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Objetivo El objetivo es presentar un caso de cirugía intracraneal en un paciente masculino de 46 años para la extirpación de glioma de bajo grado ubicado en la región fronto-temporo-insular derecha con el paciente despierto durante el procedimiento. En este caso se utilizó la técnica anestésica dormido-despierto-dormido, vía aérea asegurada con dispositivo supraglótico. Materiales y métodos Se realizó una revisión de la literatura en bases de datos como UpToDate, PubMed y ScienceDirect. Discusión La cirugía en paciente despierto ha demostrado mejorar el grado de resección tumoral y disminuir la morbilidad. Sin embargo, a pesar de su eficacia y seguridad, se utiliza en menos del 22% de las cirugías de gliomas, particularmente, en aquellos países de medianos/bajos ingresos. Conclusión La craniectomía en paciente despierto es un procedimiento factible de realizar en países de escasos recursos, con una baja incidencia de complicaciones, fallas técnicas y resultados prometedores.

To assess the value of sirolimus-eluting magnesium bioresorbable scaffolds (MgS) in the treatment of patients with in-stent restenosis (ISR). The better option for the treatment of patients with ISR remains unsettled. Bioresorbable vascular scaffolds represent an interesting strategy in this setting to avoid another permanent metal layer. The novel MgS is an attractive option to treat these challenging patients.We present the results of the first prospective series of consecutive patients with ISR treated with MgS under optical coherence tomography (OCT) guidance.A total of 14 patients (15 lesions) were prospectively included. The mean age was 67 ± 9 years and six patients (40%) presented with an acute coronary syndrome. In 10 patients (67%), underlying neoatherosclerosis was disclosed by OCT. An excellent MgS expansion was obtained in all but two patients who showed persistent suboptimal expansion in heavily calcified vessels. Minor residual malapposition ( n = 5) and angiographically silent minor edge dissections ( n = 8) were readily recognized by OCT. After a median clinical follow-up of 30 (range, 20-54) months, no patient required repeated revascularization, suffered a myocardial infarction or device thrombosis.These preliminary results suggest a potential role for the MgS in selected patients presenting with ISR.

Background Evolut Pro (EVP) is a novel self-expandable aortic valve. This prosthesis consists of an external porcine pericardial wrap designed to reduce paravalvular leak (PVL), maintaining the benefits of its predecessor, the Evolut R (EVR). The aim was to compare the functional and clinical results in the short and medium term of the new EVP with the EVR system. Methods Consecutive patients receiving either the EVR (n=50) or the EVP (n=33) from June 2015 to October 2018 were compared. Baseline characteristics, cardiovascular imaging, procedural outcomes, short and mid-term follow-up outcomes were prospectively collected and assessed. Results Residual mild PVL was common and comparable in the two groups (EVR 79% vs. EVP 70%; P=0.4). In the EVR group, the presence of PVL was directly related to prosthesis size, but this correlation was not observed in the EVP group. Conduction abnormalities were more prevalent with the EVP, but these did not translate into a higher need of permanent pacemaker implantation. Vascular and bleeding complications were infrequent in both groups. At mid-term clinical follow-up (median survival time: EVR 11±0.3 months, EVP 12±0.2 months), the 1-year rate of adverse events was similar (EVR: 24%, EVP: 33%; P=0.3). Conclusions Both protheses are effective for the treatment of severe aortic stenosis with excellent results at mid-term clinical follow up. The EVP remains associated with a significant rate of residual mild PVL that appears to be similar to that observed with EVR.

Plaque erosion (PE) is a well-known pathological substrate in patients with acute myocardial infarction. The precise etiologic diagnosis of patients with myocardial infarction and nonobstructive coronary arteries is of great importance to inform both revascularization decisions and antithrombotic

Currently there is lack of data regarding the use of optical coherence tomography (OCT) to depict the hemodynamic relevance of coronary stenoses in diabetic patients. We sought to assess the diagnostic accuracy of OCT-derived morphologic assessment in identifying hemodynamically significant coronary lesions as determined by both, the resting instantaneous wave-free ratio (iFR) and the hyperemic fractional flow reserve (FFR) in diabetic patients. Diabetic patients presenting with at least one intermediate coronary lesion were prospectively and consecutively enrolled. All lesions were systematically assessed by iFR, FFR and OCT. A total of 41 intermediate lesions were analysed. Mean iFR and FFR values were 0.90 ± 0.04 and 0.81 ± 0.06, respectively (intra-class correlation coefficient 0.49; 95% CI 0.22-0.79). A moderate correlation between iFR and OCT derived minimal lumen diameter (MLD, r = 0.49) and minimal lumen area (MLA, r = 0.50) was found. Conversely, there was a poor correlation between FFR and OCT-derived MLD (r = 0.34) and MLA (r = 0.32). The diagnostic efficiency of MLA and MLD to identify iFR significant stenoses showed an AUC of 0.82 (95% CI 0.69-0.95) for MLD and 0.83 (95% CI 0.71-0.96) for MLA. A worse diagnostic efficiency was found when FFR was used as the reference with an AUC of 0.71 (95% CI 0.54-0.87) for MLD and 0.70 (95% CI 0.53-0.87). OCT-derived MLA and MLD were the strongest independent anatomic predictors of abnormal iFR and FFR values. In diabetic patients, OCT-derived MLA and MLD showed a moderate diagnostic efficiency in identifying functionally significant coronary stenoses by FFR or iFR. In diabetics, anatomic OCT measurements better predicted resting than FFR-determined physiologically significant lesions.

Introduction and objectives: Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause for acute coronary syndrome. The optimal management and treatment of SCAD is still unknown. Methods: Data analysis of a prospective protocol including centralized care management of a consecutive series of patients with SCAD diagnosed between January 2010 and December 2018. Major adverse cardiovascular events included all-cause mortality, new myocardial infarction, coronary revascularization, ventricular arrhythmia, heart failure or stroke. Results: A total of 33 consecutive patients were included (41 lesions). Intravascular imaging modalities were used to confirm the diagnosis in 42% patients. None of the patient showed images of thrombus formation in the true lumen. Conservative treatment was the initial approach in most of the cases (82%). No deaths were reported during the index admission, but 15% experienced major adverse cardiovascular events. The coronary computed tomography angiography performed in 58% of patients during the admission identified SCADs in 79% of the patients. Most of the patients managed with conservative treatment received only 1 antiplatelet agent for a limited period of time (17 months [9-35]). During a median clinical follow-up of 33 months [13-49], 82% of patients did not have any adverse events. The angiographic surveillance obtained in 48% of patients at the 6-month follow-up confirmed the complete healing of the SCAD image in 86% of the patients. The screening for extracoronary vascular findings (97% of patients) resulted in a high prevalence of abnormalities (59%). Conclusions: The unrestricted use of intravascular imaging modalities showed no thrombus in the true lumen of patients with SCAD. In patients managed with conservative treatment, a limited course of antiplatelet monotherapy is safe and provides good clinical outcomes. Performing a coronary computed tomography angiography in the acute phase of SCAD is useful at the follow-up. The screening for extracoronary vascular findings confirmed a high prevalence of abnormalities.

A 41-year-old woman presented with an inferolateral ST-segment elevation myocardial infarction. Coronary angiography confirmed the presence of a long narrowing involving the right coronary artery posterolateral branch (figure 1A, white arrows). Spontaneous coronary artery dissection was suspected and optical coherence tomography (OCT) imaging was considered by the operator for confirmation purposes. Advancing the OCT catheter was difficult due to lack of support and it was decided to only interrogate the proximal aspect of the branch (figure 1B, arrow). OCT revealed the presence of an intramural hematoma without entry tear (figure 1C; asterisks denote wire artefact). At that moment the patient complained of chest pain that remained after removing the OCT catheter. The presence of functional branch occlusion (figure 1D, asterisk), with Thrombolysis in Myocardial Infarction (TIMI) grade 1 flow, was confirmed. Coronary flow was re-established through gentle dilation (4 atm) using a 1.5 mm balloon. Final TIMI grade 2 flow was achieved (figure 1E, asterisks) and the patient became asymptomatic. Her subsequent clinical course was uneventful. Coronary angiography performed 3 months later confirmed the complete healing of the dissected segment (figure 1F, arrows).

Mujer de 41 años que se presenta con un infarto de miocardio con elevación del segmento ST inferolateral. La coronariografía confirmó la presencia de una lesión larga en una rama posterolateral de la coronaria derecha (figura 1A, flechas blancas). El operador optó por realizar una tomografía de coherencia óptica (OCT) para confirmar la sospecha de disección coronaria espontánea. Como era difícil avanzar el catéter de la OCT, debido a la falta de soporte, se optó por interrogar únicamente el aspecto más proximal de esta rama (figura 1B, flecha). La OCT reveló la presencia de un hematoma intramural sin rotura intimal como puerta de entrada (figura 1C; los asteriscos señalan el artefacto de la guía). En ese momento, la paciente se quejó nuevamente de dolor torácico que se mantuvo hasta la retirada del catéter de la OTC. Se confirmó la presencia de oclusión funcional de la rama estudiada (figura 1D, asterisco) con flujo grado TIMI 1 (Thrombolysis in Myocardial Infarction). Se reestableció el flujo coronario mediante dilatación cuidadosa (balón de 1,5 mm de diámetro a 4 atmósferas). Finalmente se alcanzó un flujo TIMI 2 (figura 1E, asteriscos) con desaparición de los síntomas. La evolución clínica posterior cursó sin eventos. La angiografía coronaria que se realizó 3 meses después confirmó la reparación total del vaso con curación de todo el segmento que inicialmente mostraba la disección (figura 1F, flechas).

Coronary artery aneurysms (CAA) may occur following virtually any coronary intervention. We present a patient developing a CAA after magnesium resorbable vascular scaffold (MRS) implantation in the left circumflex coronary artery 1 year before for an acute myocardial infarction. Intravascular ultrasound and optical coherence tomography revealed striking images of the dissolving MRS struts, well apposed and following the CAA vessel wall, rather than the expected classical findings of late acquired malapposition. The implications of these unique findings are discussed.

A 67-year-old woman, a heavy smoker and with hypothyroidism, presented with a non–ST-segment elevation myocardial infarction with negative T waves on the inferior leads. Coronary angiography revealed a focal stenosis in the mid right coronary artery (arrow in [Figure 1A][1]) but no other coronary

A 54-year-old man presenting with an acute myocardial infarction and a total occlusion of the circumflex coronary artery was treated with a magnesium resorbable vascular scaffold (MgRS) (25 mm in length), that was carefully post-dilated at high pressure (20 bar) with a noncompliant balloon, with

Neoatherosclerosis has emerged as a major cause of in-stent restenosis (ISR). Although this entity has been described as a unique process, optical coherence tomography (OCT) enables depiction of distinct morphologic patterns, including the presence of calcified sheets within the stent. We sought to assess prevalence, predictors, and implications of calcified neoatherosclerosis (cNA) as the cause of ISR.From January 2014 to August 2016, 75 consecutive patients with 81 ISR lesions with a clinical indication for revascularization were evaluated by OCT before reintervention. In 13 (16%) lesions, cNA was the predominant pattern of ISR, all of them presenting as very-late (3 years) ISR. Patients with cNA were older (71±9 vs. 66±10 years, P=0.0157), had worse low-density lipoprotein control (97±29 vs. 81±30 mg/dl, P=0.0746), and received treatment with statins (54 vs. 85%, P=0.006) and angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (31 vs. 65%, P=0.003) less frequently compared with patients with other patterns of ISR. Time from stent implantation to ISR [odds ratio (OR)=1.3; 95% confidence interval (CI): 1.1-1.6; P=0.01] and absence of treatment with statins (OR=11.3; 95% CI: 1.7-74; P=0.012) or ACEi/ARB (OR=7.4; 95% CI: 1.3-43; P=0.026) were associated independently with the presence of cNA. During reinterventions, ISR lesions with cNA obtained poorer angiographic (postintervention minimal lumen diameter 1.8±0.4 vs. 2.2±0.5 mm, P=0.0174) and OCT (final stent expansion 83±11 vs. 88±9%, P=0.0896) results.In our cohort of consecutive patients with clinical ISR, one-sixth showed underlying cNA as the predominant substrate of restenosis. This unique underlying substrate is related to the time elapsed from stent implantation and the absence of previous treatment with statins or ACEi/ARB and is associated with poorer acute results after reintervention.

Myocardial injury is frequently detected in coronavirus disease 2019 (COVID‐19) patients. However, up to one‐third of COVID‐19 patients showing ST‐segment elevation on the electrocardiogram have angiographically normal coronary arteries. We present a case of an acute coronary syndrome due to a coronary spasm in a severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) patient. This pathophysiological mechanism was clearly demonstrated by intracoronary imaging techniques (optical coherence tomography) and invasive vasospasm test.

This case report describes a patient with coronavirus disease 2019 who developed late drug-eluting stent thrombosis.

AIMS The MAGSTEMI trial showed larger endothelium-independent vasodilatation with magnesium-based bioresorbable scaffolds (MgBRS) than with sirolimus-eluting stents (SES). However, restenosis was more frequent with MgBRS. The aims of this study were to compare the healing pattern between MgBRS and SES and to describe the main causes of restenosis, as assessed by optical coherence tomography (OCT). METHODS AND RESULTS Ninety-five consecutive patients from the randomised MAGSTEMI trial (MgBRS=48, SES=47) underwent OCT imaging at one year. Healing and bioresorption pattern were categorised into four groups: 1) indiscernible struts were observed in 33.3% versus 0% of patients (p

Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome that usually affects young to middle-aged women. Mainly because of its low prevalence, until recently, most of the evidence on this condition was derived from case reports and small series. Over the last 5 years, more robust evidence has become available from larger retrospective and prospective cohorts of patients with SCAD. The increase in knowledge and recognition of this entity has led to the publication of expert consensus on both sides of the Atlantic. However, new data are continuously accumulating from larger cohorts of patients with SCAD, bringing new light to this little-understood condition. The aim of this article is to update the knowledge on SCAD, including new information from recent studies published since the consensus documents from the European Society of Cardiology and the American Heart Association.

A 63-year-old man presented with an acute coronary syndrome 15 years after revascularization of the left anterior descending coronary artery with 2 bare-metal stents. Coronary angiography revealed a severe, heavily calcified, lesion in a large obtuse marginal branch ([Figure 1A][1]) and diffuse in

Introduction and objectives Stent thrombosis (ST) is a rare but potentially serious complication. Optical coherence tomography (OCT) provides high-resolution images and additional information to angiography in the study of this event. Methods Prospective study of patients with ST undergoing reintervention with OCT imaging. Results The study included a total of 40 consecutive patients with ST. Mean age was 69 ± 13 years and 83% were male. Early ST (≤ 30 days) was observed in 16 patients and late ST (> 30 days) in 24 patients. Stent thrombosis occurred in 17 bare-metal stents and 23 drug-eluting stents. In 34 patients (85%), adequate OCT images were obtained at the time of the ST. The predominant mechanism in early ST was stent malapposition (39%). In late ST, high frequencies of uncovered (46%) and malapposed struts (17%) were observed, especially in patients with drug-eluting stents. Furthermore, the presence of neoatherosclerosis was very high (67%) in patients with late ST. After intervention, improvements were observed in malapposition length and the amount of residual thrombus. Conclusions OCT allows identification of the underlying mechanisms potentially involved in ST. This imaging modality is helpful in guiding reintervention in these patients, which improves the area and length of malapposition, as well as the maximal residual thrombus area.

Resumen Introduccion y objetivos La trombosis del stent (TS) es una complicacion infrecuente pero potencialmente grave. La tomografia de coherencia optica (OCT) ofrece imagenes de alta resolucion e informacion adicional a la angiografia en el estudio de esta enfermedad. Metodos Estudio prospectivo en el que se incluyo a todos los pacientes con una TS a los que se realizo una OCT durante el procedimiento. Resultados Se incluyo a un total de 40 pacientes con TS consecutivos, con una media de edad de 69 ± 13 anos; el 83% eran varones. Las TS fueron precoces (≤ 30 dias) en 16 pacientes y tardias (> 30 dias) en 24. En 17 pacientes la TS se produjo en stents convencionales y en 23, en farmacoactivos. En 34 casos (85%) se realizo estudio con OCT en el momento de la TS. En las TS precoces, el mecanismo predominante (39%) fue la malaposicion del stent . En las TS tardias se observaron frecuentemente (46%) struts no recubiertos y areas de malaposicion (17%), especialmente en pacientes con stents farmacoactivos. Ademas, la presencia de neoateroesclerosis fue muy elevada (67%) en los pacientes con TS tardia. Tras la intervencion se observo una mejora en la longitud de la malaposicion y la cantidad de trombo en el stent . Conclusiones La OCT permite conocer los mecanismos subyacentes potencialmente implicados en la TS y guiar el intervencionismo en estos pacientes. La reintervencion disminuye el area y la longitud de la malaposicion, asi como la cantidad de trombo residual.

The FORZA (FFR or OCT Guidance to Revascularize Intermediate Coronary Stenosis Using Angioplasty) study randomized patients with angiographically intermediate coronary lesions (AICL) to fractional flow reserve (FFR) (n = 176) or optical coherence tomography (OCT) (n = 174) assessment ([1][1]).

Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.

Resorbable Magnesium Scaffolds (RMS) represent an interesting alternative to current drug-eluting stents. Current data from clinical trials seems to confirm good performance of these new devices with low rates of late device failure. Little is known about mechanisms leading to RMS failure. Herein, we present the first description of an early RMS in-scaffold restenosis. Optical coherence tomography (OCT) analysis at implantation detected acute non-severe malapposition and underexpansion as main promoters of RMS failure. OCT during in-scaffold restenosis intervention confirmed early severe neointimal proliferation and RMS late recoil and dismantling as the main mechanisms of device failure. We hypothesize that the fast resorption process of RMS may lead to an early loss of radial strength, that could favor late recoil, acquired underexpansion, device dismantling and might interact with distribution of sirolimus. This case also illustrates that OCT is pivotal to unravel both acute and acquired mechanisms related to RMS failure.

Objective The objective is to analyze the acute and midterm angiographic outcome of percutaneous treatment of left main coronary stem (LM-PCI) guided by optical coherence tomography (OCT). Background LM-PCI is a complex procedure, and several anatomical factors may impair its outcome. Intravascular imaging is emerging as a useful tool to guide the procedure. Methods We conducted a retrospective analysis of patients undergoing LM-PCI at three European centers between 2014 and 2017 with a control angiography at 6-12 months. Patients were divided into two groups: OCT-guidance (pre- and post-PCI) and control group (standard angiographic guidance with/out intravascular ultrasound [IVUS]). A blinded core lab analyzed all angiographic images. Primary endpoint was late lumen loss (LLL) after 6 months. Results A total of 112 patients entered the study, 55 in the OCT group and 57 in the control group (10 IVUS). Baseline and procedural characteristics were similar between groups. Overall, reference vessel diameter of the LM was 3.98 ± 0.65 mm. OCT guidance detected four cases of stent underexpansion (7.2%) and six cases of acute malapposition (10.9%). After a median of 207 ± 23 days, LLL of LM tended to be lower in the OCT group (0.12 ± 0.41 vs. 0.26 ± 0.52 mm, p = .10), and was significantly reduced in the distal portion of the main vessel (0.03 ± 0.45 vs. 0.24 ± 0.53 mm, p = .025). Percent diameter stenosis was also lower (14 ± 9 vs. 19 ± 16%, p = .05). Adverse event rates were similar in the two groups. Conclusions In this study, systematic OCT guidance during LM-PCI allowed a timely detection and correction of acute stent underexpansion and malapposition, and was associated with signs of improved angiographic outcome at midterm, compared to standard practice.