New perspectives in percutaneous coronary intervention based on an integrated approach of imaging and physiology

In this thesis we investigated: a) the prognostic role of FFR in functional evaluation of epicardial stenosis in different anatomical and clinical settings of patients with stable CAD, heart valve disease and LVD; b) the role of IMR, CFR and absolute coronary flow and microvascular resistances assessment with a new dedicated thermodilution catheter; c) the diagnostic performance of two new angiography-derived FFR technologies for a quantitative and functional assessment of CAD; d) the impact of antiplatelet agents and BVS Absorb™ implantantion on procedure-related microvascular impairment, platelet activation and the related myonecrosis; e) the safety and feasibility of new 2-stent bifurcation techniques and the clinical outcome of known bifurcations techniques. We believe that many answers have been provided by our extensive translational research. FFR remains the milestone in functional assessment of the ischemic burden related to coronary stenoses. Our findings corroborate the strong clinical outcome background of FFR, supporting FFR-guided revascularization strategies above angio-based decision making, and therefore strongly discouraging any purely anatomy guided revascularization attempts in different clinical and anatomical settings. Absolute coronary blood flow (Q) and microvascular resistance (R) can be safely and reproducibly measured with continuous thermodilution, opening new opportunities for the study of the coronary microcirculation. FFRangio and QFR provide both a comprehensive physiological assessment of the entire coronary tree within few minutes, enabling online FFR measurement during the angiographic procedure. This, in turn, may facilitate the adoption of FFR-based clinical decision making regarding coronary revascularization. Both prasugrel and BVS Abosrb™ have proven a beneficial acute effect on peri-procedural coronary microvascular function and platelet activation. Although BVS Absorb™ did not live up to its promise because of the higher events in the mid-term due to greater scaffold thrombosis, our findings are at least reassuring on the acute impact of these devices on the microcirculation. Lastly in PCI of bifurcation lesions, our feasibility results of in vitro tests, offer new solutions for both complex anatomy requiring 2-stent-technique and bailout technique in case of failure of the most consolidated provisional T-stenting

From debulking to delivery: sequential use of rotational atherectomy and Guidezilla™ for complex saphenous vein grafts intervention

Percutaneous coronary interventions (PCI) of old calcified saphenous vein grafts (SVGs) is challenging and is associated with a considerably high risk of adverse ischemic events in the short- and long-term as compared to native coronary arteries. We report a case in which a non-dilatable, calcified SVG lesion is successfully treated with rotational atherectomy followed by PCI and stenting with local stent delivery (LSD) technique using the Guidezilla™ guide extension catheter (5-in-6 Fr) in the "child-in-mother" fashion

ST-segment elevation during levosimendan infusion

Levosimendan increases the sensitivity of the heart to calcium and consequently exerts positive inotropic effects. Levosimendan is indicated in acutely decompensated severe congestive heart failure. We report that levosimendan infusion may induce myocardial ischemia in patients with acute heart failure. J Cardiovasc Med 2012, 13:454-45

An Update on New Generation Transcatheter Aortic Valves and Delivery Systems

Over the last 15 years, the management of aortic valve disease has been changed by transcatheter aortic valve replacement, which has become the standard of care across the entire spectrum of surgical risk. As a result of continuous evolution of this technique, several next-generation transcatheter heart valves (THVs) have been developed to minimize procedural complications and improve patient outcomes. This review aims to provide an update on the new generation THVs and delivery systems

High platelet reactivity and periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention: A significant association beyond definitions

No abstract availabl

Fractional flow reserveto guide and to assesscoronary artery bypass grafting

The aim of this review is to highlight the role of invasive functional evaluation in patients in whom coronary artery bypass graft (CABG) is indicated, and to examine the clinical evidence available in favour of fractional flow reserve (FFR) adoption in these patients, outline appropriate use, as well as point out potential pitfalls. FFR after CABG will also be reviewed, highlighting its correct interpretation and adoption when applied to both native coronary arteries and bypass grafts. Practice European guidelines support the use of FFR to complement coronary angiography with the highest degree of recommendation (Class IA) for the assessment of coronary stenosis before undertaking myocardial revascularization when previous non-invasive functional evaluation is unavailable or not conclusive. As a result, FFR has been adopted in routine clinical practice to guide clinicians decision as to whether or not perform a revascularization. Of note, due to the increasing confidence of the interventional cardiologists, FFR guidance is also being implemented to indicate or guide CABG. This is in anticipation of supportive clear-cut evidence, since recommendations for FFR adoption were based on randomized clinical trials investigating percutaneous coronary intervention (PCI) strategies in which patients with typical indications for CABG were excluded (e.g. left main disease, valvular disease, and coronary anatomy unsuitable for PCI). Based on the critical appraisal of the literature, FFR can play an important role in risk stratification and determining management strategy of patients either before or after CABG

Fractional flow reserveto guide and to assesscoronary artery bypass grafting

The aim of this review is to highlight the role of invasive functional evaluation in patients in whom coronary artery bypass graft (CABG) is indicated, and to examine the clinical evidence available in favour of fractional flow reserve (FFR) adoption in these patients, outline appropriate use, as well as point out potential pitfalls. FFR after CABG will also be reviewed, highlighting its correct interpretation and adoption when applied to both native coronary arteries and bypass grafts. Practice European guidelines support the use of FFR to complement coronary angiography with the highest degree of recommendation (Class IA) for the assessment of coronary stenosis before undertaking myocardial revascularization when previous non-invasive functional evaluation is unavailable or not conclusive. As a result, FFR has been adopted in routine clinical practice to guide clinicians decision as to whether or not perform a revascularization. Of note, due to the increasing confidence of the interventional cardiologists, FFR guidance is also being implemented to indicate or guide CABG. This is in anticipation of supportive clear-cut evidence, since recommendations for FFR adoption were based on randomized clinical trials investigating percutaneous coronary intervention (PCI) strategies in which patients with typical indications for CABG were excluded (e.g. left main disease, valvular disease, and coronary anatomy unsuitable for PCI). Based on the critical appraisal of the literature, FFR can play an important role in risk stratification and determining management strategy of patients either before or after CABG

Coronary lesion progression as assessed by fractional flow reserve (FFR) and angiography

To explore the evolution of coronary lesions that had repeated physiologic evaluation by FFR as an endpoint, describe the clinical significance of longitudinal FFR change (ΔFFR = FFR follow-up - FFR baseline), its correlation with angiographic indices and identify predictors of FFR follow-up