% of all patients with myocardial infarction (MI). Besides type 2 diabetes mellitus (DM), which is a common comorbidity in patients hospitalized for an acute coronary syndrome, high glucose levels (HGL) at admission are frequently observed in this context. The risk of major adverse cardiovascular events following acute coronary syndrome is increased in people with DM and HGL. However, evidence regarding diabetes and high glucose level among MINOCA patients is lacking. Purpose To examine the incidence of major adverse cardiovascular events (MACEs) in diabetic and non-diabetic MINOCA patients as well as according to HGL at presentation. Methods Among 1995 patients with acute MI admitted to our coronary care unit from 2016 to 2018, we enrolled 186 consecutive MINOCA patients according to the current ESC diagnostic criteria. HGL at admission was defined as serum glucose level above 180 mg/dl. All-cause mortality and a composite end-point of all-cause mortality and myocardial re-infarction were compared. The median follow-up time was 19.6±12.9 months. Results Diabetic MINOCA patients were older (mean age 75.5±9.6 vs 66.5±14.7; p=0.002) and with higher prevalence of hypertension (p=0.016). Conversely, there were no significant differences in gender, BMI, dyslipidemia and atrial fibrillation. Similarly, no significant differences were observed regarding clinical and ECG presentation, echocardiographic features and laboratory tests. The rates of death (30.8% vs 8.3%; p=0.013) and MACEs (22.2% vs 6.8%; p=0.025) were significantly higher in MINOCA-DM patients; conversely, no significant differences were observed for re-MI (p=0.58). At multivariate regression model adjusted for age and sex, type 2 DM was not an independent predictor of all cause deaths (p=0.36) and MACE (p=0.24). Patients with admission HGL had similar baseline characteristics, cardiovascular risk factors, clinical presentations, echocardiographic features and troponin values as compared to patients with no-HGL. HGL at admission was associated with higher incidence of all-cause-death (p Conclusion In MINOCA patients, HGL was an independent risk factor for both MACEs and death while type 2 DM was not correlated with these hard endpoints. As a consequence, HGL could have a still unexplored pathophysiological role in MINOCA. Properly powered randomized trials are warranted. Funding Acknowledgement Type of funding source: None

Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH) as it can remove the chronic, fibrotic, flow-limiting organized thrombi within the pulmonary arterial bed, addressing the primum movens of the disease (1). Despite significant improvement in all haemodynamic parameters, residual pulmonary hypertension (PH) is frequent after PTE, ranging from 17% to 31% (2,3). There is no clear definition of residual PH after PTE, and the actual incidence of this condition has been difficult to quantify. Usually, moderate residual PH is well tolerated by patients and, as shown by data from the United Kingdom cohort, clinically relevant residual PH after PTE mainly occur when the mean pulmonary arterial pressure (mPAP) is greater than 30–35 mmHg (3). The risk of persistent/recurrent PH in the long-term underlines the importance of a systematic patient follow-up, even after PTE. Balloon pulmonary angioplasty (BPA) has been developed as a compassionate procedure for symptomatic patients with CTEPH who are ineligible for surgery or with persistent/recurrent PH after PTE. BPA is not able to remove clots as PTE, but it is able to restore the flow by fragmenting the thrombotic and fibrotic material, resulting in hemodynamic and clinical improvement. Selection of good candidates for BPA, especially after PTE, includes a complete re-assessment of the patient with persistent symptomatic PH after PTE at least four to six months after surgery using high quality imaging techniques such as computed tomography pulmonary angiography (CTPA), selective pulmonary angiography (to provide fine details) and right heart catheterization (RHC) to assess the hemodynamic impairment. However, these imaging techniques are not widely available and require expertise.

Aims Conscious sedation instead of general anesthesia has been increasingly adopted in many centers for transfemoral transcatheter aortic valve replacement (TAVR). Improvement of materials and operators' experience and reduction of periprocedural complications allowed procedural simplification and adoption of a minimalist approach. With this study, we sought to assess the feasibility and safety of transfemoral TAVR routinely performed under local anesthesia without on-site anesthesiology support. Methods The routine transfemoral TAVR protocol adopted at our center includes a minimalist approach, local anesthesia alone with fully awake patient, anesthesiologist available on call but not in the room, and direct transfer to the cardiology ward after the procedure. All consecutive patients undergoing transfemoral TAVR between January 2015 and July 2018 were included. We assessed the rates of actual local anesthesia-only procedures, conversion to conscious sedation or general anesthesia and 30-day clinical outcomes. Results Among 321 patients, 6 received general anesthesia upfront and 315 (98.1%) local anesthesia only. Mean age of the local anesthesia group was 83.2 ± 6.9 years, Society of Thoracic Surgery score 5.8 ± 4.8%. A balloon-expandable valve was used in 65.7%. Four patients (1.3%) shifted to conscious sedation because of pain or anxiety; 6 patients (1.9%) shifted to general anesthesia because of procedural complications. Hence, local anesthesia alone was possible in 305 patients (96.8% of the intended cohort, 95% of all transfemoral procedures). At 30 days, in the intended local anesthesia group, mortality was 1.6%, stroke 0.6%, major vascular complications 2.6%. Median hospital stay was 4 days (IQR 3-7). Conclusion Transfemoral TAVR can be safely performed with local anesthesia alone and without an on-site anesthesiologist in the vast majority of patients.

The aim of this study was to investigate the efficacy and safety of currently used drug-eluting stents (DES).Head-to-head comparisons among newer DES have shown conflicting results.For this network meta-analysis, randomized controlled trials comparing different types of currently used DES were searched in PubMed, Scopus, and proceedings of international meetings. The primary endpoint was target lesion failure (TLF) at 1 year and at long-term follow-up.Seventy-seven trials with 99,039 patients were selected for this network meta-analysis. Among the 10 DES included in the meta-analysis, 4 received the most extensive investigation: Orsiro, XIENCE, Nobori/BioMatrix, and Resolute. At 1 year, the Orsiro stent was associated with lower rates of TLF compared with XIENCE (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.71 to 0.98; p = 0.03), Resolute (OR: 0.81; 95% CI: 0.68 to 0.95; p = 0.01), and Nobori/BioMatrix (OR: 0.81; 95% CI: 0.67 to 0.98; p = 0.03). Orsiro had the highest probability to be the best (70.8%), with a surface under the cumulative ranking curve value of 95.9%. However, after a median follow-up period of 50 months (range: 24 to 60 months), no significant difference was apparent in the rates of TLF between any DES, although Orsiro still ranked as the best stent (58.6% probability to be the best). In addition, Orsiro had a lower rate of long-term definite stent thrombosis compared with Nobori/BioMatrix (OR: 0.60; 95% CI: 0.36 to 0.98; p = 0.04) and lower rates of definite and probable stent thrombosis compared with Resolute (OR: 0.66; 95% CI: 0.45 to 0.99; p = 0.04). No differences in cardiac mortality between any DES were observed.Orsiro is associated with a lower 1-year rate of TLF compared with XIENCE, Resolute, and Nobori/BioMatrix but with an attenuation of the efficacy signal at long-term follow-up.

Background Pulmonary artery (PA) dilation is common in pulmonary arterial hypertension (PAH) and may cause left main coronary artery (LMCA) compression. This complication have been sistematically evaluated in patients with angina but no evidence is available for patients asymptomatic for angina. Purpose To evaluate the prognostic value of PA diameter and the prevalence of LMCA compression in PAH patients with and without angina. Methods All patients with PAH and a baseline angio-CT scan were included. The last angio-CT scan performed was considered for PA diameter increase velocity calculation. Patients with angina or radiological signs of suspected LMCA compression underwent a coronary (cor)-CT scan. Patients with a not negative cor-CT underwent invasive coronary angiography. If clinically indicated invasive coronary angiography was performed without a preliminary cor-CT. To evaluate the predictivity for compression at coronary angiography the PA diameter at cor-CT or at the nearest angio-CT scan was considered. Results 958 patients were included. PA diameter at baseline is higher in patients with congenital heart disease (CHD) and is not predictive of death. The velocity of PA diameter increase is lower in patients with connective tissue disease and is a risk factor for death in both overall population and different etiological subgroups except CHD and pulmonary veno-occlusive disease. 180 patients had angina and 50 had LMCA compression. 120 patients without angina underwent cor-CT and/or coronary angiography and 15 patients had LMCA compression. The best PA diameter cut-offs predicting LMCA compression in symptomatic/asymptomatic patients were, respectively, 40/42 mm (sensitivity and specificity, respectively, 80 and 72%/87 and 77%). Conclusion 28% of patients with angina and 13% of patients without angina had LMCA compression. We found a similar PA diameter predicting LMCA compression in patients with or without angina. PA diameter, instead, was not predictive of prognosis (maybe because most deaths were related to heart failure and also because patients with LMCA compression were treated with stenting, possibly preventing sudden cardiac death). Eventually, PA diameter velocity increase is associated with prognosis but this may only reflect a severe disease refractory to medical therapy. Funding Acknowledgement Type of funding source: None

A little is known about long-term hemodynamic performance of the transcatheter heart valves (THVs). The aim of the present study was to assess hemodynamic outcome, structural valve deterioration (SVD) and bioprosthetic valve failure (BVF) in patients treated with transcatheter aortic valve replacement (TAVR) five or more years ago. All consecutive patients treated at Bologna and Florence University Hospitals with TAVR between January 2008 and December 2013 were analyzed in a retrospective registry with regards to demographic, procedural and outcome data as well as follow-up data on mortality and echocardiographic characteristics. Standardized definitions were used to define outcomes and durability of the THVs. 400 patients were included in the study, mostly treated with transfemoral TAVR (71.8%), using first generation balloon-expandable (37%) or self-expanding (63%) devices. The 1-year mortality was 21.8% (87 patients) and 5-year mortality was 53.8% (215 patients). Median follow-up was 45.5months (14.0-68.9) totaling 1516.7 patient/years, with the longest follow-up being 10.25years. At least one follow-up echocardiogram was available for 320 patients (80%), SVD occurred in 19 of these patients (5.94%): moderate in 17 patients (5.31%) and severe in two patients (0.63%). The hemodynamic presentation was stenosis in most of the cases (12 patients). Late BVF was registered in 10 patients (3.13%) and this was mainly driven by transcatheter paravalvular leak closure (six patients) with subsequent good long-term outcome. Our results confirm that TAVR appears to be a long-lasting treatment strategy with low rates of structural valve degeneration and valve failure.

Aims The CLIMA study, on the relationship between coronary plaque morphology of the left anterior descending artery and twelve months clinical outcome, was designed to explore the predictive value of multiple high-risk plaque features in the same coronary lesion [minimum lumen area (MLA), fibrous cap thickness (FCT), lipid arc circumferential extension, and presence of optical coherence tomography (OCT)-defined macrophages] as detected by OCT. Composite of cardiac death and target segment myocardial infarction was the primary clinical endpoint. Methods and results From January 2013 to December 2016, 1003 patients undergoing OCT evaluation of the untreated proximal left anterior descending coronary artery in the context of clinically indicated coronary angiogram were prospectively enrolled at 11 independent centres (clinicaltrial.gov identifier NCT02883088). At 1-year, the primary clinical endpoint was observed in 37 patients (3.7%). In a total of 1776 lipid plaques, presence of MLA 180° (HR 2.4, 95% CI 1.2–4.8), and OCT-defined macrophages (HR 2.7, 95% CI 1.2–6.1) were all associated with increased risk of the primary endpoint. The pre-specified combination of plaque features (simultaneous presence of the four OCT criteria in the same plaque) was observed in 18.9% of patients experiencing the primary endpoint and was an independent predictor of events (HR 7.54, 95% CI 3.1–18.6). Conclusion The simultaneous presence of four high-risk OCT plaque features was found to be associated with a higher risk of major coronary events.