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Aim Percutaneous coronary intervention with stent implantation (PCI-S) in patients requiring chronic oral anticoagulant therapy (OAC) is associated with an increased risk of bleeding and ischemic complications. Different randomized studies showed a significant advantage of a double antithrombotic therapy and superiority of direct oral anticoagulant (DOAC) compared with warfarin, but real-world data are limited. Aim is to evaluate the antithrombotic management and clinical outcome of patients with an indication for OAC who undergo PCI-S in a 'real-world' setting. Methods The multicentre prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) Registry (ClinicalTrials.gov Identifier: NCT03392948) has been designed to enrol patients requiring OAC treated by PCI-S in 25 Italian centres. A target of at least 1080 patients will be followed for 1 year and data on thromboembolic and bleeding events and changes in antithrombotic therapy will be registered. The primary end point is a combined measure of efficacy and safety outcome (NACE), including major bleeding events and major adverse cardiac and cerebral events at 1-year follow-up in patients treated with DOAC (and dual or triple antiplatelet therapy) compared with the corresponding strategies with vitamin K antagonists. A secondary prespecified analysis has been defined to evaluate NACE in dual versus triple antithrombotic therapy after hospital discharge at 1-year follow-up. Conclusion The PERSEO Registry will investigate in a 'real world' setting the safety and efficacy of DOAC versus warfarin and dual versus triple antithrombotic therapy in patients with indication for oral anticoagulant therapy who undergo PCI-S.

Background: The itAlian pRospective Study on CANGrELOr (ARCANGELO) was aimed to assess the safety of using cangrelor during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) in the daily practice. Hypothesis: The safety of cangrelor after the transition to oral P2Y12 inhibitors was evaluated as the incidence of bleeding outcomes in the 30 days following PCI according to postauthorization safety study guidelines. Methods: Adults with ACS who were treated with cangrelor in one of the 28 centers involved in the study. Patients who consented to participate were followed in the 30 days following their PCI. Bleedings (Bleeding Academic Research Consortium [BARC] classification), major adverse cardiac events (MACEs), and adverse events were recorded. The interim results at two-thirds of the enrollment period are presented. Results: A total of 17 bleedings were observed in the 320 patients who completed the study at this stage. All bleedings were classified as BARC Type 1–2, except for one case of Type 3a (vessel puncture site hematoma). Four patients experienced MACEs (2 acute myocardial infarctions, 1 sudden cardiac death, 1 noncardiovascular death due to respiratory distress, and multiorgan failure). None of the bleedings was rated as related to cangrelor. Conclusions: The interim results of the ARCANGELO study provide a preliminary confirmation that the use of cangrelor on patients with ACS undergoing PCI is not associated with severe bleedings.

Objective The aim of the study is to describe the real-world use of the P2Y12 inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT). Materials and Methods We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used. Results Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was Conclusion Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.

AIMS The impact of glucose-6-phosphate dehydrogenase (G6PD) deficiency on coronary atherosclerosis has not been clearly investigated so far. We aimed to assess the effects of G6PD deficiency on the extent and complexity of coronary atherosclerosis in a large unselected cohort of consecutive patients with acute coronary syndromes (ACS). METHODS We studied 623 consecutive patients presenting with ACS and undergoing coronary angiography and percutaneous coronary intervention (PCI). G6PD activity was quantitatively measured in all individuals using a biochemical assay based on the G6PD/6GPD ratio in erythrocytes. Individuals were defined as deficient when the ratio was less than 0.80. The severity and complexity of coronary atherosclerosis were assessed by SYNTAX score at baseline angiography. RESULTS Fifty-six patients (9%) showed G6PD deficiency. Severe (i.e. enzymatic activity

Acute stent thrombosis is a rare event. When it occurs, procedure- and patient-related factors need to be assessed. First, our case showed that wiring was only successful with a chronic total occlusion-derived technique, indirectly demonstrating a stent-related problem. In fact, OCT showed a remarkable in-stent malapposition. Second, insufficient platelet inhibition was another important factor that contributed to acute stent thrombosis, since morphine negatively affected ticagrelor absorption and onset of action.

Background Left main (LM) coronary atresia (LMCA) is a rare coronary anomaly where the LM is congenitally absent and a variable clinical spectrum can follow. The diagnosis of LMCA is generally made in youth because of the development of symptoms, but very rarely in adulthood. In symptomatic patients, surgical revascularization is recommended, whereas, in asymptomatic patients with LMCA and without inducible myocardial ischaemia, preventive surgical treatment is controversial. Case summary A 58-year-old male patient with aortic ectasia detected during an echocardiogram performed to evaluate a hypertension-related preclinical cardiac damage and, due to this finding, an echocardiographic follow-up was suggested. Three years later, he was admitted to undergo coronary angiography (CA) after the computed tomography finding of a suspected occlusion of the LM with collateral circulation from right coronary artery (RCA) to left anterior descending and circumflex arteries. CA confirmed an LMCA and the RCA provided blood supply to the left coronary artery through collaterals whose calibre was similar to that of the target left-sided vessels. No obstructive coronary artery disease was detected. In order to detect potential myocardial ischaemia, a technetium-tetrofosmin cardiac single-photon emission computed tomography during maximal exercise-stress test was performed and it did not show a perfusion defect. Medical management with scheduled follow-up visits was deemed to be the best therapeutic option. Discussion LMCA is a rare anomaly where LM is absent and the RCA provides collateral circulation for left coronary artery. In asymptomatic patients, preventive surgical treatment is controversial.

The inability to advance the dedicated wire of the transradial sheath in a radial artery with a good pulsatile blood flow is a very rare event. In this case, the advancement of a high-performance 0.014 inch coronary wire is the only option to gain the vessel. Then, if the transradial sheath is stuck in the proximal radial artery wall, balloon angioplasty of the radial artery may allow successful reinsertion of the transradial sheath. This technique allows the preservation of radial artery access, avoiding a shift to an alternative arterial approach.

A 53-year-old male was admitted to our department for unstable angina. Coronary angiography showed a subocclusive stenosis in the ostial-proximal tract of an intermediate branch in the context of a left dominance system. We proceeded with an ad hoc percutaneous coronary intervention considering this intermediate branch lesion in the setting of a bifurcation (Medina 0,0,1), where the proximal and distal main branches were represented by the left main and left anterior descending (LAD) arteries, respectively. After pre-dilation of the intermediate branch lesion, we advanced a "safety balloon" in order to protect the LAD branch and, simultaneously, we deployed a 3.0/22 mm drug-eluting stent in the intermediate branch. After in-stent post-dilation, we felt a strong resistance during the guidewire removal from the LAD indicating a wire entrapment. After a vigorous traction of the jailed guidewire, we observed the accidental removal of the just deployed stent from the guiding catheter. We re-advanced a guidewire on the LAD and a 3.25/23 mm drug-eluting stent was successfully implanted on the intermediate branch. We briefly discuss the occurred complication and some technical aspects regarding this case.

Anticoagulation is of paramount importance during left atrial appendage occlusion procedure (LAAOP) to prevent periprocedural stroke. We present the case of a 66-year-old male patient who was scheduled to undergo LAAOP because of a prior intracranial bleeding. After transesophageal echocardiography-guided transseptal puncture, intravenous heparin 5,000 IUs were administered obtaining an ACT greater than 300 s. We planned to implant an Amplatzer-Amulet 25 mm LAA occluder through the dedicated 12F delivery sheath. After starting the tug test, TEE suddenly showed a floating thrombus whose proximal part was connected to the delivery cable. Because transesophageal echocardiography showed a good position of the device, we decided to release it and to quickly retrieve as a unit into the right atrium both the delivery cable with attached thrombus and the delivery sheath. We discuss about periprocedural anticoagulation dosing and monitoring and the importance to have specific studies in the setting of LAAOP.

To date, complete fracture of a coronary wire into a radial artery loop has never been reported. We describe the occurrence of a new complication in the transradial intervention era.

Percutaneous left atrial appendage occlusion (LAAO) is an invasive procedure, aimed to reduce thromboembolic risk in atrial fibrillation patients unsuitable for long-term anticoagulation, with a potential risk of complications. However, the incidence of procedure-related bleeding events and optimal

A 43year-old male, with a long history of coronary artery disease, was electively admitted to our institution because of dyspnea for moderate physical efforts (NYHA 2) related to an in-stent chronic total occlusion of ostial RCA and with demonstration of a significant area of inducible myocardial ischemia at stress echocardiography. After a gentle attempt of antegrade approach, the in-stent CTO of ostial RCA was successfully reopened with a retrograde approach using a knuckle technique. After IVUS evaluation which showed that the course of the retrograde guidewire was mostly within the stent strut circumference with the exception of the ostial RCA where the guidewire past between the stent and the vessel wall, implantation of 4 drug-eluting stent was performed from mid to ostial RCA with a good final result. The hospital stay was uneventful. At 6months clinical follow-up the patient was in good clinical condition. We discuss some aspects related to procedural technique, the importance of IVUS evaluation in the treatment of this patient.

A 50-year-old male was admitted to our institution because of an acute pulmonary edema successfully treated with diuretics. His cardiovascular risk factors include smoking habit and type 2 diabetes mellitus. Since the ECG showed a sinus rhythm 78 bpm and negative T waves in DI and aVL and the echocardiogram showed hypokinesia of the apex and of mid-distal anterior wall of the left ventricle with mild to moderate systolic dysfunction, the patient was scheduled for an elective coronary angiography. The coronary angiography revealed a critical stenosis of the medium left anterior descending (LAD) involving the origin of the 2nd diagonal branch (D2) (Medina 1,1,1). During the planned strategy for the bifurcation treatment according to the double kissing crush technique, we observed a dislodgement of the fully deployed stent in D2. We treat this unusual complication with an additional stent and we conclude the PCI with a good angiographic result. We discuss this very unusual complication and we compared it with other similar cases.

A 68 year-old man, with multiple cardiovascular risk factors, prior stroke, moderate aortic stenosis, prior coronary artery bypass grafts and percutaneous coronary intervention (PCI) on the mid-circumflex coronary artery, was admitted to our hospital because of severe angina (Canadian Cardiovascular

Plasma kynurenine (Kyn)/tryptophan ratio has been proposed as a useful marker for the monitoring activation of the cellular immune system. Here, we describe an easy capillary electrophoresis method with UV detection for the separation and detection of Kyn and tryptophan in human plasma using methltryptophan as internal standard. The plasma samples were simply treated with acentonitrile for the elimination of proteins, the supernatant was evaporated, and the dried sample was resuspended with water and directly injected on the capillary without sample derivatization procedures. The use of a run buffer composed by 100 mmol/L Bis-Tris propane at pH 2.15 allowed to baseline resolve the analytes within 9 min. Precision tests indicated a good repeatability of our method both for times (CV< 0.53%) and areas (CV< 2.8%). Moreover, a good reproducibility of intra-assay and interassay tests was obtained (CV < 3.9% and CV < 7.6%, respectively). The obtained limit of detections for Kyn and tryptophane, evaluated at 226 nm, were 0.15 and 0.40 μmol/L, respectively. The method suitability was tested by measuring analyte levels both in healthy volunteers, acute myocardial infarction and chronic kidney disease patients.

A 65-year-old man with stable angina refractory to medical therapy and with a low-threshold myocardial ischemia at ECG stress testing was referred for coronary angiography. The coronary angiogram showed an ostial subocclusive stenosis of a developed first diagonal branch located just upstream of a subocclusive stenosis of the mid left anterior descending (LAD) coronary artery, occluded distally, and a coronary collateral for LAD from a developed right ventricular branch arising with separate ostia from the right sinus of Valsalva. We discuss the diagnostic interpretation of this coronary anomaly and some aspects regarding the percutaneous treatment of bifurcations.

Plasma kynurenine (Kyn)/tryptophan ratio has been proposed as a useful marker for the monitoring activation of the cellular immune system. Here, we describe an easy capillary electrophoresis method with UV detection for the separation and detection of Kyn and tryptophan in human plasma using methltryptophan as internal standard. The plasma samples were simply treated with acentonitrile for the elimination of proteins, the supernatant was evaporated, and the dried sample was resuspended with water and directly injected on the capillary without sample derivatization procedures. The use of a run buffer composed by 100 mmol/L Bis-Tris propane at pH 2.15 allowed to baseline resolve the analytes within 9 min. Precision tests indicated a good repeatability of our method both for times (CV0.53%) and areas (CV2.8%). Moreover, a good reproducibility of intra-assay and interassay tests was obtained (CV3.9% and CV7.6%, respectively). The obtained limit of detections for Kyn and tryptophane, evaluated at 226 nm, were 0.15 and 0.40 μmol/L, respectively. The method suitability was tested by measuring analyte levels both in healthy volunteers, acute myocardial infarction and chronic kidney disease patients.

Objectives We have investigated on the levels of homocysteine linked to LDL in acute myocardial infarction patients. Design and methods We used capillary electrophoresis to measure LDL-bound thiols in 16 AMI individuals and 32 healthy volunteers. Results We found a significant increase of apo-B homocysteine and cysteine levels in LDL fraction of AMI subjects. Conclusions Our findings suggest that also LDL S-homocysteinylation may be considered among the markers for the CVD risk evaluation.

Anomalies of the coronary artery are incidentally detected during coronary angiography and are seldom found in daily clinical practice. In the reported studies, the incidence ranges from 0.6 to 1.3%, and men are more frequently affected. Among the different types, the detection of a double left anterior descending coronary artery emerging from the right coronary sinus is extremely rare. We describe a case of a 64-year-old male patient admitted to our institution because of ST segment elevation myocardial infarction. After successful systemic lysis, he underwent coronary angiography that showed multivessel coronary disease, a patent infarct-related artery and a double left anterior descending artery. We discuss the clinical relevance of a coronary artery emerging from the opposite Valsalva sinus and its clinical implications.

Until now only few data have been published regarding the role of computed tomography for the detection of coronary thrombosis in coronary artery ectasias. We report the case of a 49-year-old man who was admitted to our hospital for prolonged chest pain followed by syncope. An early coronary angiography, performed after electrocardiography, the evaluation of cardiac enzymes and echocardiography, was carried out and revealed a diffuse coronary artery ectasia, involving particularly the right coronary artery. In addition, the following day the patient underwent contrast-enhanced cardiac 64-slice computed tomography, which revealed the presence of an intraluminal thrombus in the distal tract of the right coronary artery. Therefore, he was put on anticoagulant therapy and was discharged 2 days later. In conclusion, in this case, computed tomography played an additional and complementary role to coronary angiography.