Procedural and Technological Innovations Facilitating Ultra-low Contrast Percutaneous Coronary Interventions

Ultra-low-dose contrast percutaneous coronary intervention (PCI) is a valuable approach in selected complex high-risk patients with renal failure. One of the objectives of ultra-low contrast PCI is to decrease the probability of developing postprocedural contrast-induced nephropathy (CIN), which predominately affects patients with baseline renal dysfunction. CIN is associated with poor clinical outcomes and increased healthcare-related costs. Another two clinical scenarios in which reduced dependence on contrast administration by the operator may contribute to improved safety are PCI in complex, high-risk indicated patients and in shock. In this review, we discuss the procedural techniques and recent technological innovations that enable ultra-low-dose contrast PCI to be performed in the cardiac cath lab

Soft nanostructures out of star-shaped triazines with flexible amide spacers: liquid crystals with a cubic to columnar transition with memory effect, gels and supramolecular chirality

This work reports the synthesis and characterization of a new family of star-shaped tricarboxamides with C3-symmetry that have flexible amide spacers linking a tris(triazolyl)triazine core with three trialkoxyphenyl groups. The presence of amide groups allows the formation of intermolecular hydrogen bonds that reinforce π-stacking and van der Waals interactions, promoting liquid crystalline behavior, and self-assembly in solvents leading to organogels. As determined by polarized optical microscopy, differential scanning calorimetry and X-ray diffraction on powder samples, all the three reported molecules present a hexagonal columnar (Colh) phase stable at room temperature. Interestingly, they show a transition to a cubic micellar mesophase (BCC) at high temperatures. A mechanism for this transition, which is consistent with the fragmentation of columns to form supramolecular spheres, was elucidated from X-ray studies on aligned samples. Moreover, on cooling from the BCC to the columnar phase a preferential orientation of columns occurs, according to which each cubic domain gives rise to four hexagonal domains. The ability of the synthesized structures to aggregate in solvent media was studied in a variety of organic solvents, and all of them were able to gel 1-octanol at low concentrations. X-ray studies of gels and xerogels were carried out and showed a molecular organization consistent with Colh order. FTIR studies were carried out to analyze the formation of hydrogen bonds and the influence of the length of the flexible spacer in the liquid crystalline state and in the organogels. Furthermore, the presence of a stereogenic center in the flexible amide spacer leads to macroscopic chirality in the liquid crystal state and the organogels in 1-octanol as demonstrated by circular dichroism spectroscopy.This work was financially supported by the Spanish projects PGC2018-093761-B-C31, PID2021-122882NB-I00, PID2021-126132NB-I00 MCIN/AEI/10.13039/501100011033/ and by “ERDF A way of making Europe”, the Gobierno de Aragón-FSE (E47_20R-research group) and the Basque Goverment (Project IT1458-22)

¿Viable o no viable? El problema del manejo de la enfermedad coronaria muy avanzada

Patients with very advanced coronary disease are a hard challenge for the clinician. This clinical report is a good example, with a patient with very extensive and severe arteriosclerosis in several vascular territories that debuted as acute leg arterial ischemia but in which the coronary disease became the worst problem. Despite myocardial viability demonstration, the extent and complexity of coronary lesions made it impossible treat them. In this kind of cases, although we know what the ideal treatment should be, the trip ends without reaching the goal of the revascularization.Los pacientes con enfermedad coronaria muy avanzada son todo un reto para el clínico. Este caso clínico es un buen ejemplo de ello, con un paciente con arterioesclerosis muy extensa y grave en varios territorios vasculares que debuta con isquemia arterial aguda, pero en el que la evolución predomina la disfunción ventricular por enfermedad coronaria. A pesar de demostrar viabilidad miocárdica en las pruebas de imagen, la extensión y complejidad de las lesiones hizo que no fuera posible tratarlas. En casos como éste, a pesar de que se conoce cuál es el tratamiento ideal, el viaje termina sin alcanzar la orilla de la revascularización

Ductus arterioso persistente en el adulto: a propósito de un caso

Patent ductus arteriosus is a rare congenital heart disease in adults and usually presents as a single anomaly. It is important for the clinical cardiologist to identify cases with patent ductus whose resultant left-to-right shunt is causing pressure overload in cardiac cavities as well as pulmonary hypertension due to hyperaflux. In these cases, closure is indicated, and currently the percutaneous occlusion is the first line of treatment, if the anatomy allows it. Surgical closure in adults involves risks due to anatomical and histological changes, and is relegated a second line.El conducto arterioso persistente es una cardiopatía congénita poco frecuente en el adulto y suele presentarse como anomalía única. Es importante para el cardiólogo clínico la identificación de los casos con ductus permeable cuyo cortocircuito izquierda-derecha resultante está causando sobrecarga de presiones en las cavidades cardíacas, así como hipertensión pulmonar por hiperaflujo. En estos casos está indicado el cierre, siendo en la actualidad la oclusión percutánea la primera línea de tratamiento, si la anatomía lo permite. El cierre quirúrgico en adultos implica un mayor riesgo debido a sus cambios anatómicos e histológicos, y se considera una opción de segunda línea

Safety of coronary revascularization deferral based on fractional flow reserve and instantaneous wave-free ratio in patients with chronic kidney disease

Background: The safety of revascularization deferral according to pressure wire examination in patients with chronic kidney disease (CKD) has not been fully established. Methods: From a retrospective cohort of 439 patients in whom revascularization was deferred after physiological assessment, we examined the incidence of patient-oriented composite endpoint (POCE: all-cause death, myocardial infarction [MI] and unplanned revascularization) in patients with CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2) and without it. Results: At 4 years of follow-up, the primary endpoint was met by 25.0% of patients with CKD and by 14.4% of patients without CKD (hazard ratio [HR] 1.56, 95% confidence interval [CI] 0.96–2.53, p = 0.071). The incidence of POCE was even higher in patients with an eGFR < 30 mL/min/1.73 m2: 43.8% (HR 3.10, 95% CI 1.08–8.92, p = 0.036). However, no differences were observed in the incidence of MI (4.2% vs. 4.4% in non-CKD), target vessel revascularization (5.8% vs. 5.9%), and target vessel MI (0.8% vs. 4.6%). Conclusions: Patients with CKD in whom pressure-wire evaluation led to deferral of coronary revascularization develop more POCE in the long term, compared to patients with normal renal function. However, the increase in POCE in patients with CKD was seldom related to deferred vessels, thus suggesting an epiphenomenon of an intrinsically higher cardiovascular risk of CKD patients

Age‐related changes in the coronary microcirculation influencing the diagnostic performance of invasive pressure‐based indices and long‐term patient prognosis

Objectives Investigate age-related changes in coronary microvascular function, its effect on hyperemic and non-hyperemic indices of stenosis relevance, and its prognostic implications. Background Evidence assessing the effect of age on fractional flow reserve (FFR), resting mean distal intracoronary pressure/mean aortic pressure (Pd/Pa), and microcirculatory function remains scarce. Methods This is a post hoc study of a large prospective international registry (NCT03690713) including 1134 patients (1326 vessels) with coronary stenoses interrogated with pressure and flow guidewires. Age-dependent correlations with functional indices were analyzed. Prevalences of FFR, resting Pd/Pa, and coronary flow reserve (CFR) classification agreement were assessed. At 5 years follow-up, the relation between resting Pd/Pa, CFR, and their age-dependent implications on FFR-guided percutaneous coronary intervention (PCI) deferral (deferred if FFR > 0.80) were investigated using vessel-oriented composite outcomes (VOCO) composed of death, myocardial infarction, and repeated revascularization. Results Age correlated positively with FFR (r = 0.08, 95% confidence interval [CI]: 0.03 to 0.13, p =  0.005), but not with resting Pd/Pa (r = −0.03, 95% CI:−0.09 to 0.02, p = 0.242). CFR correlated negatively with age (r = −0.15, 95% CI: −0.21 to −0.10, p < 0.001) due to a significant decrease in maximal hyperemic flow in older patients. Patients over 60 years of age with FFR-guided deferred-PCI abnormal resting Pd/Pa or abnormal CFR had increased risk of VOCO (hazard ratio [HR]: 2.10, 95% CI: 1.15 to 4.36, p = 0.048; HR: 2.46, 95% CI:1.23 to 4.96, p = 0.011; respectively). Conlusions Aging is associated with decrease in microcirculatory vasodilation, as assessed with adenosine-based methods like CFR. In patients older than 60 years in whom PCI is deferred according to FFR > 0.80, CFR and resting Pd/Pa have an incremental value in predicting future vessel-oriented patient outcomes

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

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