Μεταβολές των αναίμακτων δεικτών διαστρωμάτωσης κινδύνου για αιφνίδιο θάνατο σε ασθενείς με έμφραγμα του μυοκαρδίου και διατηρημένο κλάσμα εξώθησης

Εισαγωγή: Πολλαπλοί αναίμακτοι ηλεκτροκαρδιογραφικοί δείκτες διαστρωμάτωσης κινδύνου (ΑΔΔΚ) για αιφνίδιο καρδιακό θάνατο έχουν προταθεί σε μετεμφραγματικούς ασθενείς με διατηρημένο κλάσμα εξώθησης αριστεράς κοιλίας (ΚΕΑΚ). Ωστόσο, παραμένει άγνωστο αν οι δείκτες αυτοί μεταβάλλονται προϊόντος του χρόνου. Σκοπός της μελέτης ήταν η εκτίμηση πιθανών χρονικών μεταβολών που υφίστανται οι εν λόγω δείκτες στη συγκεκριμένη ομάδα μετεμφραγματικών ασθενών.Μέθοδοι: Μελετήσαμε 7 ΑΔΔΚ, όπως αυτοί περιγράφονται στη μελέτη PRESERVE EF, σε 80 μετεμφραγματικούς ασθενείς με ΚΕΑΚ ≥ 40% τουλάχιστον 40 ημέρες μετά την επαναιμάτωση καθώς και ένα χρόνο αργότερα. Αποτελέσματα: Η μέση ηλικία των ασθενών ήταν 56 ± 10 έτη και το 88% ήταν άντρες. Το μέσο ΚΕAK ήταν 50 ± 5%. Ο επιπολασμός 1) των θετικών όψιμων δυναμικών (LPS) σε 45λεπτο ηλεκτροκαρδιογράφημα συγκερασμού σε ηρεμία (28% vs 29%, p=0,860), 2) της εμφάνισης >30 εκτάκτων κοιλιακών συστολών/ώρα (9 % vs 11%, p=0,598), 3) της εμφάνισης μη εμμένουσας κοιλιακής ταχυκαρδίας (9% vs 5%, p=0,349), 4) της τυπικής απόκλισης του RR διαστήματος (SDNN) < 75 msec (4% vs 3%, p=1,000), 5) του διαστήματος QTc > 440 msec (άντρες) ή > 450 msec (γυναίκες) (18% vs 18%, p=1,000), 6) της ικανότητα επιβράδυνσης του καρδιακού ρυθμού (DC) ≤ 4,5 msec και στροβιλισμού του καρδιακού ρυθμού (HRT) ≥0% (έναρξη/onset) και ≤2,5 msec (κλίση/slope) (3% vs 4%, p=1,000) και τέλος, 7) της τιμής του εναλλασσόμενου του κύματος T (T-wave alternans) ≥ 65μV σε δύο κανάλια κατά την 24ωρη ηλεκτροκαρδιογραφική καταγραφή (6% vs 8%, p=0,755) ήταν παρόμοιος κατά τις δύο μετρήσεις. Όσον αφορά στις απόλυτες τιμές των συνεχών μεταβλητών, δεν ανευρέθη καμία στατιστικά σημαντική διαφορά μεταξύ των δύο μετρήσεων. Ωστόσο, 5 ασθενείς (6,3%) χωρίς ΑΔΔΚ κατά την πρώτη εξέταση είχαν τουλάχιστον ένα θετικό ΑΔΔΚ κατά τη δεύτερη εξέταση ενώ 6 ασθενείς (7,5%) με ένα τουλάχιστον ΑΔΔΚ κατά την πρώτη εξέταση δεν είχαν κανένα ΑΔΔΚ κατά τη δεύτερη εξέταση.Συμπέρασμα: Ενώ ο επιπολασμός των ΑΔΔΚ στους μετεμφραγματικούς ασθενείς με διατηρημένο ΚΕΑΚ ήταν παρόμοιος σε επίπεδο πληθυσμού κατά τις δύο μετρήσεις, κάποιοι ασθενείς χωρίς θετικούς ΑΔΔΚ στην πρώτη μέτρηση, ανέπτυξαν θετικούς ΑΔΔΚ μετά από ένα έτος κατά τη δεύτερη μέτρηση, καθώς και το αντίστροφο, καταδεικνύοντας την ανάγκη για επαναληπτική μέτρηση των δεικτών αυτών κατά τον επανέλεγχο των ασθενών.Background: Several noninvasive risk factors (NIRFs) have been proposed for sudden cardiac death risk stratification in post-myocardial infarction (post-MI) patients with preserved left ventricular ejection fraction (LVEF). However, it remains unclear if these factors change over time. We aimed to examine the presence of NIRFs temporal changes in the previously mentioned group of patients.Methods: We evaluated seven electrocardiographic NIRFs as they were described in the PRESERVE EF trial in 80 post-MI patients with LVEF ≥ 40%, at least 40 days after revascularization and one year later.Results: Mean patient age was 56 ± 10 years and 88% were men. Mean LVEF was 50 ± 5%. The prevalence of 1) positive late potentials (28% vs 29%, p=0.860), 2) >30 premature ventricular complexes/hour (9% vs 11%, p=0.598), 3) non-sustained ventricular tachycardia (9% vs 5%, p=0.349), 4) standard deviation of the normal-to-normal R-R intervals < 75 msec (4% vs 3%, p=1.000), 5) QTc derived from 24-hour electrocardiography > 440 msec (men) or > 450 msec (women) (18% vs 18%, p=1.000), 6) deceleration capacity ≤ 4.5 msec and heart rate turbulence onset ≥ 0% and slope ≤ 2.5 msec (3% vs 4%. p=1.000) and 7) ambulatory T-wave alternans ≥ 65μV in two Holter channels (6% vs 8%, p=0.755) were similar between the two measurements. However, 5 patients (6.3%) without any NIRFs during the first assessment had at least one positive NIRF at the second assessment and 6 patients (7.5%) with at least one NIRF at baseline had no positive NIRFs at one year.Conclusion: While the prevalence of the examined electrocardiographic NIRFs in post-MI patients with preserved LVEF between the two examinations was similar on a population basis, some patients without NIRFs at baseline developed NIRFs at one year and vice versa, highlighting the need for risk factor reassessment during follow-up

Antithrombotic Therapy in Chronic Total Occlusion Interventions

Chronic total occlusion (CTO) recanalization is among the most complex subsets of coronary interventions. Hence, optimum peri- and post-procedural anticoagulation and antiplatelet therapy is key for the achievement of successful revascularization and reduction of major adverse cardiovascular outcomes in patients undergoing CTO percutaneous coronary intervention (PCI). Unfractionated heparin is still considered the gold standard anticoagulant because its action can be reversed by protamine administration, with bivalirudin being reserved mainly for patients with heparin-induced thrombocytopenia. However, small studies comparing unfractionated heparin with bivalirudin in CTO interventions have shown similar outcomes. Glycoprotein IIb/IIIa inhibitors should, in general, be avoided. Aspirin in combination with clopidogrel for 6–12 months is the standard post CTO PCI dual antiplatelet regimen. For the most complex cases, clopidogrel can be substituted by a more potent P2Y12 inhibitor, namely ticagrelor or prasugrel

Use of Optical Coherence Tomography in MI with Non-obstructive Coronary Arteries

MI with non-obstructive coronary arteries (MINOCA) comprises an important minority of cases of acute MI. Many different causes have been implicated in the pathogenetic mechanism of MINOCA. Optical coherence tomography (OCT) is an indispensable tool for recognising the underlying pathogenetic mechanism when epicardial pathology is suspected. OCT can reliably identify coronary lesions not apparent on conventional coronary angiography and discriminate the various phenotypes. Plaque rupture and plaque erosion are the most frequently found atherosclerotic causes of MINOCA. Furthermore, OCT can contribute to the identification of ischaemic non-atherosclerotic causes of MINOCA, such as spontaneous coronary artery dissection, coronary spasm and lone thrombus. Recognition of the exact cause will enable therapeutic management to be tailored accordingly. The combination of OCT with cardiac magnetic resonance can set a definite diagnosis in the vast majority of MINOCA patients

The role of intravascular imaging in chronic total occlusion percutaneous coronary intervention

Chronic total occlusions (CTOs) represent the most complex subset of coronary artery disease and therefore careful planning of CTO percutaneous coronary recanalization (PCI) strategy is of paramount importance aiming to achieve procedural success, and improve patient's safety and post CTO PCI outcomes. Intravascular imaging has an essential role in facilitating CTO PCΙ. First, intravascular ultrasound (IVUS), due to its higher penetration depth compared to optical coherence tomography (OCT), and the additional capacity of real-time imaging without need for contrast injection is considered the preferred imaging modality for CTO PCI. Secondly, IVUS can be used to resolve proximal cap ambiguity, facilitate wire re-entry when dissection and re-entry strategies are applied and most importantly to guide stent deployment and optimization post implantation. The role of OCT during CTO PCI is currently limited to stent sizing and optimization, however, due to its high spatial resolution, OCT is ideal for detecting stent edge dissections and strut malapposition. In this review, we describe the use of intravascular imaging for lesion crossing, plaque characterization and wire tracking, extra- or intra-plaque, and stent sizing and optimization during CTO PCI and summarize the findings of the major studies in this field

In-Stent Restenosis in Saphenous Vein Grafts (from the DIVA Trial)

Saphenous vein grafts (SVGs) have high rates of in-stent restenosis (ISR). We compared the baseline clinical and angiographic characteristics of patients and lesions that did develop ISR with those who did not develop ISR during a median follow-up of 2.7 years in the DIVA study (NCT01121224). We also examined the ISR types using the Mehran classification. ISR developed in 119 out of the 575 DIVA patients (21%), with similar incidence among patients with drug-eluting stents and bare-metal stents (BMS) (21% vs 21%, p = 0.957). Patients in the ISR group were younger (67 ± 7 vs 69 ± 8 years, p = 0.04) and less likely to have heart failure (27% vs 38%, p = 0.03) and SVG lesions with Thrombolysis In Myocardial Infarction 3 flow before the intervention (77% vs 83%, p <0.01), but had a higher number of target SVG lesions (1.33 ± 0.64 vs 1.16 ± 0.42, p <0.01), more stents implanted in the target SVG lesions (1.52 ± 0.80 vs 1.31 ± 0.66, p <0.01), and longer total stent length (31.37 ± 22.11 vs 25.64 ± 17.42 mm, p = 0.01). The incidence of diffuse ISR was similar in patients who received drug-eluting-stents and BMS (57% vs 54%, p = 0.94), but BMS patients were more likely to develop occlusive restenosis (17% vs 33%, p = 0.05). © 202

Temporal changes of non-invasive risk factors for sudden death in patients with myocardial infarction and preserved ejection fraction

Background: Several noninvasive risk factors (NIRFs) have been proposed for sudden cardiac death risk stratification in post-myocardial infarction (post-MI) patients with preserved left ventricular ejection fraction (LVEF). However, it remains unclear if these factors change over time. We aimed to examine the presence of NIRFs temporal changes in the previously mentioned group of patients. Methods: We evaluated seven electrocardiographic NIRFs as they were described in the PRESERVE EF trial in 80 post-MI patients with LVEF ≥ 40%, at least 40 days after revascularization and one year later. Results: Mean patient age was 56 ± 10 years and 88% were men. Mean LVEF was 50 ± 5%. The prevalence of 1) positive late potentials (28% vs 29%, p=0.860), 2) >30 premature ventricular complexes/hour (9% vs 11%, p=0.598), 3) non-sustained ventricular tachycardia (9% vs 5%, p=0.349), 4) standard deviation of the normal-to-normal R-R intervals 440 msec (men) or > 450 msec (women) (18% vs 18%, p=1.000), 6) deceleration capacity ≤ 4.5 msec and heart rate turbulence onset ≥ 0% and slope ≤ 2.5 msec (3% vs 4%. p=1.000) and 7) ambulatory T-wave alternans ≥ 65μV in two Holter channels (6% vs 8%, p=0.755) were similar between the two measurements. However, 5 patients (6.3%) without any NIRFs during the first assessment had at least one positive NIRF at the second assessment and 6 patients (7.5%) with at least one NIRF at baseline had no positive NIRFs at one year. Conclusion: While the prevalence of the examined electrocardiographic NIRFs in post-MI patients with preserved LVEF between the two examinations was similar on a population basis, some patients without NIRFs at baseline developed NIRFs at one year and vice versa, highlighting the need for risk factor reassessment during follow-up.Εισαγωγή: Πολλαπλοί αναίμακτοι ηλεκτροκαρδιογραφικοί δείκτες διαστρωμάτωσης κινδύνου (ΑΔΔΚ) για αιφνίδιο καρδιακό θάνατο έχουν προταθεί σε μετεμφραγματικούς ασθενείς με διατηρημένο κλάσμα εξώθησης αριστεράς κοιλίας (ΚΕΑΚ). Ωστόσο, παραμένει άγνωστο αν οι δείκτες αυτοί μεταβάλλονται προϊόντος του χρόνου. Σκοπός της μελέτης ήταν η εκτίμηση πιθανών χρονικών μεταβολών που υφίστανται οι εν λόγω δείκτες στη συγκεκριμένη ομάδα μετεμφραγματικών ασθενών. Μέθοδοι: Μελετήσαμε 7 ΑΔΔΚ, όπως αυτοί περιγράφονται στη μελέτη PRESERVE EF, σε 80 μετεμφραγματικούς ασθενείς με ΚΕΑΚ ≥ 40% τουλάχιστον 40 ημέρες μετά την επαναιμάτωση καθώς και ένα χρόνο αργότερα. Αποτελέσματα: Η μέση ηλικία των ασθενών ήταν 56 ± 10 έτη και το 88% ήταν άντρες. Το μέσο ΚΕAK ήταν 50 ± 5%. Ο επιπολασμός 1) των θετικών όψιμων δυναμικών (LPS) σε 45λεπτο ηλεκτροκαρδιογράφημα συγκερασμού σε ηρεμία (28% vs 29%, p=0,860), 2) της εμφάνισης >30 εκτάκτων κοιλιακών συστολών/ώρα (9 % vs 11%, p=0,598), 3) της εμφάνισης μη εμμένουσας κοιλιακής ταχυκαρδίας (9% vs 5%, p=0,349), 4) της τυπικής απόκλισης του RR διαστήματος (SDNN) 440 msec (άντρες) ή > 450 msec (γυναίκες) (18% vs 18%, p=1,000), 6) της ικανότητα επιβράδυνσης του καρδιακού ρυθμού (DC) ≤ 4,5 msec και στροβιλισμού του καρδιακού ρυθμού (HRT) ≥0% (έναρξη/onset) και ≤2,5 msec (κλίση/slope) (3% vs 4%, p=1,000) και τέλος, 7) της τιμής του εναλλασσόμενου του κύματος T (T-wave alternans) ≥ 65μV σε δύο κανάλια κατά την 24ωρη ηλεκτροκαρδιογραφική καταγραφή (6% vs 8%, p=0,755) ήταν παρόμοιος κατά τις δύο μετρήσεις. Όσον αφορά στις απόλυτες τιμές των συνεχών μεταβλητών, δεν ανευρέθη καμία στατιστικά σημαντική διαφορά μεταξύ των δύο μετρήσεων. Ωστόσο, 5 ασθενείς (6,3%) χωρίς ΑΔΔΚ κατά την πρώτη εξέταση είχαν τουλάχιστον ένα θετικό ΑΔΔΚ κατά τη δεύτερη εξέταση ενώ 6 ασθενείς (7,5%) με ένα τουλάχιστον ΑΔΔΚ κατά την πρώτη εξέταση δεν είχαν κανένα ΑΔΔΚ κατά τη δεύτερη εξέταση. Συμπέρασμα: Ενώ ο επιπολασμός των ΑΔΔΚ στους μετεμφραγματικούς ασθενείς με διατηρημένο ΚΕΑΚ ήταν παρόμοιος σε επίπεδο πληθυσμού κατά τις δύο μετρήσεις, κάποιοι ασθενείς χωρίς θετικούς ΑΔΔΚ στην πρώτη μέτρηση, ανέπτυξαν θετικούς ΑΔΔΚ μετά από ένα έτος κατά τη δεύτερη μέτρηση, καθώς και το αντίστροφο, καταδεικνύοντας την ανάγκη για επαναληπτική μέτρηση των δεικτών αυτών κατά τον επανέλεγχο των ασθενών

An alternative treatment strategy for large vessel coronary perforations

The standard treatment for large vessel coronary perforations is implantation of a covered stent. Antegrade attempts for crossing a right coronary artery chronic total occlusion resulted in guidewire and microcatheter exit with pericardial bleeding. A balloon was inflated proximal to the perforation site to achieve temporary hemostasis. Retrograde crossing of the chronic total occlusion was achieved through an epicardial collateral using the reverse controlled antegrade and retrograde tracking technique. Stent implantation resulted in hemostasis, likely due to creation of a subintimal flap that sealed the perforation site. If technically feasible, subintimal recanalization can be an alternative treatment strategy for coronary perforations occurring during chronic total occlusion percutaneous coronary intervention

Staged revascularization in patients with acute coronary syndromes due to saphenous vein graft failure and chronic total occlusion of the native vessel

Percutaneous coronary intervention of saphenous vein graft (SVG) lesions can be challenging due to high risk for acute and long-term complications. Treating the corresponding native coronary artery lesion(s) is preferable, but may not be feasible in the acute setting, due to high technical difficulty, especially when the native coronary lesion is a chronic total occlusion (CTO). We describe a novel concept of "staged revascularization" in patients presenting with an acute coronary syndrome due to SVG failure, whose native coronary artery supplied by the SVG has a CTO. In the first stage, the culprit SVG lesion is treated restoring flow to the supplied myocardium and minimizing the extent of myocardial injury. During the second stage (typically few weeks later), revascularization of the corresponding native coronary artery lesion(s) is performed, often using the initially treated SVG for retrograde crossing of the native coronary artery CTO. We describe two cases of non-ST segment elevation acute myocardial infarction due to SVG failure that were treated with "staged revascularization": the culprit SVG was initially treated followed by staged revascularization of the corresponding native coronary artery CTO. Staged revascularization of SVG lesions causing acute coronary syndromes may allow optimization of both acute and long-term outcomes