Theory and practical based approach to chronic total occlusions

Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90 %, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries

Coping and emotional state in the acute phase of myocardial infarction

Σκοπός: Η ψυχολογική προσαρμογή στην οξεία φάση ενός Εμφράγματος του Μυοκαρδίου (ΕΜ) αποτελεί αντισταθμιστικό μηχανισμό των ασθενών στην προσαρμογή στη νέα πραγματικότητα μιας ανάλογης απειλητικής συνθήκης. Υπάρχουν ελάχιστα δεδομένα που καταδεικνύουν τη σχέση ανάμεσα στις στρατηγικές διαχείρισης από ενδονοσοκομειακούς ασθενείς και στη συναισθηματική τους κατάσταση. Η μελέτη ερευνά τη συγκεκριμένη σχέση σε ασθενείς που έχουν υποστεί ένα ΕΜ.Μέθοδος: Εκατό άνδρες ασθενείς που έχουν υποστεί ΕΜ, ηλικίας 60.5 (Διάστημα Εμπιστοσύνης (Δ.Ε): 57.5-62.7) ετών, έδωσαν συνέντευξη μετά την οξεία φάση ΕΜ κατά την τελευταία μέρα παραμονής τους στη Στεφανιαία Μονάδα. Ιατρικές πληροφορίες δόθηκαν από τους ιατρικούς φακέλους των ασθενών. Τα ερωτηματολόγια Προσανατολισμός Διαχείρισης Προβλημάτων (COPE) και Προφίλ Ψυχολογικής Διάθεσης (POMS) χρησιμοποιήθηκαν στην αξιολόγηση του τρόπου διαχείρισης και της συναισθηματικής κατάστασης αντίστοιχα.Αποτελέσματα: Η ενεργή διαχείριση σχετίστηκε θετικά με το άγχος και το θυμό. Η συναισθηματική υποστήριξη βρέθηκε να σχετίζεται αρνητικά με τις συγκεκριμένες μεταβλητές. Η πνευματική αναζήτηση και η συμπεριφορική αποδέσμευση σχετίστηκαν θετικά με την κατάθλιψη. Σημαντική διαφορά βρέθηκε στις στρατηγικές διαχείρισης και τη συναισθηματική διάθεση συγκρινόμενες με την υποκειμενική αντίληψη της σοβαρότητας.Συμπέρασμα:Oι ασθενείς μετά απο ένα ΕΜ, αναπτύσσουν στρατηγικές διαχείρισης που σχετίζονται με την συναισθηματική διάθεση. Η σημασία αυτών των συσχετίσεων μένει να εξακριβωθεί και σε μελλοντικές μελέτες.Objective: Emotional and coping adaptation after the acute phase of a myocardial infarction (MI) is a compensatory mechanism developed for patients’ adjustment to the new reality following this life threatening situation. There are however scarce data on the relationship between hospitalized MI patients’ coping behavior and their emotional state. The study investigates the associations between coping strategies and the affective status in patients surviving a MI.Methods: One-hundred male patients surviving a MI, aged 60.5 (Confidence Intervals (CI): 57.5-62.7) years, were interviewed after the acute phase of MI, at the last day of their coronary unit stay. Medical data were obtained by their medical records. Coping Orientation to Problems Experienced (COPE) and Profile of Mood States (POMS) questionnaires were used to examine coping styles and patients’ mood state respectively.Results: Active coping was positively related to anxiety and anger. Emotional support was negatively associated with these variables. Religious coping and behavioral disengagement were positively related to depression. Significant difference was found in coping styles and mood states scores between the different perceived severity beliefs.Conclusion: Patients surviving after a MI, develop coping strategies related to their emotional state. The significance of these relations remains to be clarified in future studies

A novel Desmoplakin mutation associated with left dominant arrhythmogenic cardiomyopathy and cutaneous phenotype

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Risk factors for sudden cardiac death in hypertrophic cardiomyopathy

Aim of this study was the evaluation of six non invasive clinical indices as risk factors for sudden death (SD)in hypertrophic cardiomyopathy (HCM). Previous syncope, family history of SD, non sustained ventricular tachycardia, abnormalblood pressure response during exercise, excessive hypertrophy ≥3 cm and left ventricular outflow tract obstructionwith a peak gradient ≥30 mmHg were evaluated in a cohort of 166 patients(112 males, 51.8 ± 15.6 years), followed up for amedian of 32.4 months (range 1 to 209 months). During follow up 13 patients reached study’s endpoints: SD, cardiac arrest,documented sustained ventricular tachycardia and/or Implantable Cardioverter Defibrillator (ICD)-discharge. Patients havingexperienced syncope or presenting with a Maximum Wall Thickness ≥3cm in echocardiography were more sensitive to SDemergence since they had a 13.07 (95%CI: 4.00-46.95, p < 0.0001) and a 10.07 (95%CI: 2.92-34.79, p = 0.003) greater relativerisk respectively. In our cohort of patients only two of the six ‘recognised’ potential risk factors for SD were found sensitive,a result causing scepticism about the validity of criteria used for ICD implantation in HCM patients for SD prevention

Cardiac Magnetic Resonance to Detect the Underlying Substrate in Patients with Frequent Idiopathic Ventricular Arrhythmias

Background: A routine diagnostic work-up does not identify structural abnormalities in a substantial proportion of patients with idiopathic ventricular arrhythmias (VAs). We investigated the added value of cardiac magnetic resonance (CMR) imaging in this group of patients. Methods: A single-centre prospective study was undertaken of 72 patients (mean age 46 ± 16 years; 53% females) with frequent premature ventricular contractions (PVCs ≥ 500/24 h) and/or non-sustained ventricular tachycardia (NSVT), an otherwise normal electrocardiogram, normal echocardiography and no coronary artery disease. Results: CMR provided an additional diagnostic yield in 54.2% of patients. The most prevalent diagnosis was previous myocarditis (23.6%) followed by possible PVC-related cardiomyopathy (20.8%), non-ischaemic cardiomyopathy (8.3%) and ischaemic heart disease (1.4%). The predictors of abnormal CMR findings were male gender, age and PVCs/NSVT non-outflow tract-related or with multiple morphologies. Patients with VAs had an impaired peak left ventricular (LV) global radial strain (GRS) compared with the controls (28.88% (IQR: 25.87% to 33.97%) vs. 36.65% (IQR: 33.19% to 40.2%), p &lt; 0.001) and a global circumferential strain (GCS) (−17.66% (IQR: −19.62% to −16.23%) vs. −20.66% (IQR: −21.72% to −19.6%), p &lt; 0.001). Conclusion: CMR reveals abnormalities in a significant proportion of patients with frequent idiopathic VAs. Male gender, age and non-outflow tract PVC origin can be clinical indicators for CMR referral

Accurate and reproducible reconstruction of coronary arteries and endothelial shear stress calculation using 3D OCT: Comparative study to 3D IVUS and 3D QCA

Background: Geometrically-correct 3D OCT is a new imaging modality with the potential to investigate the association of local hemodynamic microenvironment with OCT-derived high-risk features. We aimed to describe the methodology of 3D OCT and investigate the accuracy, inter- and intra-observer agreement of 3D OCT in reconstructing coronary arteries and calculating ESS, using 3D IVUS and 3D QCA as references. Methods-Results: 35 coronary artery segments derived from 30 patients were reconstructed in 3D space using 3D OCT. 3D OCT was validated against 3D IVUS and 3D QCA. The agreement in artery reconstruction among 3D OCT, 3D IVUS and 3D QCA was assessed in 3-mm-long subsegments using lumen morphometry and ESS parameters. The inter- and intra-observer agreement of 3D OCT, 3D IVUS and 3D QCA were assessed in a representative sample of 61 subsegments (n ¼ 5 arteries). The data processing times for each reconstruction methodology were also calculated. There was a very high agreement between 3D OCT vs. 3D IVUS and 3D OCT vs. 3D QCA in terms of total reconstructed artery length and volume, as well as in terms of segmental morphometric and ESS metrics with mean differences close to zero and narrow limits of agreement (BlandeAltman analysis). 3D OCT exhibited excellent inter- and intra-observer agreement. The analysis time with 3D OCT was significantly lower compared to 3D IVUS. Conclusions: Geometrically-correct 3D OCT is a feasible, accurate and reproducible 3D reconstruction technique that can perform reliable ESS calculations in coronary arteries

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure &lt; 100 mmHg (n = 1127), estimated glomerular filtration rate &lt; 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation