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This paper addresses issues in the governance of the public–private partnership (PPP) with a review of a recent case: Metro Line M4 in Milan, Italy. The paper discusses how to optimize the use of public grants by channeling some into the equity of the concessionaire. This approach creates a truly public–private special purpose vehicle (SPV) (i.e., concessionaire) that leaves efficiency incentives to the private party but results in greater public control of funding contributions as well as project costs. The paper demonstrates how public-sector involvement in the concessionaire can reduce the information asymmetry between the public and private sectors during project bidding and negotiation: greater public control of a project’s technical and financial information is a crucial factor in the reduction of project costs. Reduction in information asymmetry and the creation of a public–private SPV (concessionaire) establish a double layer of control over a project, which allows for a more efficient monitoring system during the construction and the operation of the project. The paper shows how the City of Milan developed and negotiated the Line M4 project and left little margin for increased costs, yet ensured an adequate return to the private party. This Milan experience provides lessons to improve effective project delivery in infrastructure development: the method used can create an efficient framework to reduce project costs and to discourage opportunistic behavior during project renegotiations. The potential applicability of the Line M4 governance structure to PPP projects elsewhere, including in the United States, is discussed.

Objectives: The aim of this prospective, multicenter study was to assess the safety, feasibility, acceptance, and cost of ambulatory transradial percutaneous coronary intervention (PCI) under the conditions of everyday practice. Background: Major advances in PCI techniques have considerably reduced the incidence of post-procedure complications. However, overnight admission still constitutes the standard of care in most interventional cardiology centers. Methods: Eligibility for ambulatory management was assessed in 370 patients with stable angina referred to three high-volume angioplasty centers. On the basis of pre-specified clinical and PCI-linked criteria, 220 patients were selected for ambulatory PCI. Results: The study population included a substantial proportion of patients with complex procedures: 115 (52.3%) patients with multivessel coronary artery disease, 50 (22.7%) patients with multilesion procedures, and 60 (21.5%) bifurcation lesions. After 4-6 hr observation period, 213 of the 220 patients (96.8%) were cleared for discharge. The remaining seven (3.2%) patients were kept overnight for unstable angina (n = 1), atypical chest discomfort (n = 2), puncture site hematoma (n = 1), or non-cardiovascular reasons (n = 3). Within 24 hr after discharge, no patients experienced readmission, stent occlusion, recurrent ischemia, or local complications. Furthermore, 99% of patients were satisfied with ambulatory management and 85% reported no anxiety. The average non-procedural cost was lower for ambulatory PCI than conventional PCI (1,230 ± 98 Euros vs. 2,304 ± 1814 Euros, P < 10−6). Conclusions: Ambulatory PCI in patients with stable coronary artery disease is safe, effective, and well accepted by the patients. It may both significantly reduce costs and optimize hospital resource utilization. © 2012 Wiley Periodicals, Inc.

SummaryCompared with the approved dose regimen of clopidogrel (300-mg loading dose [LD], 75-mg maintenance dose [MD]), prasugrel has been demonstrated to reduce ischaemic events in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). In ACS, antiplatelet effects of a prasugrel MD regimen have not been previously compared with either a higher clopidogrel MD or after switching from a higher clopidogrel LD. The objective of this study was to evaluate the antiplatelet effect of a prasugrel 10-mg MD versus a clopidogrel 150-mg MD in patients with ACS who had received a clopidogrel 900-mg LD. Patients with non-ST elevation ACS, treated with aspirin and a clopidogrel 900-mg LD, were randomised within 24 hours post-LD to receive a prasugrel 10-mg or clopidogrel 150-mg MD. After 14 days of the initial MD, subjects switched to the alternative treatment for 14 days. The primary endpoint compared maximum platelet aggregation (MPA, 20 μM adenosine diphosphate [ADP]) between prasugrel and clopidogrel MDs for both periods. Responder analyses between treatments were performed using several platelet-function methods. Of 56 randomised subjects, 37 underwent PCI. MPA was 26.2% for prasugrel 10 mg and 39.1% for clopidogrel 150 mg (p

Objective: We aimed to assess the safety and feasibility of thrombectomy with the Export Aspiration Catheter (EAC) before angioplasty, and its ability to improve angiographic results in patients with ST-segment elevation myocardial infarction (STEMI). Background: Distal embolization of atherothrombotic material often occurs during angioplasty in STEMI, compromising optimal myocardial reperfusion. Methods: We performed a thrombus-aspiration with EAC prior to angioplasty in 64 consecutive patients with STEMI. Successful thrombectomy was defined as an improvement of TIMI flow grade ≥1. Results: Successful thrombectomy (increase of TIMI flow ≥1) was achieved in 40 patients (62.5%). Mean TIMI flow grade increased from 0.7 ± 1 to 1.9 ± 1.2 (p < 0.0001) after thrombectomy. TIMI flow grade 3 was observed more frequently after EAC compared with guidewire alone (51.5% vs. 9%, p = 0.0062). Direct stenting was performed in most of the patients (n = 41, 64%). Distal embolization and no reflow/slow flow phenomenon occurred in 8 patients (12.5%). No vessel injury after EAC thrombectomy was reported. After treatment with balloon angioplasty and/or stenting, final TIMI flow grade 3 was achieved in 54 patients (84.5%). By multivariate analysis, ischemic time < 6 hours was a significant independent predictor of successful thrombectomy (p = 0.0437). Conclusions: Our series suggests that EAC thrombectomy prior to angioplasty in the setting of STEMI is safe and feasible. It might reduce the culprit coronary lesion's thrombus burden, leading to improved flow restoration and myocardial reperfusion. Further large randomized studies are warranted to confirm these preliminary results and to assess the impact of thrombus-aspiration on infarct size as well as on clinical outcomes.

The retrograde approach has been shown to improve the success rate of percutaneous coronary intervention for coronary chronic total occlusion (CTO) when performed by highly experienced operators. We report a very challenging case of a retrograde approach by the "reverse controlled antegrade and retrograde subintimal tracking (CART) technique" with a single guiding catheter for a CTO of the right coronary artery via an anomalous left circumflex artery.

This document explores viable solutions to mitigate the impact of risks that are preventing private lenders from expanding their involvement in housing finance in selected countries of Latin America and the Caribbean. It is based on available housing diagnostics and studies in the region, and complemented with information gathered by the consultants from public sources and correspondence with appropriate regulators and national statistical offices. This analysis provides basis for the policy and program recommendations to support a more effective, nonbiased housing financing framework in Latin America and the Caribbean.

Diagnosis of patent foramen ovale (PFO) is commonly made by echocardiography with contrast injection. PFO can be responsible for a transient right-to-left shunting with paroxysmal dyspnoea but punctual measurements of oxygen saturation may fail to detect arterial desaturations. Thus, claiming the imputability of PFO in dyspnoeic symptoms remains difficult. We report on the case of a 64-year-old man presenting an intermittent disabilitating dyspnoea, for which the pulse oximetry monitoring allowed to impute symptoms to the right-to-left shunting through the PFO and influenced the decision of percutaneous closure.