Impact of microvascular obstruction and infarct size on left ventricular remodeling in reperfused myocardial infarction: a contrast-enhanced cardiac magnetic resonance imaging study

Infarct size (IS) and microvascular obstruction (MO) following ST-elevation myocardial infarction (STEMI) reperfusion may affect left ventricular (LV) remodeling. We evaluated the impact of extent and transmurality of IS and MO in LV remodeling using contrast-enhanced cardiac magnetic resonance imaging (MRI). Thirty-six consecutive patients presenting with a first STEMI and undergoing contrast-enhanced cardiac MRI within 5?days of successful primary percutaneous coronary intervention (PPCI) were enrolled. Gadolinium-enhanced MRI at first passage and in delayed imaging was performed to assess MO and IS. LV remodeling was evaluated by echocardiography at 6-month-follow-up and defined as a percent increase in the LV end-diastolic volume >20%. Thirteen patients (36%) developed LV remodeling. IS and MO extent score was associated with LV remodeling (OR 1.5, 95% CI 1.02–2.38, P?=?0.04, and OR 3.1, 95% CI 1.45–6.64, P?=?0.003, respectively), along with IS and MO trasmurality (OR 1.4, 95% CI 1.007–2.12, P?=?0.046, and OR 3.1, 95% CI 1.24–7.89, P?=?0.016, respectively). Importantly, IS and MO extent score combination gave an OR of 3.4 (95% CI 1.4–7.9, P?=?0.004) and the combination of IS and MO transmurality increased the OR to 4.8 (95% CI 1.5–15.2, P?=?0.007). Finally, when combining simultaneously IS and MO extent score and transmurality the OR reached 5.3 (95% CI 3.34–18.2, P?=?0.0008). The evaluation of both IS and MO extent and transmurality by MRI is of prognostic utility in patients undergoing PPCI. Importantly, IS and MO transmurality significantly increases the risk of adverse remodeling and should be routinely assessed in post-STEMI patients.     

Directional atherectomy before stenting versus stenting alone in percutaneous coronary interventions: a meta-analysis

Plaque debulking before stenting is still controversial. We performed a meta-analysis of 12 randomized and non-randomized trials comparing directional coronary atherectomy (DCA) before stenting versus stenting alone. Angiographic end points were acute gain, late loss and angiographic restenosis rate. Clinical end points were early major adverse cardiac events [MACEs: death, Q-wave myocardial infarction (MI), non-Q-wave MI], late MACEs (death, Q-wave MI) and target lesion revascularization (TLR). Data are expressed as odds ratio (OR) with 95% confidence intervals (CI) or weighted mean difference (WMD) with 95% CI, as appropriate. A total of 1216 patients undergoing DCA before stent and 1484 patients undergoing stent alone have been included. DCA before stent was associated to a better acute gain compared to stenting alone (WMD 0.23, [0.18-0.28]; p<0.0001), to a striking reduction of angiographic restenosis rate (OR of 0.67, [0.54-0.84], p=0.0003) and to a significantly lower rate of late TLR (OR 0.73 [0.59-0.91], p=0.006). Late loss did not differ between the two groups (WMD 0.00 [-0.08 and 0.08], p=0.98). We found a higher rate of early MACEs for the combined approach (OR 1.87 [1.16-3.02], p=0.01), with similar prevalence of late MACEs (OR 0.83 [0.65-1.06], p=0.13). In conclusion, this meta-analysis demonstrates that DCA before stenting is superior to stenting alone with regard to acute angiographic results and TLR with a similar prevalence of late MACEs. The higher prevalence of early MACEs with DCA before stenting, however, is disturbing and probably related to distal embolization.     

Pagetoid reticulosis tumor cells with double expression of TCRγδ and TCRαβ: an off‐target phenomenon or genuine expression?

Pagetoid reticulosis (PR) is a low‐grade primary cutaneous T‐cell lymphoma showing localized patches or plaques with an intrapeidermal proliferation of neoplastic T‐cells with heterogeneous immunophenotype. We describe a 73‐year‐old woman with a 8‐year history of gluteal lesions of PR, whom large blast cells were CD4/CD8 double negative T‐cells with an activated cytotoxic profile. The case was investigated using a broad panel of monoclonal antibodies including TCRγM1, a new available antibody that recognizes the γ chain subunit of the T‐cell receptor (TCR) in formalin‐fixed paraffin‐embedded tissue. Large blast cells were simultaneously positive for TCRαβ and TCRγδ with an activated cytotoxic phenotype. It is worldwide accepted the mutual exclusive expression of TCRαβ and TCRγδ but six different studies, dealing with TCRγδ expression in various types of extra‐nodal lymphomas, reported cases whom tumor cells expressed simultaneously TCRαβ and TCRγδ. Our data and those of similar reports, suggest the possibility of existence of a subset of extra‐nodal T‐cell lymphomas showing simultaneous expression by tumor cells of TCRγδ and TCRαβ with an immunoprofile consistent with an origin from TCRγδ+ T lymphocytes. This unusual subset has preferential, but not exclusive, skin localization and variable epidermotropism.