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We present the case of a 42-year-old woman admitted due to ST-segment elevation acute coronary syndrome. The coronary angiography revealed the presence of an occluded mid-distal left anterior descending coronary artery (LAD) (figure 1A, asterisk) with an image suggestive of intramural hematoma (IMH) consistent with spontaneous coronary artery dissection (figure 1A, arrow). Guidewires were passed through the distal and diagonal LAD that resulted in flow recovery (figure 1B, line and arrowheads outlining the IMH). The intravascular ultrasound (IVUS) confirmed the presence of a large 25 cm long IMH (figure 2A,D). After dilatation with a 2.0 mm/6 mm cutting balloon (Wolverine, Boston Scientific, United States) (figure 1C, asterisks) flow improved leaving a mild residual stenosis (figure 1D). After a few minutes the retention of contrast in the LAD was confirmed (figure 3A, ellipse) followed by ischemic changes on the electrocardiogram. The angiography revealed the presence of 2 regions of critical stenosis with aggravated distal flow abnormalities (figure 3B, lines outlining the IMH, arrowheads showing the stenotic regions). A 2.25 mm/33 mm drug-eluting stent was implanted (Ultimaster Tansei, Terumo, Japan) (figure 3C, asterisks) and later dilated up to 2.75 mm with excellent angiographic (figure 3D) and IVUS results (figure 2E,F). The entire...

ABSTRACT Introduction and objectives: Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause for acute coronary syndrome. The optimal management and treatment of SCAD is still unknown. Methods: Data analysis of a prospective protocol including centralized care management of a consecutive series of patients with SCAD diagnosed between January 2010 and December 2018. Major adverse cardiovascular events included all-cause mortality, new myocardial infarction, coronary revascularization, ventricular arrhythmia, heart failure or stroke. Results: A total of 33 consecutive patients were included (41 lesions). Intravascular imaging modalities were used to confirm the diagnosis in 42% patients. None of the patient showed images of thrombus formation in the true lumen. Conservative treatment was the initial approach in most of the cases (82%). No deaths were reported during the index admission, but 15% experienced major adverse cardiovascular events. The coronary computed tomography angiography performed in 58% of patients during the admission identified SCADs in 79% of the patients. Most of the patients managed with conservative treatment received only 1 antiplatelet agent for a limited period of time (17 months [9-35]). During a median clinical follow-up of 33 months [13-49], 82% of patients did not have any adverse events. The angiographic surveillance obtained in 48% of patients at the 6-month follow-up confirmed the complete healing of the SCAD image in 86% of the patients. The screening for extracoronary vascular findings (97% of patients) resulted in a high prevalence of abnormalities (59%). Conclusions: The unrestricted use of intravascular imaging modalities showed no thrombus in the true lumen of patients with SCAD. In patients managed with conservative treatment, a limited course of antiplatelet monotherapy is safe and provides good clinical outcomes. Performing a coronary computed tomography angiography in the acute phase of SCAD is useful at the follow-up. The screening for extracoronary vascular findings confirmed a high prevalence of abnormalities.

To the Editor, Spontaneous coronary artery dissection (SCAD) is a low incidence disease that can cause acute coronary syndromes.1,2 Although substantial advances have been made in the knowledge of the physiology, diagnosis, clinical management, and prognosis of SCAD, the degree to which such knowledge has entered the medical community is still uncertain. For this reason, it was decided to conduct a descriptive research on the knowledge and attitude of the Spanish interventional cardiologists towards SCAD. The authors developed a 24-question survey including the clinical presentation, diagnosis, and acute and postcritical management of SCAD.3 The initiative was approved and supported by the Working Group on Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology. The survey was closed in December 2018 with 161 answers from 72 centers (26 respondents did not complete the variable “center”). Figure 1 shows the answers given to the question “diagnosis”. Two thirds of the respondents associated the SCAD with the profile of a young woman without any risk factors or pregnancy/puerperium- related. Regarding the angiographic manifestation, the most common pattern recognized by the respondents was not an angiographic dissection, but the loss of diffuse caliber in the blood vessel (type 2). Also, most respondents reported a low use...

A 41-year-old woman presented with an inferolateral ST-segment elevation myocardial infarction. Coronary angiography confirmed the presence of a long narrowing involving the right coronary artery posterolateral branch (figure 1A, white arrows). Spontaneous coronary artery dissection was suspected and optical coherence tomography (OCT) imaging was considered by the operator for confirmation purposes. Advancing the OCT catheter was difficult due to lack of support and it was decided to only interrogate the proximal aspect of the branch (figure 1B, arrow). OCT revealed the presence of an intramural hematoma without entry tear (figure 1C; asterisks denote wire artefact). At that moment the patient complained of chest pain that remained after removing the OCT catheter. The presence of functional branch occlusion (figure 1D, asterisk), with Thrombolysis in Myocardial Infarction (TIMI) grade 1 flow, was confirmed. Coronary flow was re-established through gentle dilation (4 atm) using a 1.5 mm balloon. Final TIMI grade 2 flow was achieved (figure 1E, asterisks) and the patient became asymptomatic. Her subsequent clinical course was uneventful. Coronary angiography performed 3 months later confirmed the complete healing of the dissected segment (figure 1F, arrows).

ABSTRACT Introduction and objectives: Distal radial access (DRA) for coronary procedures is currently recognized as an alternative to conventional transradial access, with documented advantages primarily related to access-related complications. However, widespread adoption of DRA as the default approach remains limited. Therefore, this prospective cohort study aimed to present our initial experience with DRA for coronary procedures in any clinical settings. Methods: From August 2020 to November 2023, we included 1000 DRA procedures (943 patients) conducted at a single center. The study enrolled a diverse patient population. We recommended pre- and postprocedural ultrasound evaluations of the radial artery course, with ultrasound-guided DRA puncture. The primary endpoint was DRA success, while secondary endpoints included coronary procedure success, DRA performance metrics, and the incidence of access-related complications. Results: The DRA success rate was 97.4% (n = 974), with coronary procedure success at 96.9% (n = 969). The median DRA time was 40 [interquartile range, 30-60] seconds. Diagnostic procedures accounted for 64% (n = 644) of cases, while 36% (n = 356) involved percutaneous coronary intervention (PCI), including primary PCI in 13% (n = 128). Pre-procedure ultrasound evaluation and ultrasound-guided DRA were performed in 83% (n = 830) and 85% (n = 848) of cases, respectively. Access-related complications occurred in 2.9% (n = 29). Conclusions: This study shows the safety and feasibility of DRA for coronary procedures, particularly when performed under ultrasound guidance in a diverse patient population. High rates of successful access and coronary procedure outcomes were observed, together with a low incidence of access-related complications. The study was registered on ClinicalTrials.gov (NTC06165406).

ABSTRACT Introduction and objectives: Moderate or severe paravalvular leak (PVL) following transcatheter aortic valve implantation (TAVI) has been associated with worse outcomes. Aortic valve (AV) calcification is a strong predictor of PVL. ACURATE neo (Boston Scientific Corporation, United States) is a self-expanding transcatheter heart valve to treat degenerative aortic stenosis. We evaluated PVL after ACURATE neo and neo2 implantation, and the role of AV calcification. Methods: We analyzed patients referred for TAVI with ACURATE neo and neo2 from a large volume tertiary center. All cardiac computed tomography scans were analyzed using 3Mensio Structural Heart software (Pie Medical Imaging, The Netherlands). The volume of AV calcium was quantified using contrast-enhanced cardiac computed tomography series. The 30-day clinical and echocardiographic data were prospectively recorded. Results: We included 165 patients referred for TAVI with ACURATE (neo = 87; neo2 = 78). Median age was 82 years-old, 65% were women with a median EuroSCORE II of 4.7 [IQR, 2.4-6.1]. Patients in the neo group showed a larger amount of total AV calcium (320 mm3 vs 200 mm3; P = .0305). We found no significant inter-group differences regarding clinical outcomes both in-hospital or at 30-days. At 30-days, the rate of PVL ≥ mild (61% vs 34%; P < .001) and ≥ moderate (15.9% vs 5.4%; P = .0365) were higher in the neo group. After propensity score matching adjusted by the total amount of AV calcium, neo2 was associated with a lower risk of PVL ≥ mild (OR, 0.35, 95%CI, 0.18-0.69; P = .003), and ≥ moderate (OR, 0.16; 95%CI, 0.03-0.74; P = .019). Conclusions: TAVI with ACURATE neo2 vs neo is associated with a lower risk of any degree of PVL and a reduced risk of PVL ≥ moderate. After adjusting for AV calcium volume, ACURATE neo2 was still associated with a lower risk of PVL.