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To assess the value of sirolimus-eluting magnesium bioresorbable scaffolds (MgS) in the treatment of patients with in-stent restenosis (ISR). The better option for the treatment of patients with ISR remains unsettled. Bioresorbable vascular scaffolds represent an interesting strategy in this setting to avoid another permanent metal layer. The novel MgS is an attractive option to treat these challenging patients.We present the results of the first prospective series of consecutive patients with ISR treated with MgS under optical coherence tomography (OCT) guidance.A total of 14 patients (15 lesions) were prospectively included. The mean age was 67 ± 9 years and six patients (40%) presented with an acute coronary syndrome. In 10 patients (67%), underlying neoatherosclerosis was disclosed by OCT. An excellent MgS expansion was obtained in all but two patients who showed persistent suboptimal expansion in heavily calcified vessels. Minor residual malapposition ( n = 5) and angiographically silent minor edge dissections ( n = 8) were readily recognized by OCT. After a median clinical follow-up of 30 (range, 20-54) months, no patient required repeated revascularization, suffered a myocardial infarction or device thrombosis.These preliminary results suggest a potential role for the MgS in selected patients presenting with ISR.

BACKGROUND Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two relatively common nonatherosclerotic causes of acute coronary syndrome particularly frequent in women. METHODS This study sought to compare the baseline clinical and angiographic characteristics and in-hospital outcomes of patients from two large prospective registries on SCAD and TTS (the prospective nation-wide Spanish SCAD Registry and a prospective single-center TTS registry). RESULTS A total of 318 SCAD and 106 TTS consecutive patients were included. Most patients in both groups (88%) were women. Patients in the TTS group were older [74 (interquartile range, IQR 67-81) vs. 53 years-old (IQR 47-60), P < 0.001] and presented a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS (56% vs. 42%, P = 0.009) but emotional stress was more common in the SCAD group (25% vs. 15%, P = 0.037). TTS patients showed a reduced release of cardiac biomarkers but had more severe left ventricular dysfunction (ejection fraction

Neoatherosclerosis has emerged as a major cause of in-stent restenosis (ISR). Although this entity has been described as a unique process, optical coherence tomography (OCT) enables depiction of distinct morphologic patterns, including the presence of calcified sheets within the stent. We sought to assess prevalence, predictors, and implications of calcified neoatherosclerosis (cNA) as the cause of ISR.From January 2014 to August 2016, 75 consecutive patients with 81 ISR lesions with a clinical indication for revascularization were evaluated by OCT before reintervention. In 13 (16%) lesions, cNA was the predominant pattern of ISR, all of them presenting as very-late (3 years) ISR. Patients with cNA were older (71±9 vs. 66±10 years, P=0.0157), had worse low-density lipoprotein control (97±29 vs. 81±30 mg/dl, P=0.0746), and received treatment with statins (54 vs. 85%, P=0.006) and angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (31 vs. 65%, P=0.003) less frequently compared with patients with other patterns of ISR. Time from stent implantation to ISR [odds ratio (OR)=1.3; 95% confidence interval (CI): 1.1-1.6; P=0.01] and absence of treatment with statins (OR=11.3; 95% CI: 1.7-74; P=0.012) or ACEi/ARB (OR=7.4; 95% CI: 1.3-43; P=0.026) were associated independently with the presence of cNA. During reinterventions, ISR lesions with cNA obtained poorer angiographic (postintervention minimal lumen diameter 1.8±0.4 vs. 2.2±0.5 mm, P=0.0174) and OCT (final stent expansion 83±11 vs. 88±9%, P=0.0896) results.In our cohort of consecutive patients with clinical ISR, one-sixth showed underlying cNA as the predominant substrate of restenosis. This unique underlying substrate is related to the time elapsed from stent implantation and the absence of previous treatment with statins or ACEi/ARB and is associated with poorer acute results after reintervention.

Spontaneous coronary artery dissection (SCAD) remains an infrequent, elusive, and challenging clinical entity of unknown etiology eight decades after its initial description. Our understanding of the pathophysiology of SCAD, initially limited to information from early pathological studies, case reports, and very short series, has been enriched recently by relatively large contemporary series of patients studied prospectively. The typical presentation involves a young woman without coronary risk factors suffering an acute coronary syndrome but, actually, most patients are middle-aged and have coronary risk factors. A high number of conditions have been related to SCAD, but fibromuscular dysplasia has shown a major intriguing association with potential pathophysiological implications. SCAD may present (a) with an intimal tear and the classic angiographic 'flap' leading to the appearance of two lumens (true and false), or (b) without an intimal rupture, as an intramural hematoma. An increased clinical awareness together with new diagnostic tools have led to a major surge in the diagnosis of SCAD. High-resolution intracoronary techniques provide unique diagnostic insights into the underlying pathophysiology and facilitate identification of the disease in patients misdiagnosed previously. After the initial acute ischemic insult, most patients stabilize and have a benign clinical course and eventually experience spontaneous healing of the vessel wall during follow-up. However, recurrences may still occur in up to 10-20% of cases. Accordingly, a conservative medical management (watchful waiting strategy) has been recommended as the initial approach. Revascularization remains particularly challenging and may be associated with suboptimal results, acute complications, and poor long-term outcome. Nevertheless, in patients with ongoing or refractory ischemia and adequate anatomy, revascularization should be attempted. Some novel and attractive coronary interventions have been proposed in this uniquely challenging anatomic scenario. This review aims to present a comprehensive and contemporary update on this elusive and intriguing clinical entity.

Background Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS); however, its detection carries relevant clinical implications. Cardiac computed tomography (CCT) has been found to be useful for follow-up, but data during the acute phase are scarce. Thus, our aim was to evaluate the early diagnostic ability of CCT to detect SCAD. Methods We retrospectively analyzed all the in-hospital CCT performed in a prospective cohort of patients with SCAD from 2012 to 2016. An independent expert blindly evaluated the studies and described the radiologic characteristics of the lesions. These features were compared with the invasive coronary angiography (ICA) and optical coherence tomography (OCT) findings. Results 18 lesions were analyzed from 12 episodes identified in 11 patients (100% females; median age of 57 years old). CCT recognized the presence of SCAD in 14 (78%) of the lesions, with four different morphological patterns. Most commonly (10, 71%) SCAD presented as a diffuse lumen narrowing surrounded by a 'sleeve-like' wall thickening, which corresponded to intramural hematoma in OCT evaluation. When compared with ICA, CCT showed a positive correlation (Spearman's Rho = 0.775; P = 0.001) and excellent concordance (ICC = 0.8; P = 0.004) in stenosis grading, but not for lesion length and minimal luminal area. Conclusion CCT was able to identify the presence of SCAD in most of the patients in the acute phase of this elusive and challenging clinical entity. In addition, in this setting, CCT revealed unique and distinct radiologic features and provided a precise assessment of lesion severity.

Although drug-eluting stents (DES) have markedly reduced the incidence of stent restenosis (SR), the increased number and complexity of percutaneous coronary interventions performed worldwide explain the sustained prevalence of SR. Intracoronary imaging techniques remain essential tools to unravel the underlying mechanical causes potentially leading to SR. Current clinical trial data suggest that DES are the most effective therapy for the management of both bare-metal stents SR and DES-SR. In this setting, however, drug-eluting balloons represent a valid therapeutic alternative with the attractive advantage of not requiring the implantation of an additional metallic layer. In this review, we will discuss trial data on the historical evolution and the evidence supporting currently available therapeutic modalities for patients with bare-metal stents SR or DES-SR.