Long (> or = 25 mm) stents for long coronary artery lesions. A safe conduct or a bridge too far for the interventional cardiologist?

OBJECTIVE: Increased restenosis rates have been reported after stenting long lesions with multiple standard length stents. Long slotted tube stents have become available for the treatment of long lesions or dissections.To compare clinical outcome after the use of long Multi-Link stents in long coronary lesions versus standard length Multi-Link stents in Benestent type lesions. METHODS AND RESULTS: We evaluated clinical outcome (six months) of 147 consecutive patients in whom one or more > or = 25 mm long Multi-Link stents were successfully deployed.The results were compared with the West-2 registry in which a 15 mm Multi-Link stent was used. The patients with long stents had more complex lesions and unstable symptoms. Target lesion revascularization after six months follow-up was comparable with that observed after implantation of a standard length stent (6.9% vs. 6.1%, p = 0.81). Overall cardiac event-free survival was similar for both groups (89.7% vs. 91.5%, p = 0.73). CONCLUSIONS: Patients treated with one or more long (> or = 25 mm) Multi-Link stents have a similar event-free survival and an equivalent target lesion repeat revascularization risk after six months than patients treated with a standard length stent.     

Is there a cardiomyopathy of obesity?

Obesity is associated with structural and functional changes in the heart. These changes may be precursors to more overt forms of cardiac dysfunction and heart failure. However, it is not known 1) whether cardiac hypertrophy in obese individuals results directly from increased adioposity or from the effects of comorbid conditions such as hypertension, diabetes, and sleep-disordered breathing and 2) whether functional changes (eg, mild reductions in systolic and diastolic function) in obese patients progress over time to the point where they cause heart failure, unless ischemic heart disease develops. Establishing a clear link between obesity and heart failure is complicated by the fact that obesity must be present for many decades before the risk of heart failure increases substantially. At present, there are no longitudinal studies of changes in cardiac size and function in humans with obesity. This article reviews data showing structural and functional changes in the heart in obesity and the evidence that these are or are not progressive over time. At present, we believe it is uncertain whether there is a true “cardiomyopathy of obesity.”     

Acute coronary syndrome and stress: Is there a relationship?

IntroductionAcute coronary syndrome (ACS) is the result of a complex pathophysiological process with various dynamic factors. The 10-item Perceived Stress Scale (PSS-10) is a validated instrument for estimating stress levels in clinical practice and may be useful in the assessment of ACS.MethodsWe carried out a single-center prospective study engaging patients hospitalized with ACS between March 20, 2019 and March 3, 2020. The PSS-10 was completed during the hospitalization period. The ACS group was compared to a control group (the general Portuguese population), and a subanalysis in the stress group were then performed.ResultsA total of 171 patients with ACS were included, of whom 36.5% presented ST-elevation myocardial infarction (STEMI), 38.1% were female and the mean PSS score was 19.5 ± 7.1. Females in the control group scored 16.6 ± 6.3 on the PSS-10 and control males scored 13.4 ± 6.5. The female population with ACS scored 22.8 ± 9.8 on the PSS-10 (p<0.001). Similarly, ACS males scored a mean of 17.4 ± 6.4 (p<0.001). Pathological stress levels were not a predictor of major adverse cardiovascular events or severity at admission.ConclusionsACS patients had higher perceived stress levels compared to the control group. Perceived stress level was not associated with worse prognosis in ACS patients.     

Is there a gender paradox in the early invasive strategy for non ST-segment elevation acute coronary syndromes?

This editorial refers to "Do men benefit more than women from aninterventional strategy in patients with unstable angina or non-ST-elevationmyocardial infarction? The impact of gender in the RITA 3 trial".by T.C. Clayton on page 1641 Coronary artery disease and, in particular, acute coronary syndromes(ACS), is the leading cause of mortality and morbidity in industrialisednations.¹ While major advances in the diagnosis and treatmentof ACS, both in terms of pharmacotherapy and catheter-basedrevascularisation, have resulted in a continuing, steady decreasein coronary heart disease (CHD) mortality over the last decadeamong men, the cardiovascular event rate among women has eitherlevelled off or increased – especially in older age groupsand among various ethnic minorities.^2–4 One of these advances, percutaneous coronary intervention (PCI),has become a standard treatment option for many patients –both men and women – with     

Bioabsorbable and biocompatible stents. Is a new revolution coming?

With the introduction of drug-eluting stents (DES) the problem of restenosis after percutaneous stent implantation was partially resolved. In the first generation of DES a stainless steel platform was coated with a durable polymer eluting and controlling the release of an active restenotic drug. The impairment of re-endothelization after DES implantation, one of the causes of late stent thrombosis, was to some extent attributed to the properties of the durable polymer and/or drug that it eluted. The introduction of biodegradable platforms and biocompatible polymers may potentially address this issue. Modern technologies are being applied to improve the characteristics of biodegradable stents and find new active pharmacological agents or combinations of standard antirestenotic and antithrombotic drugs that can be eluted from the stents, in order to improve their safety profile and clinical utility.     

Over‐expansion of balloon‐expandable transcatheter heart valves. Is there a limit?

• Transcatheter aortic valve implantation can be successful in selected patients with annuli beyond the current recommended limits for available transcatheter valves.
• Over‐expansion of balloon‐expandable valves beyond current guidelines may play a role.
• The limits of over‐expansion of balloon‐expandable valves are not well understood.

     

Is there any effect of chronobiological changes on coronary angioplasty?

AIMS: We hypothesized that If there is a chronobiologic variation in the development of acute ischaemic events which is mainly attributed to the tendency for thrombus formation in the morning hours, same time dependent variations must also be seen in the development of ischaemic events after percutaneous transluminal coronary angioplasty (PTCA) and PTCA with stent implantation. METHODS: Enrolled in this study were 349 consecutive patients with single vessel disease and undergoing elective single vessel angioplasty. Patients had been observed for the development of immediate postprocedural ischaemic events. Working hours of our laboratory were divided into 2-hourly intervals in order to define the ending time of procedure. Analysis of acute complications was carried out according to the ending time of procedure. RESULTS: There was no difference with regard to clinical presentation, but patients who had complications had higher blood cholesterol level (P < 0.05). Patients with stent implantation had more adverse events than the PTCA group, but this difference did not reach the statistical significance (P = 0.07). The time interval between 10:30 a.m.-12:30 p.m. was found to be an independent risk factor for the negative outcomes (P = 0.043, Relative Risk 4838). CONCLUSION: The results of our study have demonstrated that postprocedural complications after angioplasty is related to the procedure time These patients may be observed more closely for the development of immediate postprocedural ischaemic events.     

Is there a place for interferon-alpha in the treatment strategy of multicentric Castleman's disease?

INTRODUCTION: Castleman's disease is an unusual condition of unknown cause, consisting of massive proliferation of lymphoid tissue. Two forms (localized and multicentric) have been described. Interleukin-6 (IL-6) is at the core of the disease, being responsible for most of the clinical and biological signs that may be observed. Despite the benignancy of this pre-lymphoma condition, its course is usually aggressive and of poor prognosis in regard to the multicentric form. No consensus regarding treatment has been defined. Available data on the multicentric form of the disease are to scarce to allow any conclusion about the treatment timing and type of chemotherapy best suited to this condition. We report the case of a patient in whom interferon alpha (IFN-alpha) was used as first line treatment. EXEGESIS: The case of a 52-year-old man with multicentric Castleman's disease combined with high IL-6, in whom, however, testing for human herpes virus-8 proved to be negative, is described. Interferon alpha (4.5 MU/m2 three times per week during 18 months) administered as first line treatment induced dramatic improvement in the patient's general condition and normalization of the tumoral syndrome. Moreover, biological parameters and IL-6 returned to normal. Two years after interferon disruption, complete remission is still present. CONCLUSION: On the basis of the present data and those of two previous observations, anti-IL-6 and anti-infective properties of IFN-alpha are discussed. Treatment of multicentric Castleman's disease is based on corticosteroids and drugs derived from those pertaining to treatment of malignant lymphomas. Our results indicate that IFN-alpha is truly directed against Castleman's disease and has less toxicity than drugs usually prescribed. This argues for early use of IFN-alpha in Castleman's disease, in association or not with corticosteroids.     

Does a carbon ion-implanted surface reduce the restenosis rate of coronary stents?

BACKGROUND: Neointimal hyperplasia and resulting restenosis limit the long-term success of coronary stenting. Heavy metal ions induce an inflammatory and allergic reaction, and result in in-stent restenosis. However, a carbon ion-implanted surface might prevent heavy metal ions from diffusing into surrounding tissue. METHODS: 140 lesions in 140 patients with coronary lesions underwent implantation of carbon-implanted surface stents (Arthos(inert) stent group, n=70) or control stents (Arthos stent group, n=70). The primary end point was the in-stent restenosis and the secondary end point was the value of hs-CRP at 48 h and 6 months after coronary stenting. Clinical and angiographic follow-ups were performed at 6 months. RESULTS: The rate of in-stent restenosis was lower in the Arthos(inert) stent group (15.9%, 10/63) than in the Arthos stent group (20.9%, 13/62), but there were no significant differences between both groups (p=0.56). The value of hs-CRP at 48 h was lower in the Arthos(inert) stent group (13.9+/-13.4 mg/dl) than in the Arthos stent group (24.5+/-26.0 mg/dl) with significant differences (p=0.04). However, the differences between two groups were not statistically significant at 6 months (p=0.76). CONCLUSIONS: As compared with a standard coronary stent, a carbon ion-implanted stent shows no considerable benefit for the prevention of in-stent restenosis within the range of this study. Despite all the limitations of this study, a positive effect of a carbon ion-implanted stent in reducing inflammatory reaction after coronary revascularization seems likely.     

Radial artery perforation after coronary intervention: Is there a role for covered coronary stent?

We report a case of right radial artery perforation observed after successful stenting of left anterior descending artery through right radial access. This was noticed immediately after completion of the procedure, when the patient described right forearm pain and we noticed swelling of the right forearm. She was treated by a prolonged guiding catheter positioning proximal to the perforated segment, external compression by sphygmomanometer cuff followed by prolonged balloon inflation across the perforation. All these measures failed to stop the bleeding. Complete reconstruction of the perforation was achieved by PTFE covered coronary stent. To our knowledge, this is the first case to be managed utilizing this approach. © 2011 Wiley‐Liss, Inc.     

Is an invasive interventional strategy of value in non-ST-elevation acute coronary syndromes?

Cost-effectiveness can be a helpful indicator of therapeutic value and is an important consideration when determining whether to use an invasive strategy in patients with non-ST-elevation (NSTE) acute coronary syndromes. In an economic analysis using results from RITA 3, Henriksson et al. found that an invasive strategy was not cost-effective in patients with low-risk disease, but was cost-effective for patients with high-risk disease and of equivocal cost-effectiveness in patients with intermediate-risk disease. This finding is consistent with those of other studies, especially FRISC II and TACTICS-TIMI 18, which found an invasive strategy to be cost-effective in patients with biomarker-positive NSTE myocardial infarction. An invasive strategy should, therefore, be considered for treatment of patients with high-risk NSTE myocardial infarction. Although available data are not based on the latest technology, another trial in this area would be difficult to conduct and of questionable ethics.     

Drug therapy of sustained ventricular tachyarrhythmias. Is there still a role?

This article provides a review of the risks faced by patients with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) in the absence of a reversible or transient cause so that the goals of therapy can be clearly defined. The therapeutic approaches that have been proposed to achieve these goals are outlined and evidence comparing these various approaches to therapy is then summarized in order to propose an algorithm for the optimal use of antiarrhythmic drug therapies as primary therapy for selected VT/VF patients. Options for the ancillary uses of antiarrhythmic drug therapies in ICD patients are considered.