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Women with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) are at higher risk of early and late major adverse cardiac events (MACE) compared with male subjects. Moreover, previous studies suggest a differential prognostic impact of clinical presentation between

The incidence, predictors, and prognostic impact of post-discharge bleeding (PDB) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation are unclear. This study sought to characterize the determinants and consequences of PDB after PCI. The incidence and predictors

Predictive factors of atherothrombotic events in women after implantation of drug eluting stents (DES) are unclear. Prior studies of this subject were conducted on predominantly male patient populations. The objective of the current study was to investigate the predictive factors of

Coronary obstruction (CO) is a rare but potentially fatal complication in patients undergoing transcatheter aortic valve replacement (TAVR). CO is most commonly caused by the displacement of a calcified native aortic valve leaflet toward the coronary ostium [(1)][1]. An 89-year-old woman underwent

A 71-year-old gentleman with background hypertension, dyslipidemia, ex-smoker, permanent atrial fibrillation, and chronic obstructive lung disease presents to our institution with exertional dyspnea (New York Heart Association class III–IV) for aortic valve replacement assessment. Cardiovascular history includes mechanical mitral valve replacement (St. Jude Medical 25 mm) alongside coronary artery bypass (venous grafts to right coronary artery and obtuse marginal) in 2004, cerebrovascular accident in 2008 with multiple transient ischemic attacks since (latest 2012), and subacute subdural hematoma requiring evacuation (2013). As part of the transcatheter aortic valve implantation work-up, he underwent a transthoracic echocardiogram, which showed a calcific, degenerative severe aortic stenosis (mean gradient, 45 mm Hg; max aortic valve velocity, 4.3 m/s; and aortic valve area, 0.8 cm2) with associated moderate regurgitation. There was preserved left ventricular function with concentric hypertrophy. The mechanical mitral valve was functioning well with a mean transvalvular gradient of 5 mm Hg and no paravalvular leaks. There were no prominent mechanical mitral valve pivot guards protruding in the left ventricular outflow tract (Figure 1A–1C). Multislice computed tomography scan revealed a tricuspid aortic valve with extensive fibrocalcific degeneration of the cusps. Annulus perimeter was 68 mm and annulus area was calculated at 3.46 cm2. Minimum ilio-femoral diameter was 5.8 cm (both sides). Cardiac computed tomography revealed patent grafts and moderate stenoses at the mid and distal segments of the left anterior descending artery. After discussion with the heart team (Euroscore II, 8.8%; Logistic Euroscore, 22.62%; STS, 7.4%; and STS MOM of 34.9%), decision was made for a transfemoral transcatheter aortic valve implantation of an Edwards …

Objectives This study sought to evaluate the impact of baseline activated clotting time (ACT)-guided heparin administration on major bleeding after transfemoral transcatheter aortic valve implantation (TAVI). Background Bleeding after TAVI is frequent and associated with unfavorable prognosis. Proper intraprocedural heparin dose administration may reduce the risk of potential overdosing in this frail study group. Methods Of the patients who underwent transfemoral TAVI in our center from November 1, 2007 to June 31, 2012, 362 were retrospectively analyzed. Because abnormally high baseline ACT values were noted, heparin was administered at the operator's discretion, according to baseline ACT (ACT-guided, n = 174) or patient's body weight (non-ACT-guided, n = 188). The primary study objective was 30-day major bleeding as defined by the Valve Academic Research Consortium criteria. Secondary objectives were any life-threatening, and minor bleeding, and other Valve Academic Research Consortium outcomes at 30 days. Results Bleeding occurred in 167 (46.1%) patients; of these, 76 (21.0%) had major bleeding. The ACT-guided group had a significantly lower occurrence of major (7.5% vs. 33.5%, p < 0.001), life-threatening (12.1% vs. 20.2%, p = 0.04), and any bleeding (25.9% vs. 64.9%, p < 0.001). Conversely, no differences were noted in the other study objectives. After adjustment for potential confounders, the protective odds ratio for ACT-guided therapy on major bleeding was 6.4 (95% confidence interval: 2.3 to 17.9; p < 0.001) at 30 days. Conclusions In our experience, heparin administration according to baseline ACT was correlated with a significantly lower occurrence of major bleeding in transfemoral TAVI. This strategy might be a useful tool in reducing bleeding in this high-risk study group. (C) 2014 by the American College of Cardiology Foundation OI Giustino, Gennaro/0000-0002-5400-9516

There is little evidence regarding the efficacy and safety of bioresorbable scaffolds (BRS) for the percutaneous treatment ofchronic total occlusions (CTO). The aim of this study was to investigate the clinical outcomes of patients with a CTO treated with BRS or drug-eluting stents (DES). We

Transradial access (TRA) emerged in the last two decades as a valid alternative to the standard transfemoral access (TFA) for cardiac catheterization and percutaneous coronary intervention (PCI). Due to contrasting results, the penetration and uptake of TRA in real-world clinical practice has been

Early suspension of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) increases the risk of adverse cardiovascular events. However, how the risk varies according to DAPT cessation mode in patients with diabetes mellitus (DM) is unknown. We sought to examine the

The randomized SECURITY trial ([NCT00944333][1]) showed non-inferiority of 6 vs 12 month DAPT after DES implantation in a low-risk population treated with percutaneous coronary intervention (PCI). We aim to assess the outcome of elderly (≥75 year old) in comparison to younger patients (

Background: Clinical correlates and prognostic significance of coronary artery calcifications (CAC) in women undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) remain unclear. Objectives: We sought to investigate the clinical correlates and prognostic impact of CAC in women undergoing PCI with DES. Methods: We pooled patient-level data of female participants from 26 randomized trials of DES. Study population was categorized according to the presence of moderate or severe versus mild or none target lesion CAC, assessed through coronary angiography. Co-primary endpoints of interest were the composite of death, myocardial infarction (MI) or target lesion revascularization (TLR) and death, MI or stent thrombosis (ST) at 3 years of follow-up. Results: Out of 11,557 women included in the pooled dataset, CAC status was available in 6,371 women. Of these, 1,622 (25.5%) had moderate or severe CAC. In fully adjusted models, independent correlates of CAC were age, hypertension, hyperc...

Approximately 50% of patients with severe aortic stenosis (AS) are asymptomatic. Whether a strategy of early aortic valve replacement (AVR) compared to a conservative “watchful waiting” approach is preferred in these patients is uncertain and controversial. We performed a study-level meta

The contemporary incidence, associated factors and implications of stroke after acute coronary syndromes (ACS) managed with percutaneous coronary intervention (PCI) and novel antiplatelet drugs is unknown. We sought to characterize the incidence, predictors and impact of stroke on subsequent

Vascular complications (VC) after transfemoral transcatheter aortic valve replacement (TAVR) are frequent and strongly associated with subsequent morbidity and mortality. The incidence and clinical significance of VCs in patients treated with alternative anticoagulation regimens to unfractionated

Commentary on: Giacoppo D, Gargiulo G, Aruta P, et al. Treatment strategies for coronary in-stent restenosis: systematic review and hierarchical Bayesian network meta-analysis of 24 randomised trials and 4880 patients. BMJ 2015;351:h5392. Drug-eluting stents (DES) drastically improved the efficacy of percutaneous coronary intervention by reducing the risk of in-stent restenosis (ISR) and subsequent need of target lesion revascularisation (TLR). However, despite the advances in DES technology, the incidence of ISR is still significant and considering that more than five million DES are implanted each year worldwide, ISR can be considered an issue of public health magnitude. Percutaneous treatment strategies for ISR have been investigated since its first appearance in the bare-metal stent (BMS) era, however uncertainty still exists regarding the optimal therapeutic approach to implement in clinical practice. In a recent study, Giacoppo and colleagues tried to shed light on this uncertainty through a network meta-analysis of randomised controlled trials (RCTs) investigating …

Patients with non-anterior ST-segment elevation myocardial infarction (NA-STEMI) have better prognosis than those with anterior STEMI (A-STEMI). In contrast to A-STEMI, little is known regarding factors affecting long-term prognosis in patients with NA-STEMI. We therefore sought to determine the

Background— There is little evidence regarding the efficacy and safety of bioresorbable scaffolds (BRS) for the percutaneous treatment of chronic total occlusions. Methods and Results— We performed a multicenter registry of consecutive chronic total occlusion patients treated with BRS (Absorb; Abbott Vascular) and second-generation drug-eluting stents (DES) at 5 institutions. Long-term target-vessel failure (a composite of cardiac death, target-vessel myocardial infarction, and ischemia-driven target-lesion revascularization) was the primary end point. Inverse probability of treatment weight–adjusted Cox regression was used to account for pretreatment differences between the 2 groups. A total of 537 patients (n=153 BRS; n=384 DES) were included. BRS patients were younger and had lower prevalence of comorbidities. Overall mean Japan-Chronic Total Occlusion (J-CTO) score was 1.43±1.16, with no differences between groups. Procedural success was achieved in 99.3% and 96.6% of BRS- and DES-treated patients, respectively ( P =0.07). At a median follow-up of 703 days, there were no differences in target-vessel failure between BRS and DES (4.6% versus 7.7%; P =0.21). By adjusted Cox regression analysis, there were still no significant differences between BRS and DES (hazard ratio, 1.54; 95% confidence interval, 0.69–3.72; P =0.34). However, secondary analyses suggested a signal toward higher ischemia-driven target-lesion revascularization with BRS. Conclusions— Implantation of BRS versus second-generation DES in chronic total occlusion was associated with similar risk of target-vessel failure at long-term follow-up. However, a signal toward increased ischemia-driven target-lesion revascularization with BRS was observed. Large randomized studies should confirm these findings.

Coronary artery disease and atherothrombosis are complex pathologic entities. The intricate interplay between anatomical, cellular and molecular factors characterizes their pathogenesis and determines their clinical manifestations. Coronary artery revascularization strategies, by restoring myocardial blood perfusion, only partially treat ischemic heart disease in its complexity. Pharmacological therapies targeting molecular and cellular components involved in the pathophysiology of atherothrombosis are mandatory in order to prevent cardiovascular complications during and after revascularization and therefore improve clinical outcomes. The developments of antithrombotic pharmacotherapies occurred as a result of an improved understanding of the mechanisms underlying atherothrombotic disease. Unfortunately, the optimal antithrombotic therapy, in both acute and chronic settings, often set significant challenges in daily practice. The main objective of optimal antithrombotic therapies, targeting coagulation factors or the platelet system, is to maximize the anti-thrombotic efficacy while minimizing the bleeding risk. The subtle balance between ischemic and bleeding risk is a complex clinical conundrum that involves pharmacologic factors, the clinical phenotype of coronary artery disease and patient's clinical comorbidities. In a contemporary era, in which a broad armamentarium of pharmacologic agents and diagnostic tools are available, physician practice should shift toward a progressively more customized patient care. For this purpose, selection of the optimal acute and chronic percutaneous coronary intervention (PCI) pharmacotherapy, in terms of potency, duration and adherence, cannot disregard an individualized and careful evaluation of the patient's ischemic and hemorrhagic risk. It is within this context that in the present review article we sought to expose the current topics of debate and controversies in acute and chronic anticoagulant and antiplatelet therapies in patients undergoing PCI.

Platelets play a central role in ST-segment elevation myocardial infarction (STEMI) pathobiology and in the no-reflow phenomenon. However, the effect of platelet count (PC) on myocardial injury and subsequent clinical outcomes in STEMI is unclear. We investigated the effect of platelet count on

Longer DAPT (> 12 months) after drug-eluting stent (DES) implantation is associated with a lower risk of myocardial infarction (MI) counterbalanced by a higher risk of major bleeding events. We sought to simulate the therapeutic risks and benefits of longer versus short DAPT durations after PCI