Implications of a bioresorbable vascular scaffold implantation on vessel wall strain of the treated and the adjacent segments

Background Metallic stents change permanently the mechanical properties of the vessel wall. However little is known about the implications of bioresorbable vascular scaffolds (BVS) on the vessel wall strain. Methods Patients (n = 53) implanted with an Absorb BVS that had palpographic evaluation at any time point [before device implantation, immediate after treatment, at short-term (6-12 months) or mid-term follow-up (24-36 months)] were included in the current analysis. The palpographic data were used to estimate the mean of the maximum strain values and the obtained measurements were classified using the Rotterdam classification (ROC) score and expressed as ROC/mm. Results Scaffold implantation led to a significant decrease of the vessel wall strain in the treated segment [0.35 (0.20, 0.38) vs. 0.19 (0.09, 0.29); P = 0.005] but it did not affect the proximal and distal edge. In patients who had serial palpographic examination the vessel wall strain continued to decrease in the scaffolded segment at short-term [0.20 (0.12, 0.29) vs. 0.14 (0.08, 0.20); P = 0.048] and mid-term follow-up [0.20 (0.12, 0.29) vs. 0.15 (0.10, 0.19), P = 0.024]. No changes were noted with time in the mechanical properties of the vessel wall at the proximal and distal edge. Conclusions Absorb BVS implantation results in a permanent alteration of the mechanical properties of the vessel wall in the treated segment. Long term follow-up data are needed in order to examine the clinical implications of these findings

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Evolution of Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement emerged approximate to 20 years ago and changed the landscape of structural interventional cardiology. The first experiments in animal models provided proofs of the concept and the substrate for the first percutaneous valve implantation in patients. The initial promising results in a clinical setting drew the attention of the industry and of the scientific community, and an effort was made for the past 12 years to address the limitations of the technology, facilitate the procedure, minimize the risk of complications, and broaden the applications of transcatheter aortic valve replacement. This article reviews the evolution of transcatheter aortic valve replacement, presents the first steps in this field, cites the evidence from registries and clinical trials, highlights the limitations of this treatment, and discusses the future perspectives and the developments proposed to address the current pitfalls

DES the year in review: controversies

Drug-eluting stents (DES) have transformed interventional cardiology over the past decade. Whilst their efficacy has rarely been called into question, there have been concerns over the safety of the early devices, which has prompted the development of new coronary stents. Many of these new devices have entered clinical practice, however questions remain as to whether they offer the improvements in clinical outcomes that were originally anticipated. In addition, there is a debate whether the reported high efficacy of these devices enables percutaneous coronary intervention (PCI) to be performed in patient and lesion sub-groups previous entirely the domain of the cardiac surgeon. This review paper addresses these outstanding questions

New concepts in the design of drug-eluting coronary stents

Drug-eluting stents (DES) have revolutionized the practice of interventional cardiology over the past decade. Although their efficacy has never been called into question, concerns have been raised regarding their safety, particularly with respect to very late stent thrombosis. These valid concerns have prompted extensive research into improving stent safety, with particular interest in modifying the permanent polymer used on first-generation DES. Subsequently, various new types of coronary stent have been developed, including DES with biocompatible polymers, DES with biodegradable polymers, polymer-free DES, and completely bioresorbable scaffolds. Some of these new DES are already available in clinical practice, and others are currently undergoing clinical evaluation. Improvements in stent performance have made detecting statistically robust and clinically relevant differences between contemporary devices difficult. The wide array of available stents enables the choice of device to be tailored to the individual patient. Garg, S. et al. Nat. Rev. Cardiol. 10, 248-260 (2013); published online 19 February 2013; doi: 10.1038/nrcardio.2013.1