Bioresorbable scaffold - A magic bullet for the treatment of coronary artery disease?

Today, drug-eluting metal stents are considered the gold standard for interventional treatment of coronary artery disease. While providing inhibition of neointimal hyperplasia, drug-eluting metal stents have many limitations such as the risk of late and very late stent thrombosis, restriction of vascular vasomotion and chronic local inflammatory reaction due to permanent implantation of a 'metallic cage', recognized as a foreign body. Bioresorbable scaffold stents (BRS) are a new solution, which is trying to overcome the limitation of the 'metallic cage'. This structure provides short-term scaffolding of the vessel and then disappears, leaving nothing behind. The purpose of this review is to present the theoretical rationale for the use of BRS and to outline the clinical outcomes associated with their use in terms of data obtained from RCTs, clinical trials, registries and real life use. We have also tried to answer all questions on this intervention based on available data, with a focus on ABSORB BVS (Abbott Vascular, Santa Clara, USA). We consider that this new technology can be the "magic bullet" to treat coronary artery disease

RENO, a European Postmarket Surveillance Registry, confirms effectiveness of coronary brachytheraypy in routine clinical practice.

Purpose: To assess, by a European registry trial, the clinical event rate in patients with discrete stenotic lesions of coronary arteries (de novo or restenotic) in single or multiple vessels (native or bypass grafts) treated with -radiation. Methods and Materials: Between April 1999 and September 2000, 1098 consecutive patients treated in 46 centers in Europe and the Middle East with the Novoste Beta-Cath System were included in Registry Novoste (RENO). Results: Six-month follow-up data were obtained for 1085 patients. Of 1174 target lesions, 94.1% were located in native vessels and 5.9% in a bypass graft; 17.7% were de novo lesions, 4.1% were restenotic, and 77.7% were in-stent restenotic lesions. Intravascular brachytherapy was technically successful in 95.9% of lesions. Multisegmental irradiation, using a manual pullback stepping maneuver to treat longer lesions, was used in 16.3% of the procedures. The in-hospital rate of major adverse cardiac events was 1.8%. At 6 months, the rate was 18.7%. Angiographic follow-up was available for 70.4% of the patients. Nonocclusive restenosis was seen in 18.8% and total occlusion in 5.7% of patients. A combined end point for late (30–180 days) definitive or suspected target vessel closure was reached in 5.4%, but with only 2% of clinical events. Multivariate analysis was performed for major adverse cardiac events and late thrombosis. Conclusion: Data obtained from the multicenter RENO registry study, derived from a large cohort of unselected consecutive patients, suggest that the good results of recent randomized controlled clinical trials can be replicated in routine clinical practice. © 2003 Elsevier Science Inc

Computed tomography angiography for the interventional cardiologist

WOS:000339902400002In recent years, coronary CT angiography (CCTA) has become a widely adopted technique, not only due to its high diagnostic accuracy, but also to the fact that CCTA provides a comprehensive evaluation of the total (obstructive and non-obstructive) coronary atherosclerotic burden. More recently, this technique has become mature, with a large body of evidence addressing its prognostic validation. In addition, CT angiography has moved from the field of `imagers' and clinicians and entered the interventional cardiology arena, aiding in the planning of both coronary and structural heart interventions, being transcatheter aortic valve implantation one of its most successful examples. It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes. On the other hand, the increasing use of CCTA as a gatekeeper for invasive coronary angiography is expected to lead to an increase in the ratio of interventional to diagnostic procedures and significant changes in the daily cath-lab routine. In a foreseeable future, cath-labs will probably offer an invasive procedure only to patients expected to undergo an intervention, perhaps becoming in this change true interventional-labs.publishersversionpublishe

Argatroban During Percutaneous Transluminal Coronary Angioplasty: Results of a Dose-Verification Study.

Background. Thrombin is a key enzyme in thrombogenesis. In animals, specific antithrombotic therapy at the time of coronary angioplasty reduced the incidence of subacute occlusion and inhibited the restenosis response. Argatroban is a highly selective synthetic thrombin antagonist that binds in a competitive manner. This is a report of a dose-verification study, assessing the safety and feasibility of intravenous Argatroban administration in patients undergoing percutaneous transluminal coronary angioplasty. Methods. Before angioplasty an intravenous bolus of 30 g/kg argatroban was administered, followed by a continuous infusion of 3.5 g/kg/min for 72 hours. Bolus injection was repeated, and the infusion rate was increased in order to achieve an activated coagulation time (ACT) of over 300 seconds. Following interim analysis, the bolus and initial infusion rate for the subsequent treatment groups was determined. Study endpoints were the occurrence of adverse events, coagulation tests, and qualitative angiogram reading. Patients were monitored by continuous 12-lead electrocardiographic recording over 24 hours, and underwent control angiography 18–24 hours following angioplasty. Results. Four treatment groups, comprised of 2, 8, 9, and 11 patients, respectively, were studied. The first two patients were excluded from analysis, since the initial dose was ineffective to attain an ACT-authorizing coronary angioplasty. The group with the highest dosage received a 250 g/kg intravenous bolus of argatroban, followed by a 4 hour infusion of 15 g/kg/min. At 4 hours the infusion rate was lowered to 3.8 g/kg/min and was continued for 68 hours without adjustment for catheter removal. The adverse event profile included myocardial infarction, aortocoronary bypass graft, bailout procedures, and repeat coronary angioplasty. Thrombin-time (TT), activated partial thromboplastin time (APTT), and prothrombin time (PT) were significantly related to argatroban plasma concentration, as demonstrated by regression analyses (R-square 0.64, 0.71, and 0.84, respectively). Prothrombin fragments 1 and 2 and thrombin-antithrombin III complex did not fit into a mathematical model, but showed slightly increased levels after reduction or cessation of the infusion rate. Conclusions. This dose-verification study, including 30 patients at four dose levels, indicated that argatroban infusion in coronary angioplasty patients can be administered safely, and results in an adequate and predictable level of anticoagulation

Aortic valvuloplasty of calcific aortic stenosis with monofoil and trefoil balloon catheters: practical considerations

In order to evaluate the relation between balloon design (monofoil, trefoil) and valvular configuration, experimental aortic valvuloplasty was performed in four post-mortem hearts with calcific aortic sten