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Although the rate of procedural complications during transcatheter aortic valve implantation has decreased because of technological advancement and increased operator experience, device embolization remains a rare but potentially fatal complication, even with new generation devices. We report, to our knowledge, the first case of Portico valve (St Jude Medical, Minneapolis, MN) migration despite apparent optimal initial implantation depth, which was retrieved using a novel strategy after failure of a traditional retrieval technique. We also describe a mechanism of left coronary artery systolic perfusion with diastolic backflow, which led to myocardial ischemia.

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Percutaneous left atrial appendage (LAA) closure is currently utilized for the prophylaxis of thromboembolic cerebrovascular accidents in patients with non-valvular atrial fibrillation. The presence of LAA thrombus is usually considered a contraindication for the procedure, since there is a high risk of thrombus embolization. While reports in the literature have shown the feasibility of LAA closure in the presence of LAA thrombus with certain cerebral embolic protection devices, we present the first-in-man LAA closure of a patient with LAA thrombus using the TriGuard Embolic Protection Device.

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INTRODUCTION: Transradial access (TRA) emerged in the last two decades as a valid alternative to the standard transfemoral access (TFA) for cardiac catheterization and percutaneous coronary intervention (PCI). Due to contrasting results, the penetration and uptake of TRA in real-world clinical practice has been slow and still limited to high experienced center. EVIDENCE ACQUISITION: We performed an updated systematic review and study-level meta-analysis of randomized controlled trials (RCTs) that investigated the efficacy and safety of TRA versus TFA for PCI in patients with ACS. MEDLINE, Scopus, the Cochrane Library, and TCTMD.org were searched for abstracts, manuscripts, and conference reports published until April 31, 2016. The three pre-specified primary endpoints of interest were: all-cause mortality, major bleeding and major adverse cardiac events (MACE), at 30 days of follow-up. Primary analytic approach was according the intention-to-treat principle using inverse variance weighted random effect models. EVIDENCE SYNTHESIS: Study level data from 12 RCTs were extracted and analyzed. TRA compared with TFA in ACS patients undergoing invasive management was associated with a significant reduction in the risk of mortality (RR=0.72; 95% CI: 0.59-0.88; P=0.002), major bleeding (RR 0.48; 95% CI: 0.37-0.61; P<0.00001) and MACE (RR 0.81; 95% CI: 0.69-0.96; P=0.01), with similar procedural rate of success. In addition, TRA was associated with reduced in-hospital length of stay. There were no differences in the risk of stroke, myocardial infarction and target vessel or target lesion revascularization. CONCLUSIONS: The results of the present study confirm TRA as the preferred routine upfront strategy for ACS patients undergoing PCI.

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OBJECTIVES: This study explored whether cardiac magnetic resonance (CMR) could help select patients who could benefit from revascularization by identifying inducible myocardial ischemia and viability in the perfusion territory of the artery with chronic total occlusion (CTO). BACKGROUND: The benefit of revascularization using percutaneous coronary intervention (PCI) in CTO is controversial. CMR offers incomparable left ventricular (LV) systolic function assessment in addition to potent ischemic burden quantification and reliable myocardial viability analysis. Whether CMR guided CTO revascularization would be helpful to such patients has not yet been explored fully. METHODS: A prospective study of 50 consecutive CTO patients was conducted. Of 50 patients undergoing baseline stress CMR, 32 (64%) were selected for recanalization based on the presence of significant inducible perfusion deficit and myocardial viability within the CTO arterial territory. Patients were rescanned 3 months after successful CTO recanalization. RESULTS: At baseline, myocardial perfusion reserve (MPR) in the CTO territory was significantly reduced compared with the remote region (1.8 ± 0.72 vs. 2.2 ± 0.7; p = 0.01). MPR in the CTO region improved significantly after PCI (to 2.3 ± 0.9; p = 0.02 vs. baseline) with complete or near-complete resolution of CTO related perfusion defect in 90% of patients. Remote territory MPR was unchanged after PCI (2.5 ± 1.2; p = NS vs. baseline). The LV ejection fraction increased from 63 ± 13% to 67 ± 12% (p < 0.0001) and end-systolic volume decreased from 65 ± 38 to 56 ± 38 ml (p < 0.001) 3 months after CTO PCI. Importantly, despite minimal post-procedural infarction due to distal embolization and side branch occlusion in 8 of 32 patients (25%), the total Seattle Angina Questionnaire score improved from a median of 54 (range 45 to 74) at baseline to 89 (range 77 to 98) after CTO recanalization (p < 0.0001). CONCLUSIONS: In this small group of patients showing CMR evidence of significant myocardial inducible perfusion defect and viability, CTO recanalization reduces ischemic burden, favors reverse remodeling, and ameliorates quality of life.

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The completely absorbable stents represent one of the latest innovations in the field of interventional cardiology, prospecting the possibility of "vascular repair". In the published trials (ABSORB Cohort A and B, ABSORB EXTEND, and ABSORB II, III and IV) chronic total occlusions (CTOs) were considered an exclusion criteria. More recently the CTO-ABSORB pilot study demonstrated the safety and feasibility of bioresorbable vascular scaffold (BVS) use in case of CTO recanalization. We present the first case, to our knowledge, of in-stent occlusion successfully treated with an everolimus-eluting BVS and discuss its potential advantages in such kind of lesions.

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OBJECTIVES: This study aimed to characterize myocardial infarction after percutaneous coronary intervention (PCI) based on cardiac marker elevation as recommended by the new universal definition and on the detection of late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR). It is also assessed whether baseline inflammatory biomarkers are higher in patients developing myocardial injury. BACKGROUND: Cardiovascular magnetic resonance accurately assesses infarct size. Baseline C-reactive protein (CRP) and neopterin predict prognosis after stent implantation. METHODS: Consecutive patients with baseline troponin (Tn) I within normal limits and no LGE in the target vessel underwent baseline and post-PCI CMR. The Tn-I was measured until 24 h after PCI. Serum high-sensitivity CRP and neopterin were assessed before coronary angiography. RESULTS: Of 45 patients, 64 (53 to 72) years of age, 33% developed LGE with infarct size of 0.83 g (interquartile range: 0.32 to 1.30 g). A Tn-I elevation >99% upper reference limit (i.e., myocardial necrosis) (median Tn-I: 0.51 µg/l, interquartile range: 0.16 to 1.23) and Tn-I > 3× upper reference limit (i.e., type 4a myocardial infarction [MI]) occurred in 58% and 47% patients, respectively. LGE was undetectable in 42% and 43% of patients with periprocedural myocardial necrosis and type 4a MI, respectively. Agreement between LGE and type 4a MI was moderate (kappa = 0.45). The levels of CRP or neopterin did not significantly differ between patients with or without myocardial injury, detected by CMR or according to the new definition (p = NS). CONCLUSIONS: This study reports the lack of substantial agreement between the new universal definition and CMR for the diagnosis of small-size periprocedural myocardial damage after complex PCI. Baseline levels of CRP or neopterin were not predictive for the development of periprocedural myocardial damage.

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The 2-dimensional silhouette image provided by coronary angiography has well-recognized limitations. Angiographic images do not accurately represent the true complexity of the luminal morphology in coronary disease and give no indication of the functional influence of luminal changes on coronary blood flow. These limitations are more pronounced in angiographically intermediate stenoses and in patients in whom there is a clear discrepancy between the clinical picture and angiographic findings. In such cases there is often poor concordance between the estimated percentage angiographic stenosis and the corresponding intravascular ultrasound image or noninvasive functional data. The validation and clinical availability of robust and accurate physiologic indices, which can be used as an adjunct to diagnostic angiography in the cardiac catheterization laboratory, have been pivotal in promoting ischemia-driven coronary revascularization. Deferral or revascularization based on such physiologic indices is associated with improved clinical outcome as well as more favorable health economic data. Although there are several clinical indices, fractional flow reserve remains the "gold standard," with indications for physiologic assessment of angiographic intermediate stenoses, including left main stem stenoses and ostial disease as well as serial lesions. The availability of such indices is an important step in streamlining management of patients undergoing cardiac catheterization by allowing routine provision of an "all-in-one" ischemia-driven revascularization service.

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BACKGROUND: The incidence and predictors of contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) have not been specifically reported. METHODS: This retrospective analysis included all consecutive patients referred for PCI of CTO between April 2003 and March 2008, with baseline and 24 h postprocedural available creatinine levels. CIN was defined as 24 h postprocedural increase of baseline creatinine levels > or =0.5 mg/dl (CIN(05)) or > or =25% (CIN(25)). Severe renal dysfunction (SRD) was defined as acute renal failure requiring dialysis, or an increase in baseline creatinine levels > or =2.0 mg/dl (SRD(2)) or > or =50% (SRD%). Patients were classified into risk categories for CIN, according to the validated Mehran risk score. RESULTS: A total of 227 patients were included, mean age of 64+/-10 years, the majority being at low risk for CIN (55% with < or =5 points in the Mehran score). CIN(25) occurred in 6.16% (14/227) patients and CIN(05) in 0.88% (2/227). The incidence of SRD(2) or SDR% was 0% (0/227) and 0.9% (2/227), respectively, with no patient requiring dialysis. Patients who developed CIN(25) received a higher contrast volume than those who did not (312 ml (210-400) vs 260 ml (200-345), p=0.14), but the difference was not statistically significant. CONCLUSIONS: In this consecutive cohort of patients, the incidence of CIN following PCI for CTO was low despite the administration of moderate to large volumes of contrast media. Attempts at revascularization of CTO should not be discouraged or be prematurely interrupted because of the fear of CIN.

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BACKGROUND: The introduction of optical coherence tomography (OCT) as an intracoronary imaging modality has allowed accurate assessment of strut apposition and neointimal tissue coverage. This study set out to assess the inter and intraobserver variability of measurements of acute stent apposition and strut tissue coverage using OCT. METHODS: Thirty patients were studied (14 immediately after stent implantation and 16 during follow-up angiography [mean of 4.7+/-2.8 months]) using OCT (LightLab, Westford, Massachusetts, US). Data analysis was performed by 2 experienced observers. Struts were classified as "embedded", "protruding" or "malapposed" to the vessel well and recorded as percentage of total struts. Intimal coverage at follow-up was measured as the thickness of tissue covering each strut expressed in mum. Intra and interobserver variability was assessed by Bland-Altman plots and by calculation of the intraclass correlation coefficient (ICC). RESULTS: An average of 3967 struts was examined by each observer and, overall, 53.7% of struts was embedded, 36.4% protruding and 9.9% malapposed. Low intraobserver variability for all measures of strut apposition was found, with repeatability coefficients that ranged between 5.1% and 9.3% and ICC exceeding 95% in all cases. Interobserver variability was also low (repeatability coefficients 6.6-10.8 and ICC>91.3%). Mean intimal thickness in the follow-up group was 172.5 microm. Bland-Altman plots demonstrated a low intraobserver and interobserver variability for intimal thickness, with repeatability coefficients 26.7 mum and 24.1 mum, respectively and ICC exceeding 98.6% for both. CONCLUSIONS: Low intra and interobserver variability can be expected when analyzing OCT data for stent apposition and tissue coverage. This supports the validity of OCT as a clinical and research tool in the setting of intracoronary stent imaging.

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BACKGROUND: Transthoracic echocardiography left ventricular wall thickness is often increased in master athletes and it results by intense physical training. Left Ventricular Hypertrophy can also be due to a constant pressure overload. Conventional Pulsed Wave (PW) Doppler analysis of diastolic function sometimes fails to distinguish physiological from pathological LVH.The aim of this study is to evaluate the role of Pulsed Wave Tissue Doppler Imaging in differentiating pathological from physiological LVH in the middle-aged population. METHODS: we selected a group of 80 master athletes, a group of 80 sedentary subjects with essential hypertension and an apparent normal diastolic function at standard PW Doppler analysis. The two groups were comparable for increased left ventricular wall thickness and mass index (134.4 +/- 19.7 vs 134.5 +/- 22.1 gr/m2; p > .05). Diastolic function indexes using the PW technique were in the normal range for both. RESULTS: Pulsed Wave TDI study of diastolic function immediately distinguished the two groups. While in master athletes the diastolic TDI-derived parameters remained within normal range (E' 9.4 +/- 3.1 cm/sec; E/E' 7.8 +/- 2.1), in the hypertensive group these parameters were found to be constantly altered, with mean values and variation ranges always outside normal validated limits (E' 7.2 +/- 2.4 cm/sec; E/E' 10.6 +/- 3.2), and with E' and E/E' statistically different in the two groups (p < .001). CONCLUSION: Our study showed that the TDI technique can be an easy and validated method to assess diastolic function in differentiating normal from pseudonormal diastolic patterns and it can distinguish physiological from pathological LVH emphasizing the eligibility certification required by legal medical legislation as in Italy.

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Drug-eluting stents (DES) have made a tremendous impact on the practice of percutaneous coronary intervention. Recently however, long-term DES failures have become a focal point, particularly with restenosis and thrombosis. An uncommon, yet important cause of DES failure is stent fracture. Of the two established first generation DES, the sirolimus-eluting stent (SES) has been particularly linked to cases of stent fracture, likely as a result of its closed cell design compared with other DES employing an open cell system. We present 2 cases of SES fracture confirmed using high-resolution intravascular optical coherence tomography giving unique insights into the in-vivo appearance of this complication.

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BACKGROUND: Although left bundle branch block (LBBB) alters the electrical activation of the heart, it is unknown how it might change the process of myocardial coordination (MC) and how it may affect the left ventricular (LV) systolic function. The present study assessed the effects of LBBB on MC in patients with LBBB with and without dilated (DCMP) or ischemic cardiomyopathy (ICMP). METHODS: Tissue Doppler echocardiography (TDE) was performed in 86 individuals: 21 with isolated LBBB, 26 patients with DCMP + LBBB, 19 patients with ICMP + LBBB and in 20 healthy individuals (Controls). MC was assessed analyzing the myocardial velocity profiles obtained from six basal segments of the LV using TDE. The LV systolic function was assessed by standard two-dimensional echocardiography and by TDE. RESULTS: Severe alterations in MC were observed in subjects with LBBB as compared with controls (P < 0.01 for all comparisons); these derangements were even worse in patients with DCMP and ICMP (P < 0.001 for comparisons with Controls and P < 0.01 for comparison with individuals with isolated LBBB). Some parameters of MC differed significantly between DCMP and ICMP (P < 0.01). A good or very good correlation coefficient was found between variables of MC and variables of LV systolic function. CONCLUSION: LBBB induces severe derangement in the process of MC that are more pronounced in patients with cardiomyopathies and that significantly correlates with the LV systolic function. The assessment of MC may help in the evaluation of the etiology of dilated cardiomyopathy.

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Acute coronary syndromes have been described as potential complications of any type of anaphylactic reaction. The real pathogenic mechanism inducing acute myocardial ischemia in the setting of anaphylaxis is not yet completely understood. Some pathogenic mechanisms, like coronary vasospasm, plaque activation and systemic hypotension, have been suggested. The hypothesis of a central role of mast cell and inflammatory cell activation and release of potent vasoactive mediators, inducing the mechanisms mentioned above, is the mainstay of so-called "cardiac anaphylaxis". We report two cases of anaphylaxis-induced acute ST-segment elevation myocardial ischemia which occurred during coronary angiography. The first one was probably related to contrast media contact, the second one to latex glove contact. Both of them were treated with percutaneous coronary intervention that immediately resolved the myocardial ischemia.

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A 70-year-old man experienced an amoxycillin-induced anaphylactic reaction complicated by acute inferior myocardial infarction with transient ST-segment elevation. There was a spontaneous resolution of ST-segment elevation and the patient was treated for anaphylaxis. Coronary angiography showed severe obstructive coronary atherosclerosis, but not involving the infarct-related artery. Percutaneous coronary intervention of the affected artery was then performed and the patient was discharged three days later. Acute ST-elevation myocardial infarction has been described as one of the severe, still rare cardiovascular complications of anaphylaxis. In the present case, according to the previous reports, the main pathogenetic mechanism involved appears to have been coronary vasospasm probably caused by the release of potent vasoactive mast cell derived mediators in the setting of anaphylaxis.

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BACKGROUND: The appropriate evaluation of atrial electrical function is only possible by means of invasive electrophysiology techniques, which are expensive and therefore not suitable for widespread use. Mechanical atrial function is mainly determined from atrial volumes and volume-derived indices that are load-dependent, time-consuming and difficult to reproduce because they are observer-dependent. AIMS: To assess the feasibility of tissue velocity echocardiography (TVE) to evaluate atrial electromechanical function in young, healthy volunteers. SUBJECTS AND METHODS: We studied 37 healthy individuals: 28 men and nine women with a mean age of 29 years (range 20-47). Standard two-dimensional (2-D) and Doppler echocardiograms with superimposed TVE images were performed. Standard echocardiographic images were digitized during three consecutive cardiac cycles in cine-loop format for off-line analysis. Several indices of regional atrial electrical and mechanical function were derived from both 2-D and TVE modalities. RESULTS: Some TVE-derived variables indirectly reflected the atrial electrical activation that follows the known activation process as revealed by invasive electrophysiology. Regionally, the atrium shows an upward movement of its walls at the region near the atrio-ventricular ring with a reduction of this movement towards the upper levels of the atrial walls. The atrial mechanical function as assessed by several TVE-derived indices was quite similar in all left atrium (LA) walls. However, all such indices were higher in the right (RA) than the LA. There were no correlations between the 2-D- and TVE-derived variables expressing atrial mechanical function. Values of measurement error and repeatability were good for atrial mechanical function, but only acceptable for atrial electrical function. CONCLUSION: TVE may provide a simple, easy to obtain, reproducible, repeatable and potentially clinically useful tool for quantifying atrial electromechanical function.

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BACKGROUND: Left bundle branch block (LBBB) is associated with impaired left ventricular (LV) function and increased morbidity and mortality, especially in patients with structural heart diseases. The mechanisms are poorly understood. SUBJECTS AND METHODS: Subjects with isolated LBBB (n=20), right bundle branch block (RBBB, n=20), and controls (C, n=20) were studied with standard two-dimensional (2D), and color-encoded tissue-Doppler echocardiography (TDE). Inter- and intraventricular systolic and diastolic coordination were assessed from the TDE velocity profiles. LV function was assessed by 2D echocardiography, by TDE-derived peak systolic velocities, and the atrioventricular (AV) plane displacement. RESULTS: Subjects with LBBB had longer electromechanical delays and longer isovolumic relaxation times than did the C and RBBB groups (P <0.001). For the LBBB subjects compared with the RBBB and C groups, ejection times were shorter, peak systolic velocities and AV plane displacements were lower, they had larger LV end-systolic volumes and lower LV ejection fraction (all P <0.001), and the atrial contribution to A-V plane displacement was higher (P <0.01). There were no differences in diastolic or filling times among the groups. CONCLUSIONS: In patients with LBBB, delayed regional electromechanical coupling and uncoupling leads to generalized intra- and interventricular asynchrony, thereby explaining the depressed regional and global LV functions. Assessment of the electromechanical coupling and uncoupling processes and their consequences on cardiac function in patients with BBB and structural heart diseases may be possible using TDE.

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Tissue-Doppler echocardiography (TDE) has been introduced to quantify stress echocardiography by means of assessing the left ventricular (LV) segmental myocardial velocities and excursion. The interaction between LV long- and short-axis function during physical exercise has not been elucidated completely. The aim of the present study was to investigate long- and short-axis LV function, as assessed by myocardial velocities and excursions at rest and during exercise and its possible relationship with heart rate in healthy elderly individuals by TDE. Twenty-seven individuals underwent an exercise test in the supine position on a bicycle ergometer. The initial workload was 30 Watts, followed by 20-Watt increments every third minute. Standard echocardiographic images with super-imposed colour TDE were digitized at the end of each step. The following variables were studied in the LV long- and short-axis: myocardial peak systolic velocity (PSV) and excursion, isovolumic contraction and relaxation times, peak velocity at early diastole (E'-wave) and peak velocity at late diastole (A'-wave) and the E'/A' ratio. Increments in myocardial peak systolic velocity and excursion in the LV long-axis were more pronounced during low workloads. The increase in those variables in the short-axis occurred mainly at higher exercise loads. The improvement in LV long- and short-axis functions was closely related to the increase in the heart rate. Shortening of the isovolumic contraction and relaxation times occurred only at the initial stages of exercise. An increase in the long-axis E'/A' ratio occurred during exercise, whereas this ratio was unchanged in the short-axis. In conclusion, during exercise, the LV long- and short-axis functions behave differently, and increases in LV long- and short-axis functions are related to changes in heart rate. Therefore, in the interpretation of echocardiographic findings during exercise stress echocardiography, these facts have to be taken into account.

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