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International audience; Background - Staphylococcus aureus (SA) has been extensively studied as causative microorganism of surgical prosthetic-valve infective endocarditis (IE). However, scarce evidence exists on SA IE after transcatheter aortic valve replacement (TAVR). Methods - Data were obtained from the Infectious Endocarditis After TAVR International Registry, including patients with definite IE after TAVR from 59 centres in 11 countries. Patients were divided into 2 groups according to microbiologic etiology: non-SA IE vs SA IE. Results - SA IE was identified in 141 patients out of 573 (24.6%), methicillin-sensitive SA in most cases (115/141, 81.6%). Self-expanding valves were more common than balloon-expandable valves in patients presenting with early SA IE. Major bleeding and sepsis complicating TAVR, neurologic symptoms or systemic embolism at admission, and IE with cardiac device involvement (other than the TAVR prosthesis) were associated with SA IE (P < 0.05 for all). Among patients with IE after TAVR, the likelihood of SA IE increased from 19% in the absence of those risk factors to 84.6% if ≥ 3 risk factors were present. In-hospital (47.8% vs 26.9%; P < 0.001) and 2-year (71.5% vs 49.6%; P < 0.001) mortality rates were higher among patients with SA IE vs non-SA IE. Surgery at the time of index SA IE episode was associated with lower mortality at follow-up compared with medical therapy alone (adjusted hazard ratio 0.46, 95% CI 0.22-0.96; P = 0.038). Conclusions - SA IE represented approximately 25% of IE cases after TAVR and was associated with very high in-hospital and late mortality. The presence of some features determined a higher likelihood of SA IE and could help to orientate early antibiotic regimen selection. Surgery at index SA IE was associated with improved outcomes, and its role should be evaluated in future studies.

Background Recent improvement in clinical skills, technology and hardware has resulted in improved success rates with chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We performed a study level pooled analysis from the five largest registries of percutaneous coronary intervention (PCI) of CTO. Research design and methods We conducted pooled analysis of 9500 patients in registries and data on procedural characteristics, technical success, and MACCE was collected. Results A total of 9500 patients were included in the analysis. Mean age was 65.4 years with previous CABG in 24.8%, reattempt procedure in 24.8% and mean JCTO score was 2.2. Final wiring strategy in hybrid algorithm-based registries was AWE in 40.8-58%, Retrograde in 24-35%, ADR in 16-25% and in Expert JCTO and EURO CTO was AWE in 72-75% and retrograde in 25-28%. Technical success was achieved in 87.8%. In hospital MACCE was 2.5 % (95% CI: 1.8 to 3.4%), mortality 0.44% (95% CI: 0.23 to 0.84%), stroke 0.2% (95% CI: 0.1 to 0.3%); myocardial infraction 1.6% (95% CI: 1.1 to 2.2%); and cardiac tamponade 0.8% (95% CI: 0.5 to 1.3 %). Conclusion CTO PCI is currently performed with high technical success rates and low complication rates in experienced hands utilizing various techniques.

BACKGROUND Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR). OBJECTIVES The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization. METHODS Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]). RESULTS A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation >= moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47). CONCLUSIONS Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes. (C) 2021 by the American College of Cardiology Foundation.

BACKGROUND Data is controversial regarding the existence of an "obesity paradox" in patients undergoing Transcatheter Aortic Valve Replacement (TAVR). We sought to investigate the prognostic value of the body mass index (BMI) on outcomes following TAVR. METHODS This is an observational, single-center study involving all patients who underwent TAVR from 2009 to 2019. BMI was calculated in all patients before TAVR. The cohort was subdivided into four groups: underweight (

BackgroundProcedural improvements combined with the contemporary clinical profile of patients undergoing transcatheter aortic valve replacement (TAVR) may have influenced the incidence and outcomes of infective endocarditis (IE) following TAVR. We aimed to determine the temporal trends, characteristics, and outcomes of IE post-TAVR.MethodsObservational study including 552 patients presenting definite IE post-TAVR. Patients were divided in 2 groups according to the timing of TAVR (historical cohort [HC]: before 2014; contemporary cohort [CC]: after 2014).ResultsOverall incidence rates of IE were similar in both cohorts (CC vs HC: 5.45 vs 6.52 per 1000 person-years; P = .12), but the rate of early IE was lower in the CC (2.29‰ vs 4.89‰, P ConclusionsAlthough overall IE incidence has remained stable, the incidence of early IE has declined in recent years. The microorganism, high rate of complications, and very low rate of surgical treatment remained similar. In-hospital and 1-year mortality rates were high but progressively decreased over time.

© 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC By-NC-ND License (http://creativecommons.org/licenses/by-nc-nd/4), The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

Background The advent of transcatheter aortic valve replacement (TAVR) has changed the practice of treating patients with severe aortic stenosis (AS). Heart-Teams have improved their decision-making process to refer patients to the best and safest treatment. The evidence allowed centers to increase funding and TAVR volume and extend indications to different risk categories of patients. This study evaluates the outcomes of intermediate-risk patients treated for severe AS in an academic center. Methods Between 2012 and 2019, 812 patients with AS underwent TAVR or surgical aortic valve replacement (SAVR). A propensity score-matching analytic strategy was used to balance groups and adjust for time periods. Outcomes were recorded according to the Society of Thoracic Surgeons Guidelines; the primary outcome being 30-day mortality and the secondary outcomes being perioperative course and complications. Results No difference in mortality was seen but complications differed: more postoperative transient ischemic attacks, permanent pacemaker implantations, and perivalvular leaks in the transcatheter group, while more acute kidney injuries, atrial fibrillation, delirium, postoperative infections and bleeding, tamponade and need for reoperation in the surgical group as well as a longer hospital length-of-stay. However, over the years, morbidities/mortality decreased for all patients treated for AS. Conclusions Data showed an improvement in morbidities/mortality for intermediate-risk patients treated with SAVR or TAVR. Increased funding allowed for a higher TAVR volume by increasing access to this technology. Also, the difference in complications could impact healthcare costs. By incorporating important metrics such as length-of-stay, readmission rates, and complications into decision-making, the Heart-Team can improve clinical outcomes, healthcare economics, and resource utilization.

Introduction. Although epirubicin has significantly improved outcome in breast cancer (BC) patients, it is responsible for myocardial dysfunction that affects patients’ quality of life. The use of 2D global longitudinal strain (GLS) has been reported to detect early myocardial dysfunction. The aim of this study was to evaluate how GLS changes can predict cardiotoxicity. Methods. We conducted a prospective study from March 2018 to March 2020 on 66 patients with no cardiovascular risk factors, who presented with BC and received epirubicin. We measured left ventricular ejection fraction (LVEF) and GLS before chemotherapy, at three months (T3), and at 12 months (T12) from the last epirubicin infusion. Chemotherapy-Related-Cardiac-Dysfunction (CTRCD) was defined as a decrease of 10% in LVEF to a value below 53% according to ASE and EACI 2014 expert consensus. Results. The mean age at diagnosis was 47 ± 9 years old. At baseline, median LVEF was 70% and median GLS was −21%. Shortly after chemotherapy completion, two patients presented with symptomatic heart failure while asymptomatic CTRCD was revealed in three other patients at T12. Three months after the last epirubicin infusion, median LVEF was 65%, median GLS was −19%, and median GLS variation was 5%. However, in patients who presented with subsequent CTRCD, median GLS at T3 was −16% and median GLS variation was 19% ( p = 0.002 and p < 0.001 , respectively, when compared to patients who did not develop cardiotoxicity). Persistent GLS decrease at T3 was an independent predictor of CTRCD at T12. Age and left-sided thoracic irradiation did not increase the risk of cardiotoxicity in our study while the cumulative dose of epirubicin significantly affected cardiologic findings ( p = 0.001 ). Conclusion. This was the first North African study that assesses the value of measuring GLS to early detect cardiotoxicity. Patients whose GLS remained decreased after 3 months from anthracyclines-base chemotherapy had an increased risk for developing subsequent CTRCD. Further studies with larger sample size are warranted to identify the best cardioprotective molecules to be initiated in these patients before LVEF declines.

Background The BIOFLOW-III Canada registry aimed to evaluate the safety and efficacy of Orsiro sirolimus-eluting stents (SES) with biodegradable polymer, in an all-comers patient population. Methods We conducted a prospective, non-randomized, multi-center, observational all-comers registry of patients undergoing percutaneous coronary intervention (PCI) with Orsiro SES at two high-volume Canadian centers. The primary endpoint was one-year target lesion failure (TLF) defined as a composite of cardiac death, target-vessel myocardial infarction (MI), coronary artery bypass grafting and clinically driven target lesion revascularization. Four subgroups were pre-defined: i) diabetic patients; ii) small vessels (≤2.75 mm); iii) chronic total occlusions (CTO) and iv) acute MI. Results From May 2014 to July 2016, 250 patients (mean age 66.2 ± 10.8 years, 75.6% males, 30% diabetes) underwent PCI with Orsiro SES for 385 coronary lesions. The mean stent diameter was 2.98 ± 0.50 mm and the mean stent length was 22 ± 8 mm. Clinical device and procedural success rates were with 99.5% and 97.6%, respectively. The overall one-year TLF rate was 2.8% [95% confidence interval (CI) 1.4–5.8%], whereas TLF rates were 4.1% [95%CI 1.3–12.2%], 3.2% [95%CI 1.2–8.4%], 8.3% [95%CI 2.2–29.4%], and 2.6% [95%CI 0.7–9.9%] in patients with diabetes, small vessels, CTO, and acute MI, respectively. One case of possible stent thrombosis (ST) was reported (0.4% [95%CI 0.1–2.8%]), while no cases of definite/probable ST was observed at one year. Conclusion Our data provide further evidence of the safety and clinical performance of Orsiro SES in an unselected, real-world, complex patient population. Condensed abstract The BIOFLOW-III Canada registry is a prospective, non-randomized, multi-center, observational all-comers registry designed to evaluate the safety and performance of the Orsiro SES in non-selected, real-world patients. A total of 250 patients (mean age 66.2 ± 10.8 years, 75.6% males, 30% diabetes) who underwent PCI with Orsiro SES, were enrolled at two high-volume Canadian centers. The overall rate of TLF at one year was 2.8% [95%CI 1.4–5.8%], whereas TLF rates were 4.1%, 3.2%, 8.3%, and 2.6% in patients with diabetes, small vessels ≤2.75 mm, CTO, and acute MI, respectively. No case of definite/probable ST was observed.

Treatment of ostial chronic total occlusions (CTOs) of the right coronary artery (RCA) can be challenging. We present an algorithmic approach to the management of such lesions that incorporates all contemporary equipment and techniques. If the RCA ostium can be engaged with a guide catheter then antegrade crossing attempts should be performed. If the antegrade guidewire enters the subintimal space, re-entry into the distal true lumen is performed provided that the antegrade guide catheter provides enough support. If re-entry cannot be achieved, the antegrade wire is left in place to facilitate retrograde recanalization attempts (usually performed using the reverse controlled antegrade and retrograde tracking and dissection-reverse CART-technique). If the RCA ostium cannot be engaged with a guide catheter (for example in flush ostial occlusions) or if the guide catheter does not provide sufficient support, a primary retrograde approach is required, aiming for retrograde guidewire puncture into the aorta, followed by snaring and externalization. Retrograde guidewire puncture can be challenging, requiring use of stiff, highly penetrating guidewires or occasionally use of the Carlino technique. The aforementioned algorithm can facilitate crossing of ostial RCA CTOs.

A 48-year-old man with no risk factors presented with an anterolateral ST-segment elevation myocardial infarction treated with 2 drug-eluting stents. During the primary percutaneous coronary intervention (PCI), difficulty was faced in passing the guidewire distally to the occlusion in the left

We present a successfully chronic total occlusions (CTO) coronary recanalisation with the subadventitial space by excimer laser atherectomy (ELCA) adjunctive therapy. Angiogram revealed non-significant diffuse disease of the left coronary system with a complex long proximal right coronary artery (RCA) CTO (J-CTO score 4) and collaterals (Rentrop Grade 2 and Werner classification CC1) from the septal branches (Figure 1, Panel A). CTO PCI of the RCA was then indicated and planned. Initially, antegrade approach and a retrograde approach technique were attempted without success. Thereafter, a rescue Antegrade Dissection Reentry strategy (ADR) was applied. A Pilot 200 (Abbott) was advanced in a knuckle fashion in subintimal space reaching the distal cap. A Conquest Pro 12 (Asahi) successfully re-entered true lumen in posterolateral (PL) (Figure 1, Panel B). However, none balloon was able to be advanced thereafter. Thus, a Spectranetics ELCA 0.9 mm X-80 with simultaneous saline flush, frequency 80 Hz and fluence 80mJ/mm2 (Figure 1, Panel C) was applied successfully. A workhorse wire was advanced into the posterior descendent artery (PDA) followed by a non-compliant Trek balloon (Abbott) 2.5 20 mm to PL. Pre-dilatation followed by stenting was performed supported by a Guideliner (Teleflex) extension catheter. A total of three drug-eluting stents Synergy (Boston Scientific) were implanted with good angiographic result (Figure 1, Panel D). Intravascular ultrasound showed that the wire went through the subintimal space (red arrow) in both mid and distal RCA (Figure 1, Panel E), with appropriate debulking of the subintimal lesion (red arrow) and haematoma around the vessel (blue arrow) (Figure 1, Panel F), and then re-entering near the bifurcation with resolution of the haematoma (red arrow) and with optimal stenting result (Figure 1, Panel G).

We read with great interest the paper by Faurie et al. ([1][1]) regarding the performance of left ventricular (LV) stimulation via the delivery guidewire compared with standard right ventricular (RV) stimulation in transcatheter aortic valve replacement (TAVR) with balloon expandable valves. In the

Over the last 10 years, transcatheter aortic valve replacement (TAVR) has gained acceptance for patients at prohibitive, high and intermediate risk for surgical aortic valve replacement (SAVR). Recent evidence supports the utilization of TAVR in low surgical risk patients: two independent randomized trials have demonstrated short and mid-term clinical benefits of transfemoral TAVR over SAVR for endpoints such as all-cause mortality, stroke, and re-hospitalizations. The aim of the current manuscript is to provide an overview of the most important randomized clinical trials comparing TAVR with SAVR according to surgical risk, discuss the remaining challenges of TAVR and identify patients in whom open surgery remains the best practice in presence of severe AS. We also discuss how the emergence of TAVR as a suitable alternative for low-risk patients changes the Heart Team evaluation and treatment selection process.

© American Heart Association, Inc., Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

BACKGROUND The optimal strategy to treat bifurcation lesions (BFLs) in a percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) remains unknown. AIMS We sought to assess whether T-provisional or mini-crush is appropriate for BFLs within CTO vessels. PATIENTS AND METHODS From January 2011 to December 2013, patients who underwent successful CTO guidewire crossing and with a BFL within the CTO target vessel were enrolled prospectively and assigned randomly to either T-provisional stenting or the mini-crush technique for BFL treatment. One-year clinical follow-up was performed. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of cardiovascular death, myocardial infarction, target vessel revascularization, and stroke. RESULTS The prevalence of BFLs was 54.3%. A total of 146 patients with BFLs within CTO vessel were enrolled prospectively and assigned randomly to either T-provisional stenting (N=73) or the mini-crush technique (N=73). Angiographic and clinical success rates were similar in the two groups: 91.8 versus 97.2% (P=0.27) and 91.8 versus 94.5% (P=0.67), respectively.Although T-provisional stenting was associated with a nonsignificantly lower incidence of MACCE in case of BFLs located far from the CTO (9.3 vs. 22.2%; P=0.426), the mini-crush technique resulted in higher MACCE-free survival at 1 year in the presence of BFLs within the CTO body or close to the proximal or the distal cap (89.1 vs. 64.9%; P=0.007). CONCLUSION The mini-crush technique appeared to be associated with improved 1-year clinical and angiographic outcomes, particularly when used to treat BFLs located within the CTO body or close to the proximal or the distal cap.

Background Through contemporary literature, the optimal strategy to manage coronary chronic total occlusions (CTOs) remains under debate. Objectives The aim of the Italian Registry of Chronic Total Occlusions (IRCTO) was to provide data on prevalence, characteristics, and outcome of CTO patients according to the management strategy. Methods The IRCTO is a prospective real world multicentre registry enrolling patients showing at least one CTO. Clinical and angiographic data were collected independently from the therapeutic strategy [optimal medical therapy (MT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG)]; a comparative 1-year clinical followup was performed. Results A total of 1777 patients were enrolled for an overall CTO prevalence of 13.3%. The adopted therapeutic strategies were as follows: MT in 826 patients (46.5%), PCI in 776 patients (43.7%), and CABG in the remaining 175 patients (9.8%). At 1-year follow-up, patients undergoing PCI showed lower rate of major adverse cardiac and cerebrovascular events (MACCE) (2.6% vs. 8.2% and vs. 6.9%; P < 0.001 and P < 0.01) and cardiac death (1.4% vs. 4.7% and vs. 6.3%; P < 0.001 and P < 0.001) in comparison with those treated with MT and CABG, respectively. After propensity scorematching analysis, patients treated with PCI showed lower incidence of cardiac death (1.5 vs. 4.4%; P < 0.001), acute myocardial infarction (1.1 vs. 2.9%; P = 0.03), and re-hospitalization (2.3 vs. 4.4% P = 0.04) in comparison with those managed by MT. Conclusions Our data showed how CTO PCI might significantly improve the survival and decrease MACCE occurrence at 1 year follow-up in comparison with MT and/or CABG.

Coronary chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography. Several observational studies have demonstrated that successful CTO revascularization is associated with better cardiovascular outcomes and enhanced quality of life (QOL). However, in the absence of randomized trials, its prognostic benefit for patients remains debated. Over the past decade, the interest of the interventional community in CTO percutaneous coronary intervention (PCI) has exponentially grown due to important developments in dedicated equipment and techniques, resulting in high success and low complication rates. Both European and American guidelines have assigned a class IIa (level of evidence B) recommendation for CTO PCI. In the current review, we focus on the impact of CTO revascularization on clinical outcomes and QOL and on appropriate patient selection, and we provide a critical assessment of the current guidelines and recommendations on CTO PCI.

Chronic total occlusions (CTOs) represent a common lesion subset observed in patients who undergo coronary angiography. During the past decade, the interest of the interventionist community in CTOs has exponentially grown with fast advancement in dedicated equipment and techniques, which has resulted in high rates of procedural success and low rates of complications. Although different observational studies have shown that CTO revascularization was associated with good clinical outcome, its real benefit for patients remains to be determined, particularly in the absence of randomized trials. In addition, compared with non-CTO lesions, the American and European guidelines downgraded percutaneous coronary intervention in the setting of CTOs. In this viewpoint, we try to identify patients who would benefit from CTO recanalization, and discuss the issues that might improve the appropriateness of CTO percutaneous coronary intervention.

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization.

Although early myocardial reperfusion via primary percutaneous coronary intervention (PCI) allows the preservation of left ventricular function and improves outcome, the acute restoration of blood flow may contribute to the pathophysiology of infarction, a complex phenomenon called reperfusion injury. First described in animal models of coronary obstruction, mechanical post-conditioning, a sequence of repetitive interruption of coronary blood flow applied immediately after reopening of the occluded vessel, was able to reduce the infarct size. However, evidence of its real benefit remains controversial. This review describes the mechanisms of post-conditioning action and the different protocols employed focusing on its impact on primary PCI outcome.

Background A retrograde approach improves the success rate of percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs). Objectives The authors describe the European experience with and outcomes of retrograde PCI revascularization for coronary CTOs. Methods Follow-up data were collected from 1,395 patients with 1,582 CTO lesions enrolled between January 2008 and December 2012 for retrograde CTO PCI at 44 European centers. Major adverse cardiac and cerebrovascular events were defined as the composite of cardiac death, myocardial infarction, stroke, and further revascularization. Results The mean patient age was 62.0 ± 10.4 years; 88.5% were men. Procedural and clinical success rates were 75.3% and 71.2%, respectively. The mean clinical follow-up duration was 24.7 ± 15.0 months. Compared with patients with failed retrograde PCI, successfully revascularized patients showed lower rates of cardiac death (0.6% vs. 4.3%, respectively; p Conclusions The number of retrograde procedures in Europe has increased, with high percents of success, low rates of major complications, and good long-term outcomes.

Among all coronary lesions, the decision-making process for the treatment of unprotected left main (ULM) stem lesions is still challenging. Indeed, the optimal therapeutic strategy for patients with ULM disease remains controversial: coronary artery bypass grafting was established as the gold standard, but it is without doubt that percutaneous coronary intervention (PCI) performed by experienced operators achieves good results at long term follow up, especially in cases where the ostium and/or shaft of ULM are treated. Thanks to the widespread use of invasive assessment of atherothrombotic ULM stenosis, improved selection of PCI cases and techniques of stenting, better outcomes are now possible. This review seeks to define the place of PCI in ULM disease by describing the different modalities of ULM stenosis assessment.

Coronary artery disease (CAD) is known to be the main cause of morbidity and mortality in patients with diabetes mellitus. Although they do not often show typical recognized symptoms, diabetic patients suffer from more extensive CAD and hence higher incidence of multi-vessel CAD than in non-diabetic subjects. Literature has given the strength of evidence in favor of surgical revascularization in diabetic patients with multi-vessel disease. We report the case of a 61-year old active smoker and diabetic man with atypical symptoms and positive treadmill test. The coronary angiography revealed a severe three-vessel disease and distal left main involvement (SYNTAX score=49). As the patient refused to follow heart team indication to undergo coronary bypass grafting, a percutaneous coronary intervention was successfully performed with intra-aortic balloon counterpulsation support and intravascular ultrasound optimization. The mid-term outcome was good.

Objectives The study sought to assess the outcome of percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) in patients with low left ventricular ejection fraction (LVEF) (≤35%). Background Data regarding the outcome of PCI in patients with low LVEF affected by CTO are scarcely reported. Methods The authors performed a prospective longitudinal multicenter study including consecutive patients undergoing elective PCI of CTOs. Patients were subdivided into 3 groups: group 1 (LVEF ≥50%), group 2 (LVEF 35% to 50%), and group 3 (LVEF ≤35%). Results A total of 839 patients (mean 64.6 ± 10.5 years of age, 87.7% men) underwent CTO PCI attempts. Baseline LVEF ≤35% was present in 72 (8.6%) patients. The angiographic success was high (overall 93.6%) and similar among the 3 groups (93.5% vs. 94.4% vs. 91.7%, respectively; all p = NS). In group 3, no periprocedural complications of CTO PCI were observed. Mean clinical follow-up of 16.3 ± 8.2 months duration was available in 781 (93.1%) patients including those with LVEF ≤35%. At 2 years, major cardiac and cerebrovascular events (MACCE) free survival was similar in the 3 groups (86% vs. 82.8% vs. 75.2%; all p = NS). In patients with LVEF ≤35%, LVEF improved significantly in the presence of a successful CTO PCI from 29.1 ± 3.4% to 41.6 ± 7.9% (p < 0.001). Conclusions In CTO patients with low LVEF, PCI could represent a safe and effective revascularization strategy achieving good midterm outcome and LVEF improvement.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly evolved during recent years. High success rates are being achieved by experienced centers and operators, but not at less-experienced centers. Use of CTO crossing algorithms can help improve the success and efficiency of these potentially lengthy procedures. There is a paucity of clinical trial data examining clinical outcomes of CTO PCI, which is critical for further adoption and refinement of the procedure. We provide a detailed overview of the clinical evidence and current available crossing strategies, with emphasis on recent developments and techniques.

BACKGROUND The Nobori biolimus-eluting stent (BES) is a biodegradable polymer drug-eluting stent (DES). Several studies have shown its noninferiority in comparison with durable polymer DES. AIM We sought to investigate the efficacy and the safety of Nobori BES in an all-comer population undergoing a percutaneous coronary intervention. PATIENTS AND METHODS A total of 12 912 patients with 19 947 coronary lesions, undergoing percutaneous coronary intervention with Nobori BES implantation at 200 centres around the world between August 2010 and December 2015, were included in this prospective registry. Patients were stratified into four groups according to the total stent length, with cutoffs at 18, 24 and 28 mm. The primary endpoint was the occurrence of major adverse cardiac events defined as the composite of cardiac death, target vessel myocardial infarction and clinically driven target lesion revascularization at 1 year. RESULTS At 1 year, the major adverse cardiac events rate was the highest (4.6%) in the fourth quartile of stent length (>28 mm), whereas the overall rate of the primary endpoint in the all cohort was 3.5%. Both target lesion revascularization and target vessel revascularization rates were significantly higher in patients with longer stent length was implanted (all P

We read with interest the paper by Lee et al. [(1)][1] regarding the prognostic value of fractional flow reserve (FFR) in jailed left circumflex coronary artery (LCx) following simple crossover stenting from the left main coronary artery (LM) to left anterior descending coronary artery (LAD). The

Chronic total occlusions (CTOs) remain one of the last challenges in percutaneous coronary intervention (PCI). During the last decade, following the Japanese pioneers, the interest of interventionalists’ community in CTO PCI has dramatically increased leading to an important development in equipment and techniques (1,2), and a growing expertise among dedicated operators, both resulting in increased success rates (3).

Coronary arteries are not definitely functionally terminal arteries, as previously thought; indeed, they are linked and interconnected by a rich network of collaterals. Chronic total occlusions (CTOs) represent a subset of frequent lesions encountered in everyday catheterization laboratory practice, generally associated with a developed system of collateral connections. These latter have the capacity to prevent myocardial necrosis and may even uphold metabolic supply to the ischemic territory to maintain its contractile capacity. Authors have reported a rapid and progressive reduction of collateral function and their decline after antegrade flow restoration, resulting in higher myocardial susceptibility to ischemia in the CTO territory. Here, we report the case of a fatal derecruitment of collaterals for a left anterior descending CTO not reopened, after left circumflex subocclusion revascularization.

Intravascular ultrasound has been used for >20 years to guide percutaneous coronary intervention in different subsets of coronary lesions. During the last decade, the interest in percutaneous coronary intervention for chronic total occlusion (CTO) has increased dramatically, leading to high success rates. Failure of guidewire crossing is the most common reason for failed CTO attempts. Certain angiographic features, such as blunt proximal CTO cap, tortuosity, heavy calcification, and lack of visibility of path in the distal vessel, increase procedural difficulty. A better understanding of the behavior of the guidewire within the CTO segment may represent a key issue to achieve successful outcome. In this respect, intravascular ultrasound imaging might have potential roles in the recanalization of CTOs. In this paper, we focused on the usefulness and the applications of intravascular ultrasound imaging in percutaneous CTO recanalization, underlying its impact on clinical outcome. (J Am Coll Cardiol Intv 2016;9:1979–91) © 2016 by the American College of Cardiology Foundation

BackgroundSYNTAX score II (SS II) integrates anatomical SS with clinical characteristics allowing an individualized prediction of long-term mortality.AimsWe sought to assess to evaluate the usefulness of SS II in a real-world acute coronary syndromes (ACS) population with severe coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI).MethodsFrom August 2011 to May 2013, out of 1591 consecutive patients admitted for ACS, 217 (13.6%) showed severe CAD (three-vessel disease and/or left main involvement). Among the latter, 100 patients underwent PCI and were enrolled into the study. SS II was calculated in all patients. One-year clinical follow-up was performed; major adverse cardiac and cerebrovascular events (MACCE) were defined as a composite of death, nonfatal myocardial infarction, stroke, or repeat revascularization.ResultsThe median SS II was 29 (range, 14–59). Overall, MACCE occurred in 25% of patients (cardiac death 4%, myocardial infarction 4%, stroke 0%, and repeat revascularization 17%). The 1-year MACCE-free survival was significantly lower in patients with SS (⩾29), than in those with SS II (

Objective We report our initial experience with extracorporeal membrane oxygenation (ECMO) use in elective high-risk complex percutaneous coronary intervention (PCI). Background ECMO has been employed as hemodynamic support in patients with cardiac arrest and hemodynamic shock. Methods We performed a single-center prospectical study, enrolling all patients at very high-risk for coronary artery bypass grafting (CABG). Major adverse cardiac and cerebrovascular events (MACCE) were defined as a composite of death, acute myocardial infarction (MI), stroke and further need for revascularization. Results Twelve patients underwent elective high-risk PCI with ECMO support (mean age = 63.5 ± 8.7 years). The mean SYNTAX score was 30.1 ± 10.1. All PCI procedures were successful and no in-hospital MACCE was observed. At 6-months, neither death nor MI was noticed. Two patients (17%) required further revascularization, and one patient required chronic hemodialysis. Conclusions Elective high-risk PCI supported by ECMO is a viable alternative for patients who are at very high risk for CABG.

Background The benefits of cardiac rehabilitation in diabetic patients are well recognized. We aimed to assess its impact on ventricular repolarization indexes and the occurrence of ventricular arrhythmias in patients with coronary artery disease (CAD) and diabetes type 2. Methods From January 2012 to August 2013, 122 consecutive patients [diabetics (n = 59) and non diabetics (n = 63)] were prospectively enrolled in an out-patient rehabilitation program. Clinical examination, 12-lead ECG, 24-Holter ECGs and maximal exercise testing were performed at the beginning and end of the rehabilitation program in all patients. Results Diabetic patients showed significant decreases of repolarization indexes: QTc (−6.4%; p = 0.006), QTc disp (−22.6%; p = 0.050) and JTc (−9.4%; p = 0.003). At the end of the rehabilitation program diabetic patients showed a higher decrease in ventricular arrhythmias according to Lown classes' grading in comparison to non diabetics (−1.05 ± 0.84 vs −0.74 ± 0.91; p = 0.048). Insulin therapy was associated with a lower decrease in Lown classes compared to oral anti-diabetics (−0.95 ± 0.80 vs −1.61 ± 0.84; p Conclusion Cardiac rehabilitation provided an improvement in the majority of ventricular repolarization indexes in patients with diabetes type 2 and CAD, decreasing the frequency of ventricular arrhythmias, particularly in those not treated by insulin.

The prognostic value of left ventricular ejection fraction (LVEF) is well established in patients with coronary artery disease. Data regarding patients with low EF affected by chronic total occlusions (CTOs) are scarcely reported. We performed a multicenter prospective study enrolling 839 CTO

Recent improvement in clinical skills, technology and hardware has resulted in improved success rates with chronic total occlusion angioplasty. We sought to perform pooled analysis of procedural characteristics, procedural outcomes and complications following contemporary chronic toatal occlusion

We aimed to determine the prevalence of iatrogenic aortic dissection in chronic total occlusion (CTO) recanalization procedures, and to assess the management strategy and outcome of such a complication.This study was a retrospective analysis of CTO percutaneous coronary intervention (PCI) cases performed by a single CTO experienced operator. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root.Among 956 CTO PCI cases, iatrogenic aortic dissection occurred in 8 patients for an overall frequency of 0.83%. The right coronary artery was the CTO involved vessel in all cases with ostial location and severe calcifications in 37.5% and 62.5% of cases, respectively. Four patients underwent the antegrade approach and a retrograde strategy was adopted in the remaining 4 patients. The iatrogenic aortic dissection started from the right sinus of Valsalva in 87.5% of cases and catheter trauma was the presumed mechanism of dissection in most cases. Stenting of the entry point was performed in all cases, and dissection was limited (40 mm) in all patients. No patients required emergency surgery. One cardiac death was observed 12 days after the index procedure (12.5%), and a mean follow-up of 31.5 months was uneventful in the remaining 7 patients.CTO recanalization procedures might be associated with a greater incidence of iatrogenic aortic dissection than non-CTO PCI. The therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment.

A promising variant of the subintimal tracking and re-entry (STAR) technique, called "mini-STAR," has been recently described as a successful rescue technique after revascularization failure by conventional techniques for coronary chronic total occlusion (CTO).The current study enrolled patients with CTO who underwent successful revascularization by the mini-STAR technique as a bailout strategy. Two-year clinical follow-up and angiographic control procedures were performed.From March 2009-September 2011, 100 of 117 patients (mean age, 61.4 ± 10.9 years) underwent successful recanalization of CTO by the mini-STAR technique as a bailout strategy. Drug-eluting stents (DESs) were implanted in all cases. At 2-year follow-up, the major adverse cardiac events (MACE)-free survival was 89.2%, with a target lesion revascularization (TLR) rate of 6.5%. Angiographic follow-up was performed in 72% of patients. CTO target lesion restenosis was observed in 25% of patients, whereas the reocclusion rate was 12.5%. At multivariate Cox analysis, final thrombolysis in myocardial infarction (TIMI) flowgrade 3 was related to occurrence of MACE (hazard ratio, 5.9; 95% confidence interval [CI], 1.4-24.4; P = 0.013). Final TIMI flowgrade 3 (odds ratio [OR], 5.41; 95% CI, 1.05-27.73; P = 0.043) and CTO stent length (OR, 0.96; 95% CI, 0.93-0.99; P = 0.017) were independent predictors of reocclusion. The independent variables related to restenosis were first-generation DESs (OR, 4.10; 95% CI, 1.23-13.64; P = 0.022) and CTO stent length (OR, 0.97; 95% CI, 0.95-0.99; P = 0.027).As bailout strategy for CTO revascularization, the mini-STAR technique shows low MACE and TLR rates at long-term follow-up.

The treatment of coronary chronic total occlusions (CTO) continues to solicit technical innovations. As success primarily depends on crossing the lesion with a wire, all aspects regarding tip shape retention, torque precision, and penetration ability of the guide-wire have greatly influenced new techniques and strategies. The world of interventional cardiology has to look carefully at these developments, and to use them accordingly to improve the success rate in ordinary percutaneous coronary interventions. We present a didactical case report of a CTO revascularization treated with a new ‘dual core’ technology guide-wire.

Received 4 July 2014; revision accepted for publication 14 October 2014. A 67-year-old diabetic man was admitted for stable angina (CCS class II) despite optimal medical therapy. The echocardiogram showed hypokinesia of the lateral wall, with mild reduction of the left ventricular ejection fraction (50%). Coronary angiography revealed a CTO of the LCx, receiving collaterals (CC2) from the LAD via septal branches. LCx CTO revascularization was indicated. After a first unsuccessful antegrade attempt, we opted for a retrograde approach. A right 7-Fr femoral access was performed and a 7-Fr XB 4 guiding catheter (Cordis Co., USA) introduced in the left main coronary artery. A retrograde Sion guidewire (Asahi Intec Co., Japan) was employed with a Corsair microcatheter (Asahi Intec Co., Japan), and successfully reached the distal cap of the LCx CTO. A Miracle 6 guidewire (Asahi Intec Co., Japan) was able to cross the lesion retrogradely, and was inserted into the guiding catheter. However, the microcatheter was not able to advance because of the severe angulation of the LCx and Antegrade insertion in retrograde device: the AIRD technique. An efficient strategy in retrograde revascularization of chronic total occlusions