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Introduction and objectives Neoatherosclerosis is one of the causes of in-stent restenosis (ISR). Our objective was to evaluate the influence of neoatherosclerosis on prognosis and treatment response in patients with ISR. Methods This is a pooled analysis of the optical coherence tomography (OCT)-substudies of 2 multicenter, randomized clinical trials, RIBS IV and V, comparing treatment with paclitaxel-coated balloon vs everolimus-eluting stent in patients with ISR. OCT evaluation was performed at baseline and at 6 to 9 months. Neoatherosclerosis was defined in baseline OCT as neointima with calcified or lipid content. We evaluated the angiographic and OCT results at 6 to 9 months and the occurrence of major adverse cardiovascular events at 3 years of follow-up in patients with and without neoatherosclerosis treated with paclitaxel-coated balloon or everolimus-eluting stents. Results Sixty-four patients underwent OCT at the time of the index procedure. Neoatherosclerosis was documented in 23 (36%) lesions. Angiographic follow-up at 6 to 9 months showed no differences in restenosis [5 (24%) vs 6 (15%) P = .49], minimum lumen diameter (1.79 ± 0.7 vs 1.94 ± 0.6 mm; P = .41) or late loss (0.33 ± 0.7 vs 0.15 ± 0.5; P = .34) in patients with and without neoatherosclerosis, respectively. Follow-up OCT confirmed the absence of differences in quantitative parameters and the characteristics of tissue coverage between the 2 groups. At 3 years of follow-up, the major adverse cardiovascular events rate was 3 (13%) vs 5 (12%) in the neoatherosclerosis and nonneoatherosclerosis groups (HR, 0.94; 95%CI, 0.22-3.93; P = .93). Conclusions In this limited study population, OCT-defined neoatherosclerosis did not seem to influence acute and long-term outcomes in patients randomized to paclitaxel-coated balloon or everolimus-eluting stents for ISR.

Introduction and objectives Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome. The characteristics and in-hospital clinical course of patients with SCAD in Spain remain unknown. Methods We present data from consecutive patients included in the national prospective SCAD registry. Angiographic analysis was performed in a centralized core laboratory. Results Between June 2015 and April 2019, we included 318 patients with SCAD (358 lesions) from 31 centers. Median age was 53 years, and 88% were women. The most frequent presentation was non–ST-segment elevation acute myocardial infarction (53%). The most frequently involved artery was the left anterior descending coronary artery (44%), predominantly affecting the distal segments (39%) and secondary branches (54%). Most lesions (62%) appeared on angiography as intramural hematoma, without double lumen. Conservative management was selected as the initial approach in most patients (78%). During the index admission, 6% of patients had a major adverse event and 4 patients (1.3%) died. Independent predictors of adverse events were initial management with percutaneous coronary intervention (OR, 5.97; P = .004) and angiographic presentation as intramural hematoma (OR, 4.96; P = .028). Conclusions In Spain, SCAD affects mainly middle-aged women. In most patients, the initial management strategy was conservative with excellent in-hospital survival. Initial management with percutaneous coronary intervention and angiographic presentation as intramural hematoma were related to the presence of in-hospital adverse events. Registered at ClnicalTrials.gov (Identifier: NCT03607981).

Introduction and objectives Percutaneous closure of paravalvular leakage is an alternative to surgery in high-risk patients, but its use has been limited by a lack of specific devices. More appropriate devices—like the Amplatzer Vascular Plug III —have recently been developed, but information about their efficacy and safety is still scarce. The objective of the present study was to assess the mid-term results of paravalvular leakage closure with this device. Methods We analyzed the clinical and echocardiographic course both in-hospital and mid-term (13 [9] months) in a series of 20 consecutive patients (age, 68 years; logistic EuroSCORE, 29) with paravalvular leakage and attempted percutaneous closure. Results Closure was attempted for 23 leaks (17 mitral and 6 aortic) during 22 procedures in 20 patients. Implantation was successful in 87% of the leaks and the procedure was successful in 83%—with success being defined as a reduction in regurgitation of ≥ 1 degree. Survival at 1 year was 64.7% and survival free of the composite event of death/surgery was 58.8%. The degree of residual regurgitation was not associated with mortality but was associated with functional status. Survivors showed significant improvement in functional class. Conclusions Percutaneous closure of leakage with the Amplatzer Vascular Plug III is safe and efficient in the mid-term. However, mortality among high-risk patients is high independently of the degree of residual regurgitation, indicating that these procedures are performed when heart disease has reached an advanced stage.

Of 12 patients with sudden death and a high probability of coronary artery disease who underwent cardiac catheterization, 4 (25%) showed coronary arteries without significant obstructive lesions or angiographic signs of instability. The study protocol included an invasive study of coronary vasoreactivity and an intracoronary imaging study with intravascular ultrasound. The coronary reactivity study showed coronary vasospasm in 1 patient. Intravascular ultrasound showed active coronary plaques with images suggesting intraluminal thrombus in all patients. The diagnosis reached was sudden death secondary to ventricular arrhythmias in the context of acute coronary syndrome; the use of an implantable cardioverter-defibrillator was therefore not indicated. In conclusion, in patients with sudden death with a high probability of coronary artery disease but with coronary arteries lacking significant lesions, intracoronary imaging (eg, by intravascular ultrasound) may be essential to establish a diagnosis and appropriate treatment, even in patients with induced coronary vasospasm.

Very late thrombosis in an implanted bare-metal stent is a very uncommon event outside the context of brachytherapy and few data about its pathophysiology are available. We performed an intravascular ultrasound study during primary angioplasty in five patients with very late bare-metal stent thrombosis and carried out a histological analysis of the material removed by manual thrombectomy. The mean time from the index procedure was 7 ± 4 years. Intravascular ultrasound findings were: calcified atherosclerosis with in-stent plaque rupture, complex plaque in the distal segment of the stent, in-stent neointimal proliferation associated with underexpansion, and severe in-stent proliferation. Histological findings were consistent with the intravascular ultrasound images: recent thrombus with areas of old thrombosis in all cases and remnant atheromatous plaque and endothelium. Consequently, in-stent or distal stent atherosclerosis progression and progressive neointimal proliferation were the likely pathophysiological mechanisms.

Percutaneous implantation of aortic valve prostheses has recently emerged as a therapeutic option for patients with severe symptomatic aortic stenosis for whom surgical valve replacement is not suitable. We describe our initial experience with this technique at our institution. Percutaneous implantation of an Edwards Sapiens aortic prosthesis was performed using the transfemoral approach in 4 patients with severe symptomatic aortic stenosis for whom surgery was not suitable (mean EuroSCORE, 23%). The procedure was successful in all patients, with optimal implantation of the prosthesis and no complications. By 1 month of follow-up, no patient had experienced an event and all had improved their functional class.