Debate. Drug-coated balloons for de novo coronary artery lesions. Still not enough evidence, and the new drug-eluting stents are still better

What is the evidence available on the use of drug-coated balloons (DCB) in the de novo lesion setting

Intracoronary Brachytherapy: a New Technique to Prevent Restenosis After Percutaneous Coronary Interventions

Percutaneous trans luminal coronary angioplasty (PTCA) is an accepted treatment for coronary artery disease. However, angiographical restenosis is reported in 40-60% of patients after a successful PTCA. Mechanisms involved in the restenosis process are elastic recoil of the artery, local thrombus formation, vascular remodeling with shrinkage of the vessel and an overact healing process with neointimal hyperplasia. Neointimal hyperplasia develops by migration and proliferation of smooth muscle cells and myofibroblasts after balloon induced trauma of the arterial wall and by deposition of an extracellular matrix by the smooth muscle cells. The introduction of the stent in the arsenal of the interventional cardiologist has reduced the restenosis rate to 15-20%, by preventing elastic recoil and negative remodeling. However, the occurrence of restenosis after stent implantation remains unresolved, especially in small vessels and long lesions, where it may exceed 30% of the cases. It is primary caused by neointimal hyperplasia, which occurs due to trauma of the arterial wall b

Energy use and energy efficiency, the way to reduce energy consumption in university buildings

The Technical University of Catalonia (UPC) has been developing since 1996 a number of actions and strategies to reduce the energy consumption of its 96 buildings. From the collaboration agreement signed in 2006 with the Catalan Institute of Energy (ICAEN), UPC has agreed to develop measures to encourage energy savings and enhance energy efficiency on its own buildings, distributed over ten campuses. One of the first actions carried out was the implementation of the Resource Consumption Efficiency Plan (PECR), which culminated in 29 energy audits carried out on different types of buildings: schools, sports facilities, libraries and administration buildings and services. These were performed by Technical Architecture and Building Engineering students as a Final Degree Project.Peer ReviewedPostprint (published version

Percutaneous Coronary Intervention in Diabetic Patients

Cardiovascular disease (CVD) is responsible for 30% of deaths worldwide and is the leading cause of premature mortality in patients with diabetes mellitus (DM). One of the main contributors to the increased atherothrombotic risk in DM patients relates to their pro- inflammatory and prothrombotic status that involves abnormalities in endothelial and vascular smooth muscle cells, in platelet function and the coagulation cascade. The characteristics of CAD in diabetic patients is distinctive and infers an increased risk. Likewise, CAD in diabetics is characterised by being diffuse, affecting the left main stem more frequently, involving multiple vessels, and also affecting the distal coronary tree. Percutaneous coronary intervention in diabetics has been shown to have less favourable long-term clinical outcomes, compared to non-diabetics. With the advent of improved stent designs and antiplatelet drugs; the percutaneous coronary intervention (PCI) results have improved in the diabetic population. However, one of the main determinants of poorer outcomes in DM is the progression of atherosclerosis, which is more pronounced in diabetics and remains the primary cause of cardiac events at one year follow up after percutaneous revascularisation. Whilst new generation of drug-eluting stents has narrowed the gap between surgery and PCI in diabetic patients, coronary artery bypass grafting (CABG) remains the gold standard in diabetics with diffuse multivessel coronary artery disease

Very long-term efficacy and safety of paclitaxel-eluting balloon after a bare-metal stent for the treatment of ST-elevation myocardial infarction: 8-year results of a randomized clinical trial (PEBSI study)

Drug-eluting stents; Drug-coated balloons; Myocardial infarctionStents alliberadors de fàrmacs; Globus recoberts de fàrmacs; Infart de miocardiStents liberadores de fármacos; Globos recubiertos de fármacos; Infarto de miocardioBackground: Drug-eluting stents (DES) are considered the therapy of choice in ST-segment elevation myocardial infarction (STEMI); however, a low persistent rate of revascularizations and stent thrombosis exist over the time. We have previously shown that a paclitaxel (PTX)-drug-coated balloon (DCB) after a bare-metal stent (BMS) implantation (DCB-combined strategy) yields superior angiographic and clinical results compared to BMS in the short term. However, the long-term safety and efficacy of this approach remain uncertain. Methods: An 8-year clinical follow-up was conducted on patients enrolled in the randomized PEBSI-1 trial (NCT01839890). The original trial included patients who suffered a STEMI, patients were randomly assigned to receive a DCB-combined strategy or BMS only and the primary endpoint was in-stent late luminal loss (LLL) at 9-month follow-up. After the completion of this study, death, myocardial re-infarction, ischemia-driven repeated revascularizations included target lesion revascularization (TLR) and target vessel revascularization (TVR), and stent thrombosis, were assessed by yearly contact by a clinical visit, telephone or by electronic records. These outcomes were adhered to ARC-2 criteria. Results: The rate of incomplete follow-up was very low, with only 3 out of 111 patients (2.7%) in the DCB-combined strategy group and 1 out of 112 patients (0.9%) in the BMS group. At 8 years there were a lower rate of TVR [3.7% vs. 14.3%; hazard ratio (HR): 0.243; 95% confidence interval (CI): 0.081–0.727; P=0.006], and a trend towards lower TLR (2.8% vs. 8.9%; HR: 0.300; 95% CI: 0.083–1.090; P=0.052) in the DCB-combined strategy group. No statistical difference between the DCB-combined strategy and BMS groups were found for all causes of death, deaths from cardiovascular disease, reinfarctions or stent thrombosis. Notably in the DCB-combined strategy group, no episode of stent thrombosis occurred after the first year. Similarly, there were no cardiovascular deaths, TVR and TLR in the DCB-combined strategy group after 5 years. In contrast, during the period from year 5 to 8, the BMS group experienced an additional cardiovascular death, as well as one case of TVR, one case of TLR, and one case of stent thrombosis. Conclusions: In STEMI patients, the DCB-combined strategy maintains its safety and clinical efficacy over time. Our rates of TVR, TLR, and very late stent thrombosis (VLST) at very long-term are the lowest ever found in a STEMI trial. Further studies are warranted to assess the potential superiority of this novel strategy as compared with new-generation DES to prevent very late events in these patients. Trial Registration: ClinicalTrials.gov; identifier: NCT01839890.This investigation has received the support of the Spanish Clinical Research Network (SCReN), financed by the ISCIII-Subdirección General de Evaluación y Fomento de la Investigación, under the project PT13/0002/0005 (Plan Estatal de I+D+I 2013-2016) and co-funded by the European Regional Development Fund (FEDER). An unrestricted research grant was received from Biotronik

Timing of Complete Revascularization Stratified by Index Presentation During On- and Off-Hours

Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear. On-hours was defined as an index revascularization performed between 8:00 A.M. and 6:00 P.M., Monday to Friday, or else the procedure was defined as performed during off-hours. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. We used Cox regression models to relate randomized treatment with study end points. We evaluated multiplicative and additive interactions between on- versus off-hours and randomized treatment. The BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease) trial enrolled 1,097 and 428 patients during on- and off-hours, respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs 29.5%, p &lt;0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR, respectively, during on-hours (hazard ratio 0.80, 95% confidence interval 0.54 to 1.19). During off-hours, the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% confidence interval 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.</p

Timing of Complete Revascularization Stratified by Index Presentation During On- and Off-Hours

Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear. On-hours was defined as an index revascularization performed between 8:00 A.M. and 6:00 P.M., Monday to Friday, or else the procedure was defined as performed during off-hours. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. We used Cox regression models to relate randomized treatment with study end points. We evaluated multiplicative and additive interactions between on- versus off-hours and randomized treatment. The BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease) trial enrolled 1,097 and 428 patients during on- and off-hours, respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs 29.5%, p &lt;0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR, respectively, during on-hours (hazard ratio 0.80, 95% confidence interval 0.54 to 1.19). During off-hours, the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% confidence interval 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.</p

Fate of stent-related side branches after coronary intervention in patients with in-stent restenosis

AbstractOBJECTIVESWe sought to assess the fate of stent (ST)-related side branches (SB) after coronary intervention in patients with in-ST restenosis.BACKGROUNDIn-ST restenosis constitutes a therapeutic challenge. Although the fate of lesion-related SB after conventional angioplasty or initial coronary stenting is well established, the outcome of ST-related SB in patients with in-ST restenosis undergoing repeat intervention is unknown.METHODSOne hundred consecutive patients (age 61 ± 11 years, 22 women) undergoing repeat intervention for in-ST restenosis (101 ST) were prospectively studied. Two hundred and twenty-six SB spanned by the ST were identified. The SB size, type, ostium involvement, location within the ST and take-off angle were evaluated. The SB TIMI (Thrombolysis in Myocardial Infarction trial) flow grade was studied in detail before, during, immediately after the procedure, and at late angiography.RESULTSOcclusion (TIMI flow grade = 0) was produced in 24 (10%) SB, whereas some degree of flow deterioration (≥1 TIMI flow grade) was observed in 57 SB (25%). The SB occlusion was associated with non–Q wave myocardial infarction in two patients (both had large and diseased SB). Side-branch occlusion at the time of initial stenting (RR [relative risk] 11.1, 95% CI [confidence interval] 3.5–35.5, p < 0.001), diabetes (RR 3.5, 95% CI 1.1–10.5, p = 0.02), SB ostium involvement (RR 5.0, 95% CI 1.4–17.2, p = 0.004), baseline SB TIMI flow grade <3 (RR 5.5, 95% CI 1.7–18.1, p = 0.005), and restenosis length (RR 1.05 95% CI 1.01–1.11, p = 0.03) were identified as independent predictors of SB occlusion. Late angiography in 19 initially occluded SB revealed that 17 (89%) were patent again. The long-term clinical event-free survival (81% vs. 82% at two years) in patients with and without initial SB occlusion was similar.CONCLUSIONSOcclusion or flow deterioration of SB spanned by the ST is relatively common during repeat intervention for in-ST restenosis. Several factors (mainly anatomic features) are useful predictors of this event. However, most SB occlusions are clinically silent and frequently reappear at follow-up