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Resumen Introduccion y objetivos Comparar la estrategia de revascularizacion percutanea de lesiones graves en ramas coronarias secundarias (RS) (diametro ≥ 2 mm) de arterias epicardicas mayores frente al tratamiento conservador. Metodos Estudio de cohortes retrospectivo en el que se compara a pacientes con lesiones graves en RS de arterias epicardicas principales tratados con revascularizacion percutanea o con un tratamiento farmacologico a criterio del operador. Se analizo el porcentaje de eventos relacionados con la rama (muerte cardiovascular, infarto de miocardio atribuible a RS o necesidad de revascularizacion de la RS). Resultados Se analizaron 679 lesiones en RS (662 pacientes). Tras un seguimiento medio de 22,2 ± 10,5 meses, no hubo diferencias significativas entre ambos grupos de tratamiento en mortalidad de causa cardiovascular (el 1,7 frente al 0,4%; p = 0,14), infarto agudo de miocardio (IAM) no fatal (el 1,7 frente al 1,7%; p = 0,96) o necesidad de revascularizacion de la RS (el 4,1 frente al 5,4%; p = 0,45) ni en el porcentaje total de eventos (el 5,1 frente al 6,3%; p = 0,54). Las variables que mostraron asociacion con la ocurrencia de eventos en el analisis multivariable fueron la diabetes (sHR = 2,87; IC95%, 1,37-5,47; p = 0,004), IAM previo (sHR = 3,54; IC95%, 1,77-7,30; p Conclusiones En el seguimiento, el porcentaje de eventos relacionados con la RS fue bajo respecto al total de pacientes, sin diferencias significativas entre una y otra estrategia de tratamiento. Las variables que se asociaron con la ocurrencia de eventos en el analisis multivariable fueron la diabetes mellitus, el antecedente de IAM y la mayor longitud de la lesion.

INTRODUCTION AND OBJECTIVES To analyze the percutaneous revascularization strategy for severe lesions in the secondary branches (SB) (diameter ≥ 2mm) of major epicardial arteries compared with conservative treatment. METHODS This study analyzed patients with severe SB lesions who underwent percutaneous revascularization treatment compared with patients who received pharmacological treatment. The study examined the percentage of branch-related events (cardiovascular death, myocardial infarction attributable to SB, or the need for revascularization of the SB). RESULTS We analyzed 679 SB lesions (662 patients). After a mean follow-up of 22.2±10.5 months, there were no significant differences between the 2 treatment groups regarding the percentage of death from cardiovascular causes (1.7% vs 0.4%; P=.14), nonfatal acute myocardial infarction (AMI) (1.7% vs 1.7%; P=.96), the need for SB revascularization (4.1% vs 5.4%; P=.45) or in the total percentage of events (5.1% vs 6.3%; P=.54). The variables showing an association with event occurrence on multivariate analysis were diabetes (SHR, 2.87; 95%CI, 1.37-5.47; P=.004), prior AMI (SHR, 3.54; 95%CI, 1.77-7.30; P

Background Thrombolysis is still used when primary angioplasty is delayed for a long time, but 25%–30% of patients require rescue angioplasty (RA). There are no established recommendations for antithrombotic management in RA. This registry analyzes regimens for antithrombotic management. Methods A retrospective, multicenter, observational registry of consecutive patients treated with RA at 8 hospitals. All variables were collected and follow-up took place at 6 months. Results The study included 417 patients. Antithrombotic therapy in RA was: no additional drugs 22.3%, unfractionated heparin (UFH) 36.6%, abciximab 15.5%, abciximab plus UFH 10.5%, bivalirudin 5.7%, enoxaparin 4.3%, and others 4.7%. Outcomes at 6 months were: mortality 9.1%, infarction 3.3%, definite or probable stent thrombosis 4.3%, revascularization 1.9%, and stroke 0.5%. Mortality was related to cardiogenic shock, age > 75 years, and anterior location. The stent thrombosis rate was highest with bivalirudin (12.5% at 6 months). The incidence of bleeding at admission was high (14.8%), but most cases were not severe (82% BARC ≤2). Variables independently associated with bleeding were: femoral access (OR 3.30; 95% CI 1.3–8.3: p = 0.004) and post-RA abciximab infusion (OR 2.26; 95% CI 1.02–5: p = 0.04). Conclusions Antithrombotic treatment regimens in RA vary greatly, predominant strategies consisting of no additional drugs or UFH 70 U/kg. No regimen proved predictive of mortality, but bivalirudin was related to more stent thrombosis. There was a high incidence of bleeding, associated with post-RA abciximab infusion and femoral access.

Evidence regarding therapy with drug-eluting stents in the left main coronary artery (LM) is based mostly on trials performed with first-generation drug-eluting stents. The aim of this study was to evaluate long-term clinical outcomes after treatment for unprotected LM disease with paclitaxel-eluting stents (PES) and everolimus-eluting stents (EES). The ESTROFA-LM is a multicenter retrospective registry including consecutive patients with unprotected LM disease treated with PES or EES. A total of 770 patients have been included at 21 centers, 415 with treated PES and 355 with EES. Treatment with 2 stents was more frequent with PES (17% vs 10.4%, p = 0.007), whereas intravascular ultrasound was more frequently used with EES (35.2% vs 26%, p = 0.006). The 3-year death and infarction survival rates were 86.1% for PES and 87.3% for EES (p = 0.50) and for death, infarction, and target lesion revascularization were 83.6% versus 82% (p = 0.60), respectively. Definite or probable thrombosis was 1.6% for PES and 1.4% for EES (p = 0.80). The use of 2 stents, age, diabetes, and acute coronary syndromes were independent predictors of mortality. In the subgroup of distal lesions, the use of intravascular ultrasound was an independent predictor of better outcome. Comparison of propensity score-matched groups did not yield differences between the 2 stents. In conclusion, the results of this multicenter registry show comparable safety and efficacy at 3 years for PES and EES in the treatment of LM disease. The use of bifurcation stenting techniques in distal lesions was a relevant independent predictor for events. The use of intravascular ultrasound appears to have a positive impact on patients treated for LM distal disease.

AIMS Our aim was to assess the safety and efficacy of paclitaxel-eluting balloon (PTX-B) treatment after bare metal stent (BMS) implantation in patients undergoing primary angioplasty. METHODS AND RESULTS After BMS implantation, patients were randomised (1:1) to treatment with a PTX-B or no PTX-B treatment (BMS group). The primary endpoint was in-stent late luminal loss (LLL) at nine-month follow-up. OCT was carried out on the first 20% of consecutive patients included in the study. Two hundred and twenty-three patients were randomised (BMS: 112, PTX-B: 111). At nine months, median LLL was 0.80 mm (interquartile range [IQR] 0.36-1.26) in the BMS group vs. 0.31 mm (IQR 0.00-0.58) in the PTX-B group, p

Objectives This study sought to evaluate second-generation drug-eluting stent (DES) thrombosis in clinical practice. Background First-generation DES are associated with a significant incidence of late thrombosis. There is paucity of data regarding real practice late thrombosis incidence and predictors with second-generation DES, zotarolimus-eluting stent (ZES), and everolimus-eluting stents (EES). Methods A prospective, large-scale, non-industry-linked multicenter registry was designed. Complete clinical-procedural data and systematic follow-up of all patients treated with these stents was reported in a dedicated registry supported by the Spanish Working Group on Interventional Cardiology. Results From 2005 to 2008, 4,768 patients were included in 34 centers: 2,549 treated with ZES, and 2,219 with EES. The cumulative incidence of definite/probable thrombosis for ZES was 1.3% at 1 year and 1.7% at 2 years and for EES 1.4% at 1 year and 1.7% at 2 years (p = 0.8). The increment of definite thrombosis between the first and second year was 0.2% and 0.25%, respectively. In a propensity score analysis, the incidence remained very similar. Ejection fraction (adjusted hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.95 to -0.99; p = 0.008), stent diameter (adjusted HR: 0.37; 95% CI: 0.17to 0.81; p = 0.01) and bifurcations (adjusted HR: 2.1; 95% CI: 1.14 to 3.7; p = 0.02) emerged as independent predictors of thrombosis. In the subgroup of patients with bifurcations, the use of ZES was independently associated with a higher thrombosis rate (adjusted HR: 4; 95% CI: 1.1 to 13; p = 0.03). Conclusions In a real practice setting, the incidence of thrombosis at 2 years with ZES and EES was low and quite similar. The incidence of very late thrombosis resulted lower than was reported in registries of first-generation DES. In the subset of bifurcations, the use of ZES significantly increased the risk of thrombosis.

Drug eluting stents decrease the rate of restenosis, however, concerns still remains about their safety, especially in ST-segment elevation myocardial infarction (STEMI). The quest for new devices and procedures, aiming for an improved safety/efficacy balance, in STEMI is still warranted. The aim of

The occurrence of balloon slippage (“watermelon seeding”; WMS) during treatment of patients with in-stent restenosis (ISR) has been described, but predisposing factors and the potential implications of this phenomenon remain unknown. In the Restenosis Intrastent: Balloon Angioplasty vs. Elective Stenting (RIBS) randomized study, 450 patients with ISR were included. Of these, 42 patients (9%) presented WMS during the procedure. WMS was detected in 26 patients (12%) in the balloon arm and 16 (7%) in the stent arm (P = 0.11). In the stent arm, WMS was only noticed during balloon predilation, never during stent implantation. As compared with 408 patients without WMS, patients with WMS had more severe (TIMI flow 1; 21% vs. 8%; P = 0.01) and diffuse (length > 15 mm: 45% vs. 28%; P = 0.02) ISR lesions. Patients with WMS required more balloon inflations, longer total inflation time, had more frequent crossover to stenting or ended the procedure with residual dissections, and eventually obtained poorer acute results (minimal lumen diameter, 2.35 ± 0.5 vs. 2.53 ± 0.5 mm; P = 0.03). In addition, at 6-month follow-up, patients with WMS had a smaller minimal lumen diameter (1.26 ± 0.7 vs. 1.61 ± 0.7 mm; P = 0.007) and a higher restenosis rate (56% vs. 37%; P = 0.017). On logistic regression analysis, the WMS phenomenon emerged as an independent predictor of recurrent restenosis (adjusted RR = 2.1; 95% CI = 1.1–4.1; P = 0.04). The WMS phenomenon may complicate treatment of patients with ISR. Long and severe lesions appear to predispose to this technical problem that never occurs during stent deployment. In patients with ISR, WMS is associated with cumbersome procedures and poorer acute and long-term angiographic results. © 2005 Wiley-Liss, Inc.

Antagonists of the glycoprotein IIb/IIIa receptor block the binding of fibrinogen and von Willebrand factor to the platelet receptor. This effect can lead to bleeding and thrombocytopenia. We analyzed the incidence and clinical repercussions of severe thrombocytopenia (

Los antiagregantes antiglucoproteina IIb/IIIa bloquean la union del fibrinogeno y el factor de Von Willebrand a sus receptores. Pueden causar hemorragia y trombocitopenia. Se ha analizado la incidencia y la repercusion clinica de la trombocitopenia extrema severa (< 20.000 por µl) secundaria a abciximab en un estudio prospectivo de 375 pacientes (el 74%, varones) sometidos a cateterismo cardiaco percutaneo y tratados con abciximab en nuestro hospital. Se registraron las caracteristicas clinicas, demograficas, del procedimiento y los datos analiticos, asi como el recuento plaquetario (antes del procedimiento y a las 4 y 12 h de este) y el hematocrito. La incidencia de trombocitopenia aguda extrema en los 375 pacientes fue del 1,1%. Todos fueron varones y no presentaron complicaciones hemorragicas relevantes. Debe considerarse esta complicacion en las primeras horas posteriores a la administracion del farmaco. Su manejo consistio en vigilancia del sangrado, suspension del farmaco y transfusion plaquetaria.

Introduccion y objetivos El objetivo del estudio es analizar el seguimiento de pacientes a los que se practico valvulotomia mitral percutanea y los factores predictores de supervivencia libre de eventos. Metodos Analizamos 220 valvulotomias mitrales percutaneas consecutivas realizadas entre 1988 y 1996 para establecer la incidencia de eventos (muerte, reestenosis, cirugia mitral, clase funcional IV de la New York Heart Association, nueva valvulotomia mitral percutanea y embolia sistemica) y las caracteristicas pre y posvalvulotomia predictoras de aquellos, en un seguimiento entre 1 y 96 meses (mediana 42 meses). Resultados La supervivencia global fue del 94,7% y la supervivencia libre de eventos del 59,2% a 96 meses. Analizando las variables del perfil basal (metodo actuarial de Kaplan-Meier), la fibrilacion auricular (p 2 era predictora de estar libre de eventos: el 72,9 frente al 10,5% (test log-rank p Conclusiones Los eventos a medio plazo tras valvulotomia mitral percutanea se pueden predecir en funcion de caracteristicas pre y posvalvulotomia. La edad 3 56 anos, una puntuacion ecocardiografica 3 9 y la fibrilacion auricular fueron factores preprocedimiento relacionados con eventos adversos. Los pacientes con ningun o un factor adverso en el perfil clinico basal no tienen diferencias significati vas en la evolucion a medio plazo, mientras que los que presentan dos, y sobre todo, tres caracteristicas adversas tienen una menor supervivencia libre de eventos. Un area mitral 3 1,5 cm 2 es la unica variable posprocedimiento predictora independiente de la evolucion libre de eventos.

The evidences of therapy with drug-eluting stents (DES) in ST-elevation myocardial infarction are mostly based on trials performed with first-generation DES. There is paucity of data with long-term follow up with second-generation DES in this setting. The ESTROFA-MI is a multicenter retrospective

This study sought to evaluate second-generation drug-eluting stent (DES) thrombosis in clinical practice.First-generation DES are associated with a significant incidence of late thrombosis. There is paucity of data regarding real practice late thrombosis incidence and predictors with second-generation DES, zotarolimus-eluting stent (ZES), and everolimus-eluting stents (EES).A prospective, large-scale, non-industry-linked multicenter registry was designed. Complete clinical-procedural data and systematic follow-up of all patients treated with these stents was reported in a dedicated registry supported by the Spanish Working Group on Interventional Cardiology.From 2005 to 2008, 4,768 patients were included in 34 centers: 2,549 treated with ZES, and 2,219 with EES. The cumulative incidence of definite/probable thrombosis for ZES was 1.3% at 1 year and 1.7% at 2 years and for EES 1.4% at 1 year and 1.7% at 2 years (p = 0.8). The increment of definite thrombosis between the first and second year was 0.2% and 0.25%, respectively. In a propensity score analysis, the incidence remained very similar. Ejection fraction (adjusted hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.95 to -0.99; p = 0.008), stent diameter (adjusted HR: 0.37; 95% CI: 0.17to 0.81; p = 0.01) and bifurcations (adjusted HR: 2.1; 95% CI: 1.14 to 3.7; p = 0.02) emerged as independent predictors of thrombosis. In the subgroup of patients with bifurcations, the use of ZES was independently associated with a higher thrombosis rate (adjusted HR: 4; 95% CI: 1.1 to 13; p = 0.03).In a real practice setting, the incidence of thrombosis at 2 years with ZES and EES was low and quite similar. The incidence of very late thrombosis resulted lower than was reported in registries of first-generation DES. In the subset of bifurcations, the use of ZES significantly increased the risk of thrombosis.

Objectives We sought to analyze the very late outcomes of patients treated for in-stent restenosis (ISR) according to treatment allocation and 10 prespecified variables. Background Long-term results (>2 years) of patients with ISR undergoing repeat coronary interventions are not well established. Methods The Restenosis Intrastent: Balloon angioplasty versus elective Stenting (RIBS) randomized study compared these two strategies in 450 patients with ISR. A detailed systematic protocol was used for late clinical follow-up. Results At one-year follow-up (100% of patients), the event-free survival was similar in the two groups (77% stent implantation [ST] arm, 71% balloon angioplasty [BA] arm, log-rank p = 0.19). Additional long-term clinical follow-up (median 4.3 years, range 3 to 5 years) was obtained in 98.6% of patients. During this time 22 additional patients died (9 ST arm, 13 BA arm), 7 suffered a myocardial infarction (3 ST arm, 4 BA arm), 23 required coronary surgery (11 ST arm, 12 BA arm), and 9 underwent repeat coronary interventions (4 ST arm, 5 BA arm) (nonexclusive events). At four years the event-free survival was 69% in the ST arm and 64% in the BA arm (log-rank p = 0.21). Among the 10 prespecified variables, vessel size ≥3 mm had a major influence on the clinical outcome at four years, with better results in the ST group (hazard ratio 0.51, 95% confidence interval 0.3 to 0.89, p = 0.016). Conclusions Patients with ISR undergoing repeat interventions have a significant event rate at late follow-up. Continued medical surveillance should be continued after one year. Patients with large vessels have a better outcome after repeat stenting.

Clinical Impact of IVUS-guided Left Main PCI: Insights from the Multicenter Study ESTROFA-LM. Fernando Alfonso, Jose Maria De La Torre Hernandez, Angel Sanchez Recalde, Manuel F. Jimenez Navarro, Armando Perez De Prado, Felipe Hernandez, Omar Abdul-Jawad Altisent, Gerard Roura, Tamara Garcia Camarero, Jaime Elizaga, Fernando Rivero, Federico Gimeno, Ramon Calvio, Jose Moreu, Francisco Bosa, Jose Ramon Rumoroso, Juan A. Bullones, Arsenio Gallardo, Jose A. Fernandez Diaz, Jose R. Ruiz Arroyo, Victor Aragon, Monica Masotti. Hospital Universitario Marques de Valdecilla, Santander, Spain; Hospital Clinico San Carlos, Madrid, Spain; Hospital La Paz, Madrid, Spain; Hospital Virgen de la Victoria, Malaga, Spain; Hospital de Leon, Leon, Spain; Hospital 12 de Octubre, Madrid, Spain; Hospital Vall d’Hebron, Barcelona, Spain; Hospital Bellvitge, Barcelona, Spain; Hospital Gregorio Maranon, Madrid, Spain; Hospital La Princesa, Madrid, Spain; Hospital de Valladolid, Valladolid, Spain; Hospital de la Corua. CHUAC, La Corua, Spain; Hospital Virgen de la Salud, Toledo, Spain; Hospital Clinico de Tenerife, Santa Cruz de Tenerife, Spain; Hospital de Galdakano, Bilbao, Spain; Hospital Carlos Haya, Malaga, Spain; Hospital de Albacete, Albacete, Spain; Hospital Puerta de Hierro, Madrid, Spain; Hospital Clinico Lozano Blesa, Zaragoza, Spain; Hospital de Jaen, Jaen, Spain; Hospital Clinic, Barcelona, Spain. Background: Percutaneous revascularization of left main coronary artery (LMCA) lesions with drug eluting stent (DES) is an alternative to surgery in high risk patients and in those cases with non severe coronary disease. Whether the use of intravascular ultrasound (IVUS) during the procedure adds a clinical benefit remains unclear. There is only one single study (MAIN COMPARE) that supports this statement. Therefore we sought to investigate the clinical impact of the use of IVUS in this setting. Methods: From a retrospective multicenter study that compared different DES in the setting of left main we have analyzed the clinical impact of the use of IVUS. Consecutive patients from 21 different hospitals with leftmain lesions treatedwithDESwere included. A systematic follow upwas performed. A propensity scorematchingmethodwas used to obtain matched pairs of patients with and without IVUS guidance during DES implantation in LMCA. Results: A total of 770 pts were included in the registry. IVUS was used in 233 cases (30.2%) and not used in 537 pts. After a three years follow up period the use of two stents, age, diabetes and acute coronary syndrome were found independent predictors of events in the global group after a Cox analysis. In the subgroup of 409 (53.1%) patients with distal left main lesions the independent predictors were the use of two stents, age, diabetes and the use of IVUS, being the latest a protective predictor (HR 0.5, IC 95% 0.23-0.99; p1⁄40.04). After propensity score matching 200 matched pairs of patients treated with DES in LMCA with and without IVUS were included in the analysis. Among these, 80 and 85 pts in each group respectively were treated in distal LM lesions. The data for survival free of events at 3 years are shown in table: No IVUS N1⁄4200 IVUS N1⁄4200 p Cardiac death, MI and TLR 86.7% 90.2% 0.9 Cardiac death and MI 89.2% 94.7% 0.6 TLR 97.3% 94% 0.4 Distal lesions No IVUS n[85 IVUS n[80 Cardiac death, MI and TLR 82% 94.4% 0.08 Cardiac death and MI 84% 95.7% 0.09 TLR 97.5% 95.7% 0.9 The American Journal of Cardiology APRIL 23e26, 2013 AN Conclusion: The results of this multicenter registry suggest a potential clinical benefit derived from IVUS-guided PCI with DES in distal left main lesions.