Interventional cardiology in Europe 1999

Aims The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer revascularization approaches and its distribution in different regions in Europe. Methods and Results Questionnaires distributed to delegates of the national societies of cardiology represented in the European Society of Cardiology to be completed by local institutions and operators yielded that 1 452 751 angiograms and 452 019 PTCAs were performed in 1999. This is an increase of 28% and 16%, respectively, compared with 1998. Most of these increases are due to high relative increases in eastern European countries. The number of PTCAs per 106 inhabitants rose to 714 in 1999. Coronary stenting increased by 31% to about 313 000 stents implanted in 1999. Complication rates remained stable, the need for emergency coronary artery bypass grafting showing a further slight decrease to currently 0.3%. Conclusion Interventional cardiology in Europe is still growing, mainly due to rapid growth in countries with lower socio-economical levels. In some central European countries a saturation seemed to be reached with only minor increases in procedures performed. Coronary stenting remains the only noteworthy and growing complement or alternative to balloon angioplast

Percutaneous coronary interventions in Europe 1992-2001

Aims The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer re-vascularisation approaches and its distribution in different regions in Europe. We report the data of the year 2001 and give an overview of the development of coronary interventions since 1992, when the first data collection was performed. Methods and Results Questionnaires were distributed to delegates of the individual national societies of cardiology represented in the European Society of Cardiology. These were completed by the local institutions and operators and showed that 1,806,238 angiograms and 617,176 percutaneous transluminal coronary angioplasties (PTCAs) were performed in 2001. This is an increase of 10% and 17%, respectively, compared with the year 2000. The population-adjusted PTCA rate rose from nearly 800 procedures per 106 inhabitants in the year 2000 to approximately 990 procedures per 106 inhabitants in 2001. Coronary stenting increased by 25% to about 488,900 stents implanted in 2001. Complication rates remained unchanged, and the need for emergency coronary artery bypass grafting is still at 0.2% per percutaneous intervention. Conclusion Interventional cardiology in Europe is still expanding, mainly due to rapid growth in countries with lower socio-economical levels. Most central European countries reported only minor increases in procedures performed. Coronary stenting remains the only noteworthy adjunctive strategy to balloon angioplast

A broken heart in a broken car

Takotsubo syndrome (TTS) is still a relatively understudied and often undetected disease. It is usually preceded by emotional or physical triggers. We here report a case of TTS following a car accident. Typical apical ballooning with moderate reduction of left ventricular ejection fraction (LVEF) and increased level of pro-B-type natriuretic peptide (BNP) as well as slightly increased creatine kinase and troponin T values were found in this 76-year-old female patient, 6 h after a car accident. At 10 weeks follow-up, we observed a normalization of regional wall motion, LVEF, electrocardiogram and pro-BNP. TTS is an acute heart failure syndrome and an important differential diagnosis of acute coronary syndrome

Remodelling of the aortic root in severe tricuspid aortic stenosis: implications for transcatheter aortic valve implantation

Detailed knowledge of aortic root geometry is a prerequisite to anticipate complications of transcatheter aortic valve (TAV) implantation. We determined coronary ostial locations and aortic root dimensions in patients with aortic stenosis (AS) and compared these values with normal subjects using computed tomography (CT). One hundred consecutive patients with severe tricuspid AS and 100 consecutive patients without valvular pathology (referred to as the controls) undergoing cardiac dual-source CT were included. Distances from the aortic annulus (AA) to the left coronary ostium (LCO), right coronary ostium (RCO), the height of the left coronary sinus (HLS), right coronary sinus (HRS), and aortic root dimensions [diameters of AA, sinus of Valsalva (SV), and sino-tubular junction(STJ)] were measured. LCO and RCO were 14.9 ± 3.2mm (8.2-25.9) and 16.8 ± 3.6mm (12.0-25.7) in the controls, 15.5 ± 2.9mm (8.8-24.3) and 17.3 ± 3.6mm (7.3-26.0) in patients with AS. Controls and patients with AS had similar values for LCO (P = 0.18), RCO (P = 0.33) and HLS (P = 0.88), whereas HRS (P < 0.05) was significantly larger in patients with AS. AA (r = 0.55,P < 0.001), SV (r = 0.54,P < 0.001), and STJ (r = 0.52,P < 0.001) significantly correlated with the body surface area in the controls; whereas no correlation was found in patients with AS. Patients with AS had significantly larger AA (P < 0.01) and STJ (P < 0.01) diameters when compared with the controls. In patients with severe tricuspid AS, coronary ostial locations were similar to the controls, but a transverse remodelling of the aortic root was recognized. Owing to the large distribution of ostial locations and the dilatation of the aortic root, CT is recommended before TAV implantation in each patien

A PET/CT-follow-up imaging study to differentiate takotsubo cardiomyopathy from acute myocardial infarction

Takotsubo cardiomyopathy (TTC) is still an under-recognized disease and little data exists on the coexistence of TTC and obstructive coronary artery disease. Our patient case of an 80-year-old female lady highlights the impact of a positron emission tomography/computed tomography (PET/CT) follow-up imaging study to delineate this unique entity from acute coronary syndrome (ACS). Furthermore, we show for the first time that coronary flow reserve and myocardial blood flow is globally impaired in TTC and not only restricted to the non-contracting parts. This indicates a global microcirculatory impairment effect of the heart in the acute stage of TTC. Our case also demonstrates that a transient metabolic defect is also involved in this disease. Follow-up imaging by PET/CT in our patient case unmasked TTC and facilitated to exclude the differential diagnosis of ACS

Clonal restriction and predominance of regulatory T cells in coronary thrombi of patients with acute coronary syndromes

Aims Regulatory T cells (Treg) exert anti-inflammatory and atheroprotective effects in experimental atherosclerosis. Treg can be induced against specific antigens using immunization strategies associated with clonal restriction. No data exist on Treg in combination with clonal restriction of T cells in patients with acute coronary syndromes (ACS). Methods and results Among T cell subsets characterized by flow cytometry, Treg (CD4+ CD25+ CD127low) were twice as frequent in coronary thrombi compared with peripheral blood. Treg prevailed among T cell subsets identified in coronary thrombi. To evaluate clonal restriction, genomic DNA was extracted from coronary thrombi and peripheral blood in order to evaluate T cell receptor (TCR) β chain diversity by means of Multi-N-plex PCR using a primer specific for all TCR β V gene segments and another primer specific for TCR β J gene segments. T cell receptor diversity was reduced in thrombi compared with peripheral blood (intra-individual comparisons in 16 patients) with 8 gene rearrangements in the TCR common in at least 6 out of 16 analysed coronary thrombi. Compared with age-matched healthy controls (n = 16), TCR diversity was also reduced in peripheral blood of patients with ACS; these findings were independent of peripheral T cell numbers. Conclusion We provide novel evidence for a perturbed T cell compartment characterized by clonal restriction in peripheral blood and coronary thrombi from patients with ACS. Our findings warrant further studies on Treg as novel therapeutic targets aimed at enhancing this anti-inflammatory component of adaptive immunity in human atherothrombosi

Cellular actors, Toll-like receptors, and local cytokine profile in acute coronary syndromes

Aims Inflammation plays a key role in acute coronary syndromes (ACS). Toll-like receptors (TLR) on leucocytes mediate inflammation and immune responses. We characterized leucocytes and TLR expression within coronary thrombi and compared cytokine levels from the site of coronary occlusion with aortic blood (AB) in ACS patients. Methods and results In 18 ACS patients, thrombi were collected by aspiration during primary percutaneous coronary intervention. Thrombi and AB from these patients as well as AB from 10 age-matched controls without coronary artery disease were assessed by FACS analysis for cellular distribution and TLR expression. For further discrimination of ACS specificity, seven non-coronary intravascular thrombi and eight thrombi generated in vitro were analysed. In 17 additional patients, cytokine levels were determined in blood samples from the site of coronary occlusion under distal occlusion and compared with AB. In coronary thrombi from ACS, the percentage of monocytes related to the total leucocyte count was greater than in AB (47 vs. 20%, P = 0.0002). In thrombi, TLR-4 and TLR-2 were overexpressed on CD14-labelled monocytes, and TLR-2 was increased on CD66b-labelled granulocytes, in comparison with leucocytes in AB. In contrast, in vitro and non-coronary thrombi exhibited no overexpression of TLR-4. Local blood samples taken under distal occlusion revealed elevated concentrations of chemokines (IL-8, MCP-1, eotaxin, MIP-1α, and IP-10) and cytokines (IL-1ra, IL-6, IL-7, IL-12, IL-17, IFN-α, and granulocyte-macrophage colony-stimulating factor) regulating both innate and adaptive immunity (all P < 0.05). Conclusion In ACS patients, monocytes accumulate within thrombi and specifically overexpress TLR-4. Together with the local expression patterns of chemokines and cytokines, the increase of TLR-4 reflects a concerted activation of this inflammatory pathway at the site of coronary occlusion in AC

Rationale and design of the MULTISTARS AMI Trial: a randomized comparison of immediate versus staged complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease

Background: About half of patients with acute ST-segment elevation myocardial infarction (STEMI) present with multivessel coronary artery disease (MVD). Recent evidence supports complete revascularization in these patients. However, optimal timing of non-culprit lesion revascularization in STEMI patients is unknown because dedicated randomized trials on this topic are lacking. Study design: The MULTISTARS AMI trial is a prospective, international, multicenter, randomized, two-arm, open-label study planning to enroll at least 840 patients. It is designed to investigate whether immediate complete revascularization is non-inferior to staged (within 19-45 days) complete revascularization in patients in stable hemodynamic conditions presenting with STEMI and MVD and undergoing primary percutaneous coronary intervention (PCI). After successful primary PCI of the culprit artery, patients are randomized in a 1:1 ratio to immediate or staged complete revascularization. The primary endpoint is a composite of all-cause death, non-fatal myocardial infarction, ischemia-driven revascularization, hospitalization for heart failure, and stroke at 1 year. Conclusions: The MULTISTARS AMI trial tests the hypothesis that immediate complete revascularization is non-inferior to staged complete revascularization in stable patients with STEMI and MVD