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To the Editor, Aortic pseudoaneurysm is a rare high-risk complication following surgery with aortic manipulation. This is the case of a 66-year-old male patient with a past medical history of aortic valve replacement 16 years ago. He required a second surgery 3 months later due to prosthetic valve endocarditis with mechanical valve replacement with homograft valve implantation. Since then, the patient has remained asymptomatic until 1 year ago when he developed progressive dyspnea. The echocardiographic study revealed severe aortic regurgitation with heavily calcified valve and ascending aorta. A new surgical intervention was performed to replace the homograft by a bioprosthesis. Surgery was very complex due to the presence of significant calcification. Two months after this last intervention the patient was admitted with clinical signs of thoracic pain and hemoptysis. The computed tomography scan performed revealed the presence of a narrow-necked aortic pseudoaneurysm at the ascending aorta lateral wall, probably at the level of the cannulation performed during the previous surgery with a large periaortic hematoma (figure 1). Although the surgical repairment of the aortic pseudoaneurysm is the routine treatment, in this case it would have been the fourth reintervention. Instead, percutaneous treatment was decided.

Introduction and objectives: Regadenoson, a selective agonist of the A2a receptors of adenosine, has been proposed as an alternative for the measurement of fractional flow reserve (FFR). The goal of our study was to assess the utility of regadenoson compared to the use of intracoronary adenosine. Methods: Forty-one intermediate coronary lesions (30%-70%), in which functional assessment with pressure wire was indicated, were included both prospective and consecutively. Each patient was sequentially administered intracoronary adenosine and intravenous regadenoson and hemodynamic data while the adverse effects were recorded with hyperemia induced by both drugs. The differences seen in the final FFR were analyzed using the linear regression model and the clinically relevant discrepancies were identified assuming 0.80 as the cut-off point. Results: The mean of the FFR was significantly lower with regadenoson compared to adenosine (0.838 ± 0.072 vs 0.852 ± 0.073, P = .002) and in 4 cases (9.8%) clinically relevant differences were found. The regression analysis showed a strong linear correlation between the individual values (r = 0.925, P < .001). Both adenosine and regadenoson significantly reduced mean arterial blood pressure and only regadenoson significantly increased baseline heart rate. In 2 cases (4.9%) asystole was recorded > 3 seconds after the administration of adenosine and no complications were observed with regadenoson. Conclusions: The administration of regadenoson through an intravenous single bolus has shown a significant reduction in the value of FFR compared to the administration of intracoronary adenosine boluses and the observed differences may be relevant in the clinical decision-making process.

To the Editor, Currently, transradial approach is the most widely used access route both in coronary angiographies and percutaneous coronary interventions.1 However, it is not rare to find anatomical difficulties like severe spasm, small-caliber vessel, loops or tortuosities that cannot be overcome with the usual techniques and lead to access route changes eventually.2 In these situations, the advance of the catheter can dissect or perforate the artery and cause hematomas or even compartmental syndrome, although this entity is rare.3 As the main cause of resistance when advancing the catheter, Patel et al.4 identified the so-called razor effect exerted by the catheter distal border on the vessel wall (figure 1A), a mechanism that has been confirmed in optical coherence tomography studies.5 These same authors described the balloon-assisted tracking (BAT) technique4 that consists of inflating an angioplasty balloon that partially protrudes across the catheter distal border to keep its coaxial position with the artery avoiding the razor effect and providing better maneuverability (figure 1B). Therefore, the anatomical difficulty is crossed using a 0.014 in soft tip angioplasty guidewire. Afterwards, a 1.5 mm to 2.0 mm semicompliant balloon is inflated between 6 and 8 atm at the tip of the catheter and advanced en bloc...

Up to 25% of patients who undergo a percutaneous coronary intervention show some limitation in the use of drug-eluting stents. The aim of this study was to evaluate if titanium-nitride-oxide-coated stents could be a good alternative to everolimus-eluting stents in diabetic patients.A total of 173 diabetic patients with lesions at moderate risk of restenosis (exclusion criteria: diameter2.5 mm or length28 mm in vessels3mm, chronic occlusion) were randomized to a titanium group (83 patients) or an everolimus group (90 patients).Baseline characteristics were well balanced; 28.3% of patients were insulin dependent. At 1 year, the incidence of major adverse cardiac events (death, nonfatal myocardial infarction, stroke, or repeat target vessel revascularization) was significantly higher in the titanium group than in the everolimus group (total, 14.5% vs 4.4%; P = .02; noninsulin-dependent subgroup, 9.7% vs 3.2%; P = .14; insulin-dependent subgroup, 28.6% vs 7.1%; P = .04). The incidence of death, nonfatal myocardial infarction, stroke, or any revascularization was 16.9% in the titanium group and 7.8% in the everolimus group (P = .06). Target lesion and vessel revascularizations occurred in 8.4% compared with 3.3% (P = .15) and in 13.3% compared with 3.3% (P = .01) in the titanium and everolimus groups, respectively. Angiographic follow-up at 9 months showed significantly less late lumen loss in the everolimus group (in-segment, 0.52 [standard deviation, 0.58) mm vs -0.05 [0.32] mm; in-stent, 0.76 [0.54] mm vs 0.13 [0.31] mm; P.0001).The everolimus-eluting stent is superior to the titanium stent for clinical and angiographic end points in diabetic patients with lesions at moderate risk of restenosis.

Introduccion y objetivos Hasta un 25% de los pacientes sometidos a intervencionismo coronario percutaneo presentan alguna limitacion para la utilizacion de los stents farmacoactivos. Nuestro objetivo es evaluar si el stent bioactivo de titanio y oxido nitrico podia ser una buena alternativa al stent de everolimus para pacientes diabeticos. Metodos Se aleatorizo a 173 pacientes diabeticos con lesiones de riesgo de reestenosis intermedio (criterios de exclusion: diametro 28 mm en vasos < 3 mm, oclusion cronica): 83 pacientes en el grupo con titanio y 90 en el grupo con everolimus. Resultados Las variables basales estaban bien equilibradas, el 28,3% eran insulinodependientes. Al ano, las incidencias de eventos adversos cardiacos mayores (muerte, infarto de miocardio no fatal, ictus o nueva revascularizacion del vaso tratado) eran significativamente mas frecuente en el grupo con titanio que en el grupo con everolimus (total, el 14,5 frente al 4,4%; p = 0,02; subgrupo no insulinodependiente, el 9,7 frente al 3,2%; p = 0,14; insulinodependiente, el 28,6 frente al 7,1%; p = 0,04) y de muerte, infarto de miocardio no fatal, ictus o cualquier revascularizacion, del 16,9% en el grupo con titanio y el 7,8% en el grupo con everolimus (p = 0,06). La revascularizacion de la lesion diana se produjo en el 8,4 frente al 3,3% (p = 0,15), y la del vaso tratado, el 13,3 frente al 3,3% (p = 0,01). El seguimiento angiografico a 9 meses mostro una perdida luminal tardia significativamente menor en el grupo con everolimus (en el segmento, 0,52 ± 0,58 frente a �0,05 ± 0,32 mm; en el stent, 0,76 ± 0,54 frente a 0,13 ± 0,31 mm; p < 0,0001). Conclusiones El stent de everolimus fue superior al titanio en pacientes diabeticos incluso con lesiones de riesgo de eventos clinicos y angiograficos intermedio.

Aims We evaluated the ability of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance (CMR) to identify acute new-onset heart failure (HF) with left ventricular systolic dysfunction (LVSD), whether or not in relation to underlying coronary artery disease (CAD), in patients with no clinical evidence of associated ischaemic cardiomyopathy. Methods and results Hundred consecutive patients admitted with acute new-onset decompensated HF and EF ,40%, with no clinical or electrocardiographic data suggestive of CAD. The patients were classified according to the presence or absence of significant CAD (stenosis � 70% in at least one major vessel). Twenty-one patients (21%) had significant CAD. Seventy-nine (79%) had no lesions. Eighteen of the 21 patients (85%) with CAD had subendocardial/transmural LGE. In the diagnosis of CAD, LGE has a sensitivity of 85.7% (95% CI, 80‐91) and specificity of 92.4% (95% CI, 87‐96), respectively, with a negative predictive value of 96% (95% CI, 90‐99). It has an area under the receiver operating characteristic curve of 0.906 (95% CI, 0.814‐0.998). Conclusion In patients with new-onset HF and LVSD for whom there are no clinical and exploratory data suggestive of ischaemic heart disease, CMR with LGE is an excellent means of ruling out significant CAD and is a valid alternative to angiography.

Introduccion y objetivos Los stents liberadores de farmacos (SLF) han demostrado reducir la reestenosis y por ello se han incorporado al tratamiento de pacientes con infarto agudo de miocardio con elevacion del ST (IAMEST). En este trabajo se han evaluado los resultados clinicos y angiograficos a largo plazo de los SLF en pacientes con IAMEST. Metodos Se realizo prospectivamente un seguimiento clinico y angiografico de 81 pacientes con IAMEST sometidos a intervencionismo coronario percutaneo con implante de SLF. Este grupo se comparo con otro de 82 pacientes con caracteristicas similares, tratados con stents convencionales (SC) en un periodo anterior. Resultados Al ano no hubo diferencias significativas en las tasas de mortalidad (2,5% en el grupo SLF y 7,3% en el grupo SC; p = 0,15) o reinfarto (4,8% del grupo SLF y 4,8% del grupo SC; p = 0,98). La necesidad de nueva revascularizacion de la lesion fue menor en el grupo SLF (8,6 y 23,2%; p = 0,001) al igual que la tasa de reestenosis (13,8% del grupo SLF y 30,9% del grupo SC; p = 0,02). Se registraron 5 trombosis agudas o subagudas de stent (3 SLF y 2 SC; p = 0,64) y una tardia despues del ano en un stent de sirolimus. Conclusiones El implante de SLF en pacientes con IAMEST no reduce la mortalidad o el reinfarto al ano respecto a los SC; sin embargo, reduce la tasa de reestenosis y la necesidad de nueva revascularizacion. La incidencia de trombosis de stent fue similar en los dos grupos.

Introduction and objectives Drug-eluting stents (DES) have proven to be effective in reducing the rate of restenosis and have, therefore, been incorporated into the treatment of patients with ST-elevation acute myocardial infarction (STEMI). The aim of this study was to investigate long-term clinical and angiographic outcomes following the use of DESs in patients with STEMI. Methods A prospective study involving clinical and angiographic follow-up was performed in 81 patients with STEMI who underwent percutaneous coronary intervention including DES implantation. This group was compared with 82 patients with similar characteristics who were treated with bare-metal stents (BMS) in an earlier period. Results At one year, there was no significant difference between the groups in the mortality (2.5% in the DES group vs 7.3% in the BMS group; P =.15) or reinfarction rate (4.8% in the DES group vs 4.8% in the BMS group; P =.98). The target lesion revascularization rate was significantly lower in the DES group (8.6% vs 23.2% in the BMS group; P =.001), as was the restenosis rate (13.8% vs 30.9% in the BMS group; P =.02). Acute or subacute stent thrombosis was diagnosed in 5 patients (3 with a DES and 2 with a BMS; P =.64), and one late stent thrombosis was detected after a year, in a sirolimuseluting stent. Conclusions Implantation of a DES in patients with STEMI did not result in a reduction in either the mortality or reinfarction rate at 1 year compared with BMS implantation. However, there were reductions in the rates of restenosis and target lesion revascularization. The incidence of thrombosis was similar with the 2 types of stent.

La trombosis del stent (TS) es una complicacion temida del intervencionismo coronario percutaneo por sus consecuencias catastroficas, cuya incidencia aproximada es del 1% y que puede ser mas frecuente en procedimientos realizados en pacientes/lesiones de alto riesgo o procedimientos multivaso. Analizamos la aparicion de TS en una poblacion de 404 pacientes consecutivos en un periodo en el que se utilizaron tanto stents recubiertos como stents convencionales, con una incidencia global del 2,23%, una mortalidad del 22,2% y una tasa de infarto agudo de miocardio no fatal del 66,6%. Los factores predictores de aparicion de TS fueron: indicacion por infarto agudo de miocardio, implante de multiples stents, peor fraccion de eyeccion, diametro de stent mas pequeno, presencia de diseccion residual y abandono precoz de clopidogrel.

Coronary stent thrombosis is a catastrophic complication of percutaneous coronary intervention. Its incidence is reported to be about 1%, though it can occur more frequently in high-risk patients, in high-risk lesions, and in multivessel procedures. We investigated the occurrence of stent thrombosis in 404 consecutive patients in a period when conventional and drug-eluting stents were both being used. We found an overall incidence of 2.23%, a mortality rate of 22.2%, and a non-fatal myocardial infarction rate of 66.6%. Predictors of stent thrombosis were acute myocardial infarction, multiple stent placement, poor ejection fraction, small stent diameter, the presence of residual dissection, and premature discontinuation of clopidogrel.

El origen anomalo de la arteria coronaria izquierda en el seno de Valsalva derecho es una anomalia que suele asociarse con isquemia miocardica y muerte subita. Aunque puede coexistir con aterosclerosis coronaria, esta no suele asentar en el trayecto coronario anomalo. Cuando coexiste esta anomalia coronaria con la enfermedad aterosclerotica coronaria resulta dificil diferenciar el origen de los sintomas isquemicos. Presentamos un caso en el que se emplearon 3 modalidades diagnosticas para dilucidar el origen de los sintomas isquemicos en un paciente con origen anomalo de la coronaria izquierda en el seno de Valsava derecho y trayecto entre la aorta y el tronco pulmonar asociado con lesions ateroscleroticas obstructivas en la coronaria derecha: la angiografia convencional como diagnostico inicial,la tomografia computarizada para identificar con exactitud el trayecto de la coronaria anomala y su relacion con estructuras vasculares y la ecocardiografia de esfuerzo para valorar isquemia en territorio de la coronaria izquierda tras el tratamiento de las lesiones en la coronaria derecha.

Introduccion y objetivos Un porcentaje variable de pacientes con infarto agudo de miocardio tratados con angioplastia primaria mantienen el segmento ST elevado a pesar de restablecer el flujo coronario, probablemente por inadecuada reperfusion celular. Analizamos si la persistencia del segmento ST elevado es un signo que puede predecir un peor pronostico. Pacientes y metodo Comparamos los resultados clinicos y angiograficos de 116 pacientes con infarto agudo de miocardio tratados con exito mediante angioplastia primaria, clasificados en dos grupos dependiendo de la persistencia (≥ 50%) o reduccion ( Resultados En 96 pacientes (grupo I) el segmento ST mejoro tras la angioplastia y en 20 pacientes (grupo II) no hubo mejoria. No existieron diferencias en las caracteristicas clinicas y angiograficas basales excepto mayor prevalencia de clase Killip 4 en el grupo II (7,2 frente a 25%; p = 0,01). Tampoco hubo diferencias en las caracteristicas y los resultados del procedimiento. La extension del dano miocardico fue mayor en el grupo II (CK 3.149 ± 1.636 frente a 2.185 ± 2.010 U/l; p = 0,02) y se asocio a una peor fraccion de eyeccion ventricular en el estudio angiografico tardio (47 ± 16 frente a 55 ± 16%; p = 0,05). La mortalidad al ano fue del 8,3% en grupo I y del 30% en grupo II (p = 0,01). Conclusiones La persistencia del segmento ST elevado tras una angioplastia primaria con exito permite diferenciar un grupo de pacientes en los que, a pesar de restablecer un buen flujo coronario epicardico, el riesgo de acontecimientos adversos esta incrementado. Introduction and objectives A variable percentage of patients with myocardial infarction treated with successful primary angioplasty and restoration of coronary flow show persistent ST-segment elevation, probably due to inadequate cellular reperfusion. We studied if persistent STsegment elevation was a predictor of worse prognosis. Patients and method We comparatively studied the clinical and angiographic results of 116 acute myocardial infarction patients after successful primary angioplasty, which were classified into two groups depending on the persistence (> 50%) or reduction (≤ 50%) of ST-segment elevation between the electrocardiograms recorded before and after coronary angioplasty. Results In 96 patients (Group I) the ST-segment elevation improved after angioplasty and in 20 patients (Group II) there was no improvement. Baseline characteristics were similar in both groups except for Killip class 4, which was more prevalent in group II (7.2 vs. 25%; p = 0.01). There were no differences in the characteristics or results of the procedure. There was more myocardial damage in group II (CK 3,149 ± 1,636 vs. 2,185 ± 2,010 U/l; p = 0.02), associated with a more impaired left ventricular ejection fraction in the late angiographic control (47 ± 16 vs 55 ± 16%; p = 0.05). At a one-year follow-up the mortality was 8.3% in group I and 30% in group II (p = 0.01). Conclusions The persistence of ST-segment elevation after successful primary angioplasty identifies a group of patients that may suffer an increased risk of adverse events in spite of good epicardial flow.

Introduccion y objetivos En la angioplastia primaria, la reoclusion o reestenosis de la arteria responsable del infarto es frecuente. El stent podria mejorar los resultados de la angioplastia y la evolucion a largo plazo de estos pacientes. Presentamos la evolucion clinica y angiografica de un grupo de pacientes con infarto agudo de miocardio tratados con stent primario. Pacientes y metodos Se ha realizado seguimiento durante un ano de 74 pacientes consecutivos con infarto agudo de miocardio tratado con angioplastia primaria e implante de stent. En el 91% de los pacientes se realizo un control angiografico a partir del sexto mes para evaluar el grado de reestenosis y la tasa de reoclusiones de la arteria responsable. Resultados Hubo 8 muertes intrahospitalarias y tres durante el ano de seguimiento (mortalidad total de 14,8%) y un reinfarto no fatal (1,5%). La recurrencia acumulada de isquemia fue del 6% al tercer mes y del 15% al sexto mes, sin incremento al ano de seguimiento. En 7 pacientes se realizo una nueva angioplastia y tres fueron revascularizados quirurgicamente. El 80% de los enfermos que fueron dados de alta estaban libres de eventos al ano de seguimiento. En el control angiografico solo un paciente presento oclusion de la arteria responsable del infarto, y la tasa de reestenosis fue del 27%. Conclusiones Estos resultados ponen de manifiesto que el stent puede ser utilizado de manera eficaz durante la angioplastia primaria en pacientes no seleccionados con baja incidencia a largo plazo de episodios adversos y una reducida tasa de reestenosis.

Introduccion y objetivos El uso de stents intracoronariosha sido generalmente contraindicadodurante la angioplastia coronaria transluminal percutanea(ACTP) primaria en el infarto agudo demiocardio (IAM) debido a su posible trombogenicidad.Presentamos los resultados intrahospitalariosde un grupo de pacientes sometidos a implante destent durante una ACTP primaria. Metodos Desde enero de 1995 a abril de 1996, 31pacientes fueron sometidos a implante de stent duranteuna ACTP primaria. La edad media fue de 62± 11 anos. La localizacion del infarto fue anterioren 20 casos (65%) e inferior en 11 pacientes(35%). Cuatro pacientes estaban en clase IV de Killip.El tiempo medio desde el comienzo del dolorfue 129 ± 29 min. Las indicaciones para el implantedel stent fueron: resultado suboptimo en el 64%,diseccion en el 29% y electivo en el 6%. Todos lospacientes fueron heparinizados durante 72 h y recibieronterapeutica antiagregante con ticlopidina yaspirina. Resultados Se consiguio restaurar la permeabilidaddel vaso con un flujo TIMI 3 en 29 pacientes(94%) y con un flujo TIMI 2 en 2 pacientes. En el80% de los pacientes se realizo control angiograficosin observar ninguna oclusion del stent y todosmostraron flujo TIMI 3. Hubo 3 muertes (9%):2 pacientes debido a shock cardiogenico y uno porsevera disfuncion ventricular derecha. Hubo recurrenciade angina en 2 casos (6%), debido a otraslesiones coronarias. Un paciente con enfermedadde tronco principal izquierdo fue sometido a revascularizacionquirurgica electiva. Conclusiones El stent intracoronario puede serusado con exito durante la angioplastia primariacon una baja incidencia de complicaciones. Los beneficiosa largo plazo deberan ser establecidos.

Coronary stent thrombosis is a catastrophic complication of percutaneous coronary intervention. Its incidence is reported to be about 1%, though it can occur more frequently in high-risk patients, in high-risk lesions, and in multivessel procedures. We investigated the occurrence of stent thrombosis in 404 consecutive patients in a period when conventional and drug-eluting stents were both being used. We found an overall incidence of 2.23%, a mortality rate of 22.2%, and a non-fatal myocardial infarction rate of 66.6%. Predictors of stent thrombosis were acute myocardial infarction, multiple stent placement, poor ejection fraction, small stent diameter, the presence of residual dissection, and premature discontinuation of clopidogrel.

Anomalous origin of the left coronary artery from the right sinus of Valsalva is an anatomical abnormality that is usually associated with myocardial ischemia and sudden death. Although this abnormality may coexist with obstructive atherosclerotic coronary disease, disease is not usually found in the anomalous course of the artery. When this coronary anomaly and obstructive coronary disease are both present, it is difficult to determine the cause of ischemic symptoms. We report a case in which three different diagnostic techniques were used to find the cause of ischemic symptoms in a patient whose left coronary artery originated anomalously in the right sinus of Valsalva and followed a course between the aorta and the pulmonary trunk and who had obstructive atherosclerotic lesions in the right coronary artery. The techniques were conventional angiography, which was used for the initial diagnosis, multislice computerized tomography, which was used to determine the anomalous course of the artery and its relationship with vascular structures, and exercise echocardiography, which was used to evaluate ischemia in the left coronary artery territory after treatment of the stenoses in the right coronary artery.

A variable percentage of patients with myocardial infarction treated with successful primary angioplasty and restoration of coronary flow show persistent ST-segment elevation, probably due to inadequate cellular reperfusion. We studied if persistent ST-segment elevation was a predictor of worse prognosis.We comparatively studied the clinical and angiographic results of 116 acute myocardial infarction patients after successful primary angioplasty, which were classified into two groups depending on the persistence (50%) or reduction (/= 50%) of ST-segment elevation between the electrocardiograms recorded before and after coronary angioplasty.In 96 patients (Group I) the ST-segment elevation improved after angioplasty and in 20 patients (Group II) there was no improvement. Baseline characteristics were similar in both groups except for Killip class 4, which was more prevalent in group II (7.2 vs. 25%; p = 0.01). There were no differences in the characteristics or results of the procedure. There was more myocardial damage in group II (CK 3,149 1,636 vs. 2,185 2,010 U/l; p = 0.02), associated with a more impaired left ventricular ejection fraction in the late angiographic control (47 16 vs 55 16%; p = 0.05). At a one-year follow-up the mortality was 8.3% in group I and 30% in group II (p = 0.01).The persistence of ST-segment elevation after successful primary angioplasty identifies a group of patients that may suffer an increased risk of adverse events in spite of good epicardial flow.

Mujer de 40 anos sin factores de riesgo cardiovascular que consulto por dolor toracico. El electrocardiograma mostro elevacion del segmento ST en derivaciones anteriores, y se realizo coronariografia urgente, que evidencio una imagen compatible con trombo oclusivo en el tronco comun izquierdo. Tras pasar una guia, desaparecio la oclusion y se restablecio el flujo en todo el arbol coronario; en la ecografia intracoronaria no se objetivo trombo ni diseccion coronaria. Se traslado a la paciente a nuestro centro por infarto agudo de miocardio anterolateral. A su llegada presentaba recidiva de dolor precordial, nueva elevacion del segmento ST y shock cardiogenico; se realizo nueva coronariografia, que mostro oclusion completa del tronco comun izquierdo por masa compatible con trombo. Con soporte inotropico y contrapulsacion aortica, se implanto stent en el tronco comun izquierdo, con lo que se restauro el flujo coronario (figura 1). La ecocardiografia transtoracica mostro disfuncion sistolica biventricular grave y una masa en la raiz aortica. Mediante ecocardiografia transesofagica bidimensional y tridimensional (figura 2) se confirmo la presencia de una masa trombotica de 30 mm anclada a nivel del ostium y stent del tronco comun izquierdo (flecha) y progresando hacia la valvula aortica. Finalmente hubo que implantar asistencia ventricular como puente al trasplante cardiaco; la masa desaparecio, probablemente en relacion con el tratamiento anticoagulante. La presencia de trombos en la aorta ascendente es una causa rara de infarto agudo de miocardio. El diagnostico debe realizarse con ecocardiografia transesofagica, ya que permite caracterizar la masa y realizar el diagnostico diferencial con otras masas. Su tratamiento es controvertido, y se recomienda anticoagulacion y trombectomia para los casos en que la anticoagulacion fracase. Figura 2. Figura 1.