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Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute myocardial infarction. Coronary angiography remains the best diagnostic tool; however, clinical suspicion and experience is required to interpret angiographic findings. This study sought to assess the clinical implications of the "broken line" (BKL) angiographic pattern in a large, nationwide, cohort of patients with SCAD. The Spanish SCAD registry (NCT03607981) prospectively enrolled consecutive patients with SCAD. All angiograms were centrally analyzed and the BKL pattern was systematically assessed. The BKL angiographic pattern was found in 64 of 389 patients (16%). Patients with the BKL appearance were more frequently female (97 vs 87%, p0.05), presented more often as intramural hematoma (83 vs 58%, p0.001), had longer lesions (47 ± 29 vs 36 ± 22 mm, p0.01), and had severe tortuosity (25 vs 10%, p0.01) but showed better initial coronary flow (thrombolysis in myocardial infarction flow 2.6 ± 0.8 vs 2.1 ± 1.2, p0.01). Patients with BKL received more frequently conservative medical management (91 vs 76%, p0.01). At late clinical follow-up (median 29 months, interquartile range 17 to 38) predefined adverse events (death, myocardial infarction, revascularization, recurrent SCAD, or stroke) occurred less frequently (3.5 vs 15%, p0.05) in patients with the BKL appearance. The better clinical outcomes of patients in the BKL group persisted after adjusting for potential confounders (adjusted hazard ratio 0.2, 95% confidence interval 0.1 to 0.9, p0.05). In conclusion, patients with SCAD presenting the BKL angiographic pattern are more frequently female and present more often as intramural hematoma with longer lesions and severe vessel tortuosity but have better coronary flow. Patients with the BKL morphology have a favorable prognosis (NCT03607981).

Introduction and objectives COVID-19 is currently causing high mortality and morbidity worldwide. Information on cardiac injury is scarce. We aimed to evaluate cardiovascular damage in patients with COVID-19 and determine the correlation of high-sensitivity cardiac-specific troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) with the severity of COVID-19. Methods We included 872 consecutive patients with confirmed COVID-19 from February to April 2020. We tested 651 patients for high-sensitivity troponin T (hs-TnT) and 506 for NT-proBNP on admission. Cardiac injury was defined as hs-TnT > 14ng/L, the upper 99th percentile. Levels of NT-proBNP > 300 pg/mL were considered related to some extent of cardiac injury. The primary composite endpoint was 30-day mortality or mechanical ventilation (MV). Results Cardiac injury by hs-TnT was observed in 34.6% of our COVID-19 patients. Mortality or MV were higher in cardiac injury than noncardiac injury patients (39.1% vs 9.1%). Hs-TnT and NT-proBNP levels were independent predictors of death or MV (HR, 2.18; 95%CI, 1.23-3.83 and 1.87 (95%CI, 1.05-3.36), respectively) and of mortality alone (HR, 2.91; 95%CI, 1.211-7.04 and 5.47; 95%CI, 2.10-14.26, respectively). NT-ProBNP significantly improved the troponin model discrimination of mortality or MV (C-index 0.83 to 0.84), and of mortality alone (C-index 0.85 to 0.87). Conclusions Myocardial injury measured at admission was a common finding in patients with COVID-19. It reliably predicted the occurrence of mortality and need of MV, the most severe complications of the disease. NT-proBNP improved the prognostic accuracy of hs-TnT.

Background This study aimed to assess the correlation between the standard of care, the index of microvascular resistance (IMR) versus the novel microvascular resistance (Rmicro) and to determine the pathologic cut-off value in a selected population with suspected coronary microvascular dysfunction (CMD). Methods One-hundred and twenty patients with high clinical suspicion of CMD due to ischemic symptoms in the absence of significant epicardial coronary lesions were prospectively included. Following a standardized systematic protocol, coronary flow reserve, IMR, fractional flow reserve, Q and Rmicro were measured in the left anterior descending coronary artery using a temperature/pressure sensor-tipped guidewire and a dedicated infusion catheter. Results There was a high prevalence of CMD with 50 (42%) patients showing an IMR ≥ 25. Median IMR was 23 [IQR: 14–34] and median Rmicro was 464 Woods Units (WU) [IQR: 354–636WU]. ROC analyses identified 500 WU as the optimal Rmicro cut-off to identify patients with an IMR ≥ 25, with an area under the ROC curve (C statistic) of 0.83 (95% CI: 0.74 to 0.89, p Conclusions Rmicro derived from continuous intracoronary thermodilution is an accurate index to measure microvascular resistances enabling the invasive diagnostic of CMD.

Introducción y objetivos: La enfermedad por coronavirus 2019 (COVID-19) se ha convertido en una enfermedad pandémica. Datos de estudios retrospectivos han mostrado una peor evolución en pacientes con enfermedad cardiovascular (ECV) y factores de riesgo cardiovascular (FRCV). Nuestro objetivo fue evaluar la relación entre la ECV y los FRCV con la evolución hospitalaria de pacientes con COVID-19. Métodos: Se diseñó un registro prospectivo que incluyó a pacientes consecutivos con COVID-19 ingresados en nuestro centro hospitalario. El periodo de inclusión abarcó desde el 27 de febrero al 7 de abril de 2020. Se monitorizaron los eventos clínicos hasta el 2 de mayo de 2020. Resultados: Se incluyó un total de 876 pacientes. La edad media fue de 62 ± 18 años; un 47% fueron > 65 años. Un 69% de los pacientes tenían al menos un FRCV; un 15% tenían ECV previa. Aquellos pacientes con ECV fueron significativamente más mayores (77 ± 11 frente a 60 ± 18 años; p 65 años (OR = 15; IC95% 5-43), la insuficiencia cardiaca (OR = 3.27; IC95%, 1.38-7.72) y la insuficiencia renal crónica (OR = 8.55; IC95%, 1.47-5.46) fueron predictores independientes de mortalidad hospitalaria por COVID-19. Conclusiones: En pacientes ingresados por COVID-19, la presencia de ECV o FRCV se asocia con un mayor riesgo de muerte durante la hospitalización. Una mayor edad, la historia de insuficiencia cardiaca y la insuficiencia renal crónica fueron predictores independientes de muerte por COVID-19.

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).

Objectives This study sought to compare the performance of a novel drug-coated balloon (DCB) (Elutax SV, Aachen Resonance, Germany), with an everolimus-eluting stent (EES) (Abbott Vascular...

Plaque erosion (PE) is a well-known pathological substrate in patients with acute myocardial infarction. The precise etiologic diagnosis of patients with myocardial infarction and nonobstructive coronary arteries is of great importance to inform both revascularization decisions and antithrombotic

Objectives This study used optical coherence tomography to investigate the mechanism of false lumen (FL) formation in spontaneous coronary artery dissection (SCAD) by studying: 1) differences between fenestrated and nonfenestrated SCAD; 2) vasa vasorum density; and 3) light attenuation characteristics of the FL. Background SCAD is an increasingly recognized cause of acute coronary syndromes, characterized by FL formation and compression of the true lumen (TL). The mechanisms underlying FL formation remain poorly understood. Methods A total of 65 SCAD patients (68 vessels) who underwent acute OCT imaging as part of routine clinical care were included. Images were classified by the absence or presence of a connection (fenestration) between the TL and FL. Indexed measurements of TL stenosis, external elastic lamina (EEL) area, FL area, and light attenuation of the FL were assessed. Vasa vasorum densities of SCAD cases were compared with those in control non-SCAD myocardial infarction cases. Results In nonfenestrated cases, there was significantly larger expansion of the EEL area (9.1% vs. −1.9%; p Conclusions These observational data suggest that the absence of a fenestration leads to increased FL pressure and compression of the TL. Although vasa vasorum may still be implicated in pathogenesis, increased vasa vasorum density could be an epiphenomenon of vascular healing.

Coronary artery aneurysms (CAA) may occur following virtually any coronary intervention. We present a patient developing a CAA after magnesium resorbable vascular scaffold (MRS) implantation in the left circumflex coronary artery 1 year before for an acute myocardial infarction. Intravascular ultrasound and optical coherence tomography revealed striking images of the dissolving MRS struts, well apposed and following the CAA vessel wall, rather than the expected classical findings of late acquired malapposition. The implications of these unique findings are discussed.

A 54-year-old man presenting with an acute myocardial infarction and a total occlusion of the circumflex coronary artery was treated with a magnesium resorbable vascular scaffold (MgRS) (25 mm in length), that was carefully post-dilated at high pressure (20 bar) with a noncompliant balloon, with

Resumen Introduccion y objetivos La hormona tiroidea afecta al metabolismo de todos los tejidos del organismo. El objetivo es analizar la prevalencia y las implicaciones de las alteraciones tiroideas en una cohorte de pacientes consecutivos con diseccion coronaria espontanea (DCE). Metodos Se evaluo a 73 pacientes diagnosticados de DCE y se compararon las caracteristicas y la evolucion clinica de los pacientes eutiroideos frente a los hipotiroideos. Se comparo posteriormente la prevalencia de alteraciones tiroideas y las caracteristicas clinicas de estos pacientes con las de 73 pacientes con sindrome coronario agudo pero sin DCE emparejados por edad, sexo y presentacion clinica. Resultados La media de edad fue 55 ± 12 anos y el 26% tenia hipotiroidismo. Los pacientes con DCE e hipotiroidismo eran todas mujeres (el 100 frente al 69%; p = 0,01), tenian disecciones mas distales (el 74 frente al 41%; p = 0,03), en arterias en tirabuzon (el 68 frente al 41%; p = 0,03) y recibieron tratamiento mas conservador (el 79 frente al 41%; p = 0,007). Durante un seguimiento medio de 4,1 ± 3,8 anos, la tasa de eventos adversos fue del 23%, sin diferencias segun el estado de la funcion tiroidea. La prevalencia de hipotiroidismo fue significativamente mayor en los pacientes con DCE que en el grupo con sindrome coronario agudo sin DCE (el 26 frente al 8%; p = 0,004). Conclusiones Hay una elevada prevalencia de hipotiroidismo en los pacientes con DCE. Los pacientes hipotiroideos con DCE son mas frecuentemente mujeres, tienen disecciones mas distales y en arterias en tirabuzon y reciben tratamiento mas conservador.

[Abstract] Cardiovascular diseases, particularly severe stenosis, are the main cause of death in the western world. The primary method of diagnosis, considered to be the standard in the detection and quantification of stenotic lesions, is a coronary angiography. This article proposes a new automatic multiscale segmentation algorithm for the study of coronary trees that offers results comparable to the best existing semi-automatic method. According to the state-of-the-art, a representative number of coronary angiography images that ensures the generalisation capacity of the algorithm has been used. All these images were selected by clinics from an Haemodynamics Unit. An exhaustive statistical analysis was performed in terms of sensitivity, specificity and Jaccard. Algorithm improvements imply that the clinician can perform tests on the patient and, bypassing the images through the system, can verify, in that moment, the intervention of existing differences in a coronary tree from a previous test, in such a way that it could change its clinical intra-intervention criteria. Galicia. Consellería de Cultura, Educación e Ordenación Universitaria; GRC2014/049 Ministerio de Economía y Competitividad; TIN2015-70648-P

A 63-year-old man presented with an acute coronary syndrome 15 years after revascularization of the left anterior descending coronary artery with 2 bare-metal stents. Coronary angiography revealed a severe, heavily calcified, lesion in a large obtuse marginal branch ([Figure 1A][1]) and diffuse in

Introduction and objectives Stent thrombosis (ST) is a rare but potentially serious complication. Optical coherence tomography (OCT) provides high-resolution images and additional information to angiography in the study of this event. Methods Prospective study of patients with ST undergoing reintervention with OCT imaging. Results The study included a total of 40 consecutive patients with ST. Mean age was 69 ± 13 years and 83% were male. Early ST (≤ 30 days) was observed in 16 patients and late ST (> 30 days) in 24 patients. Stent thrombosis occurred in 17 bare-metal stents and 23 drug-eluting stents. In 34 patients (85%), adequate OCT images were obtained at the time of the ST. The predominant mechanism in early ST was stent malapposition (39%). In late ST, high frequencies of uncovered (46%) and malapposed struts (17%) were observed, especially in patients with drug-eluting stents. Furthermore, the presence of neoatherosclerosis was very high (67%) in patients with late ST. After intervention, improvements were observed in malapposition length and the amount of residual thrombus. Conclusions OCT allows identification of the underlying mechanisms potentially involved in ST. This imaging modality is helpful in guiding reintervention in these patients, which improves the area and length of malapposition, as well as the maximal residual thrombus area.

Resumen Introduccion y objetivos La trombosis del stent (TS) es una complicacion infrecuente pero potencialmente grave. La tomografia de coherencia optica (OCT) ofrece imagenes de alta resolucion e informacion adicional a la angiografia en el estudio de esta enfermedad. Metodos Estudio prospectivo en el que se incluyo a todos los pacientes con una TS a los que se realizo una OCT durante el procedimiento. Resultados Se incluyo a un total de 40 pacientes con TS consecutivos, con una media de edad de 69 ± 13 anos; el 83% eran varones. Las TS fueron precoces (≤ 30 dias) en 16 pacientes y tardias (> 30 dias) en 24. En 17 pacientes la TS se produjo en stents convencionales y en 23, en farmacoactivos. En 34 casos (85%) se realizo estudio con OCT en el momento de la TS. En las TS precoces, el mecanismo predominante (39%) fue la malaposicion del stent . En las TS tardias se observaron frecuentemente (46%) struts no recubiertos y areas de malaposicion (17%), especialmente en pacientes con stents farmacoactivos. Ademas, la presencia de neoateroesclerosis fue muy elevada (67%) en los pacientes con TS tardia. Tras la intervencion se observo una mejora en la longitud de la malaposicion y la cantidad de trombo en el stent . Conclusiones La OCT permite conocer los mecanismos subyacentes potencialmente implicados en la TS y guiar el intervencionismo en estos pacientes. La reintervencion disminuye el area y la longitud de la malaposicion, asi como la cantidad de trombo residual.

Objectives This study sought to assess the value of bioresorbable vascular scaffolds (BVS) in patients with in-stent restenosis (ISR). Background Currently both drug-eluting stents (DES) and drug-eluting balloons (DEB) are recommended in patients with ISR. However, the value of BVS in this setting remains unclear. Methods RIBS VI (Restenosis Intra-stent: drug-eluting Balloon vs everolimus-eluting Stent) was a prospective multicenter study (19 Spanish sites) that included 141 patients treated with BVS for either bare-metal stent (BMS) ISR or DES-ISR. Late angiography was scheduled at 6 to 9 months. Inclusion/exclusion criteria were similar to those used in the RIBS IV (patients with DES-ISR) and RIBS V (patients with BMS-ISR) trials, where DEB (n = 249) was compared with everolimus (EES)-DES (n = 249). Results of BVS in RIBS VI were compared with those obtained with DEB and EES in the RIBS IV and V trials. Results On late angiography (n = 134; 95% of eligible) the in-segment minimal lumen diameter (primary endpoint) was 1.87 ± 0.5 mm, late lumen loss was 0.23 ± 0.4 mm, and restenosis rate was 11%. At 1-year follow-up (100% of patients) no patient died, 4 (2.8%) experienced a myocardial infarction, and 16 (11.3%) required target lesion revascularization. One patient (0.7%) who discontinued antiplatelet therapy experienced definitive BVS thrombosis. Freedom from cardiac death, myocardial infarction, and target lesion revascularization was 86%. The minimal lumen diameter at follow-up after BVS was similar to that obtained with DEB (1.88 ± 0.6 mm; p = NS) but smaller than that achieved after EES (2.16 ± 0.7 mm; p Conclusions This study suggests the safety and efficacy of BVS in patients with ISR. In this challenging anatomic scenario BVS obtained late angiographic and clinical results similar to DEB but inferior to EES. (Restenosis Intrastent: Bioresorbable Vascular Scaffolds Treatment [RIBS VI]; NCT02672878 )

Coronary interventions on small vessels, representing up to 30% to 40% of procedures, are challenging and often disappointing because of suboptimal acute results and high restenosis rates [(1,2)][1]. In this setting, bare-metal stents (BMS) proved to be superior to balloon angioplasty (BA), with the

We read with great interest the study from the Vancouver General Hospital confirming that spontaneous healing occurs during follow-up in most patients with spontaneous coronary artery dissection (SCAD) [(1)][1]. This is the largest study (n = 156/182 lesions) assessing the angiographic fate (median

An 82-year-old man with hypertension, diabetes mellitus type 2, and chronic renal failure under hemodialysis was admitted with rest angina. Coronary angiography showed 2-vessel coronary artery disease, with significant stenosis in the first and second diagonal branches that were small vessels, and a

Neoatherosclerosis (NA) is a major cause of in-stent restenosis (ISR). Optical coherence tomography (OCT) depicted different patterns of NA, including calcified sheets within the stent. Our aim was to describe the prevalence and predictors of calcified neoatherosclerosis (cNA). We identified

A 65-year-old male was admitted to our institution due to atypical chest pain. His previous medical history revealed the presence of an anterior wall myocardial infarction that extended clinically silent 30 years ago. Angiographic images revealed the presence of a linear filling defect in the