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Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors for CAP include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. There are 3 major types of CAP depending on location: (a) large vessel perforation, (b) distal vessel perforation, and (c) collateral perforation. Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with coil or fat embolization. In this article we provide a state-of-the-art overview of the contemporary management of CAP.

In the last decades a significant increase of the migratory phenomenon from South Asian countries to the Western World has occurred for social, economic and geopolitical reasons. The aim of this review is to describe cardiovascular risk factors, pathogenesis and treatments of coronary artery disease in South Asian patients. It is well established that South Asian populations have a higher prevalence of coronary artery disease and premature onset of myocardial infarction episodes than other populations. This higher predisposition might be caused by genetic factors, common in both South Asian patients residing in their birth country and in those residing abroad, but it may also be due to the new spatial environment in which they live. It will be important to examine the leading cardiovascular risk factors determining increasing incidence of coronary artery disease in the South Asian population. These include: insulin resistance, hypertension, dyslipidaemia and abdominal obesity caused by a diet rich in refined carbohydrates and saturated fats. Furthermore, it is important to examine emerging cardiovascular risk factors strictly related to this particular ethnic group. The evidence of higher levels of prothrombotic and proinflammatory factors, for example lipoprotein(a) and proinflammatory adipokines, as well as the influence of air pollution and psychosocial stress, may have consequences on the risk, treatment and outcomes of the coronary artery disease in this population. Migrants from South Asia deserve to be addressed and framed with particular care in terms of cardiovascular risk and especially in the management of acute coronary events.

Patients with coronary microvascular dysfunction represent a widespread population, and despite the good prognosis, many of them, because of the angina symptoms, have a poor quality of life with strong limitations in their daily activities. In 2017, a new classification of microvascular dysfunction as well as a new definition of ischemia in patients with no obstructive coronary artery disease became available. This new definition improves Kemp's initial work, where cardiac X syndrome was initially described. This work summarizes the last updates on the subject with particular attention to the new classification of microvascular dysfunction, with particular attention to microvascular and vasospastic angina definition and diagnostic criteria.

Background: The relationship between left ventricular ejection fraction (LVEF) and the success and safety of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods: We examined the clinical characteristics and outcomes of CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO) after stratifying patients by LVEF (≤35%, 36%–49%, and ≥50%). Results: A total of 7827 CTO PCI procedures with LVEF data were included. Mean age was 64 ± 10 years, 81% were men, 43% had diabetes mellitus, 61% had prior PCI, 45% had prior myocardial infarction, and 29% had prior coronary artery bypass graft surgery. Technical success was similar in the three LVEF strata: 85%, 86%, and 87%, p = 0.391 for LVEF ≤35%, 36%–49%, and ≥50%, respectively. In-hospital mortality was higher in lower LVEF patients (1.1%, 0.4%, and 0.3%, respectively, p = 0.001). In-hospital major adverse cardiovascular events (MACE) were numerically higher in lower EF patients (2.7%, 2.1%, and 1.9%, p = 0.271). At a median follow-up of 2 months (interquartile range: 19-350 days), patients with lower LVEF continued to have higher mortality (4.9%, 3.2%, and 1.4%, p < 0.001) while the MACE rates were similar (9.3%, 9.6%, and 7.4%, p = 0.172). Conclusion: CTO PCI can be performed with high technical success in patients with reduced LVEF but is associated with higher in-hospital and post-discharge mortality.

Antegrade dissection and reentry (ADR) refers to an attempt to cross a coronary chronic total occlusion (CTO) lesion through wire and/or equipment passage in the subintimal space followed by reentry to the distal true lumen. From the original subintimal tracking and reentry (STAR) technique description by Colombo in 2005, refinement of the technique, improved characteristics of the microcatheters and wires, and better understanding of subadventitial vessel trauma have led to higher success rates, lower complications rates, and improved long-term outcomes. In this chapter, we discuss the technique, its outcomes, and limitations.

Historically, cardiac catheterization has been performed via transfemoral access (TFA). Although TFA remains necessary in multiple diagnostic and interventional settings, this technique has been associated with vascular access site complication rates ranging from 2% to 6%, prolonged hospital stay, and more deaths compared with radial artery access. Furthermore, safe utilization of the femoral artery can be compromised by abdominal obesity, atherosclerosis at the puncture site, and antithrombotic therapy, all which increase the bleeding risk.1 In the last decade, transradial artery access (TRA) emerged as the recommended approach for percutaneous coronary interventions (PCI), particularly in the acute setting where TRA compared with TFA showed a clear reduction of bleeding complications and mortality.2,3 For these reasons, a “radial first” approach is recommended in both European and American guidelines. For patients with stable ischemic heart disease, TRA has produced less bleeding than TFA, though without a mortality benefit.6,7 Importantly, most stable ischemic heart disease studies comparing access sites have excluded patients with complex coronary lesions. The evidence supporting TRA PCI feasibility and performance in chronic total occlusions (CTO) comes from observational studies and 1 randomized trial. The latter, the COLOR trial (Complex Large-Bore Radial Percutaneous Coronary Intervention [PCI] Trial), showed that for complex PCI procedures requiring large-bore access, TRA compared with TFA is associated with a significant reduction in clinically relevant access site bleeding and vascular complications, without differences in procedural success rates. In this study

Objectives: The aim of this study was to identify independent predictors of procedural success after retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: Retrograde CTO PCI is an established technique, but predictors of success remain poorly understood. Methods: A multivariable logistic regression model was used to analyze potentially important demographic, clinical, anatomical, and technical aspects of retrograde CTO PCI cases uploaded to the multicenter European CTO (ERCTO) Club Registry. Results: In calendar years 2018 and 2019, 2,364 retrograde CTO PCI cases constituted the primary analysis cohort. A primary retrograde strategy was used in 1,953 cases (82.6%), and an initial antegrade approach was converted to retrograde in 411 cases (17.4%). Procedural success was achieved in 1,820 cases (77.0%) and was more likely to occur after a primary retrograde attempt versus conversion from an initial antegrade approach (80.9% vs 58.4%; P < 0.0001). After multivariable analysis, an absence of lesion calcification (OR: 1.86; 95% CI: 1.37-2.51; P < 0.0001), a higher degree of distal vessel opacification (OR: 2.47; 95% CI: 1.72-3.55; P < 0.0001), little or no proximal target vessel tortuosity (OR: 1.84; 95% CI: 1.28-2.64; P = 0.001), Werner collateral connection CC1 (OR: 4.87; 95% CI: 2.90-8.19; P < 0.0001) or CC2 (OR: 5.33; 95% CI: 3.02-9.42; P < 0.0001), and the top tertile of operator volume (>120 cases over 2 years) (OR: 1.88; 95% CI: 1.26-2.79; P = 0.002) were associated with the greatest chance of achieving angiographic success. Conclusions: Less calcification with good distal vessel opacification, little or absent proximal vessel tortuosity, and visible collateral connections, along with high-volume operator status, were all independently predictive of angiographically successful retrograde CTO PCI.

© 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., 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.

Objectives We aimed to evaluate the efficacy and safety of antegrade fenestration and reentry (AFR) for chronic total occlusion (CTO) recanalization in a multicenter registry. Background Adoption of antegrade dissection/reentry (ADR) for CTO recanalization has been limited, and novel ADR techniques are needed. Methods AFR involves the balloon-induced creation of multiple fenestrations between the false and true lumen. A targeted true lumen reentry is subsequently achieved with a low tip-load polymer-jacketed guidewire. Following the initial description and dissemination of AFR, patients undergoing AFR-based CTO recanalization at nine centers were included in the present registry. Study endpoints were AFR success, procedural success, and target-lesion failure (TLF) on follow-up. Results We included 41 patients. Mean J-CTO score was 2.5 ± 1.4. In 80.5% of cases, AFR was performed after failed antegrade wire escalation. Another ADR technique was used before AFR in one-third of cases. AFR achieved distal true lumen reentry in n = 27/41 (65.9%) cases. In n = 14/41 (34.1%) cases with AFR failure, use of alternative techniques led to successful CTO recanalization in eight additional patients. The overall technical and procedural success rates were 85.4% and 82.9%, respectively. No AFR-related complications were observed. One-year TLF rate was 8.3% overall, with no differences between successful and failed AFR. Conclusions We report on AFR feasibility in a multicenter registry of patients undergoing CTO recanalization. We observed a moderate success rate, coupled with the absence of complications. Moreover, even a failed AFR attempt did not preclude the use of alternative techniques to achieve recanalization. Further studies should confirm and extend our findings.

Dual lumen microcatheters (DLMC) have become indispensable tools in the setting of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Other than allowing preservation and treatment of bifurcated coronary branches within or in the proximity of the CTO-body, they enable the use of modified parallel wiring, antegrade dissection and re-entry, collateral selection and retrograde negotiation of the distal CTO-cap. This Euro-CTO consensus document describes current DLMCs and suggests a practical guide to anatomies and techniques in which these devices are applicable.

The aim of this randomized prospective study was to evaluate the quality of life (QoL) using the “Seattle Angina Questionnaire” (SAQ) in patients with chronic total occlusion (CTO) in coronary arteries treated with either percutaneous coronary intervention (PCI) or optimal medical therapy (OMT), or only with OMT. The potential benefits of recanalization of CTO by PCI have been controversial because of the scarcity of randomized controlled trials. A total of 100 patients with CTO were randomized (1:1) prospectively into the PCI CTO or the OMT group (50 patients in each group). There were no baseline differences in the SAQ scores between the groups, except for physical limitation scores (P = 0.03). During the mean follow-up (FUP) of 275 ± 88 days, patients in the PCI group reported less physical activity limitations (72.7 ± 21.3 versus 60.5 ± 27, P = 0.014), less frequent angina episodes (89.8 ± 17.6 versus 76.8 ± 27.1, P = 0.006), better QoL (79.9 ± 22.7 versus 62.5 ± 25.5, P = 0.001), greater treatment satisfaction (91.2 ± 13.6 versus 81.4 ± 18.4, P = 0.003), and borderline differences in angina stability (61.2 ± 26.5 versus 51.0 ± 23.7, P = 0.046) compared to patients in the OMT group. There were no significant differences in SAQ scores in the OMT group at baseline and during the FUP. There was a statistically significant increase in all five domains in the PCI group. Symptoms and QoL measured by the SAQ were significantly improved after CTO PCI compared to OMT alone.

myocardial infarction

About 40% of patients undergoing coronary angiography for chest pain with anginal features have angiographically normal or near-normal coronary arteries. It was necessary to standardize all myocardial ischemia scenarios in stable patients in the absence of coronary artery disease, therefore the term INOCA (ischemia with non-obstructive coronary artery disease) was coined. The aim of this article is to summarize and to clarify the vast and controversial chapter of INOCA, in order to better understand the pathophysiological, nosographic, diagnostic and therapeutic aspects.

Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.

Patients with coronary microvascular dysfunction (CMVD) represent a widespread population and despite the good prognosis, many of them have a poor quality of life with strong limitations in their daily activities because of the angina symptoms. This article summarizes the most frequent clinical presentation pictures like stable and unstable microvascular angina. Main risk factors are discussed, followed by the latest updates on the subject about different pathogenic hypotheses, diagnosis and treatment. Not very well understood microvascular alterations, like slow flow phenomenon and no reflow are discussed and both prognosis and the impact of the disease in the quality of life are analyzed.

Objective: The aim of this study was to evaluate in patients with microvascular angina and heart failure with preserved ejection fraction, the speckle-tracking echocardiography, and longitudinal myocardial strain to evaluate the possible presence of alterations in heart failure with preserved ejection fraction patients compared with a control population. We also investigated the correlation between the longitudinal strain analysis and the TIMI frame count after coronary angiography. Methods: Our study was performed on a population 41 patients with microvascular angina that underwent coronary angiography and speckle-tracking echocardiography. We divided the sample into two categories: patients with heart failure with preserved ejection fraction (n-21) and patients without heart failure with preserved ejection fraction (n-20). We calculated TIMI frame count indices for each patient based on angiographic images. Results: Patients with heart failure with preserved ejection fraction had reduced global longitudinal strain values (−17.88) compared with the total control population, and this reduction was statistically significant (P=.028). This reduction was more marked in patients who had a significantly increased TIMI frame count. Therefore, a statistically significant correlation was observed between TIMI frame count and global longitudinal strain. Conclusion: Our results show that cardiac contractile mechanics are altered in patients with heart failure with preserved ejection fraction at a subclinical level hard to identifiable with conventional echocardiography. The dysfunction of the microcirculation and the consequent alteration of the TIMI frame count probably results in a reduction of myocardial performance.

Endovascular treatment of calcified carotid disease represents one of the main challenges for the interventionalists. Plaque calcium load is one of the most important factors affecting the risk of procedural complications. A new tool called Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical, Inc.) has been recently approved for the treatment of heavily calcified coronary and lower limb arteries but minimal data exist about the treatment of carotid arteries. We report our early experience of carotid stenting using S-IVL. We report two cases of symptomatic patients with severely calcified carotid artery diseases who were turned down for vascular surgeries. The first case was successfully performed through radial access using a distal cerebral embolic protection device in the context of contralateral carotid occlusion. In the second case, a very tight and calcified left internal carotid artery stenosis was successfully treated through femoral access using a proximal cerebral protection device. In both cases, advanced imaging confirmed effective calcium debulking and good stent expansion after IVL treatment. S-IVL effectiveness basically resides in integrating the effect of balloon angioplasty with the calcium-disrupting power of sonic pressure waves. This could be able to minimize the risk of cerebral embolization due to aggressive conventional balloon predilatation or poststenting dilatation usually needed to obtain an adequate luminal gain in carotid stenting. According to our small case series, the use of S-IVL for the treatment of heavily calcified carotid artery lesions seems to be helpful in this particular setting.

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).

Chronic total occlusion (CTO) of the coronary arteries are relatively common, observed in approximatively 15-25% of patients with coronary artery disease undergoing coronary angiography. The right coronary artery represents the most common CTO vessel, which represents about half of the CTO cases.The CTO prevalence is much higher ( 90%) among patients with prior coronary artery bypass graft (CABG), while a CTO is found in only one tenth of patients referred for ST-elevation myocardial infarction (STEMI)

Currently, there is no effective therapy for COVID-19, and several approaches are under investigation. Nevertheless, some drugs are used off-label despite the absence of clear data on their effectiveness. Among these, hydroxychloroquine suppresses SARS-CoV-2 replication in vitro,1 and clinical trials are ongoing to evaluate its use as an anti-COVID-19 agent. To date, the FDA and EMA allow its use only in hospitalized patients with severe COVID-19 or in those at high risk, in cases where other trials are not feasible. According to a small non-randomized study, hydroxychloroquine’s efficacy might be enhanced by azithromycin, as the combination of these two drugs appeared to accelerate viral clearance.2 However, these findings were not substantiated by another study performed in severe COVID-19 cases.3 In addition to the lack of consistent or conclusive efficacy data of these drugs, whether they are used individually or in combination, concern is increasing about potential safety issues. Both hydroxychloroquine and azithromycin may lead to QT prolongation-related life-threatening arrhythmias through the blockage of the rapid delayed rectifier potassium current (IKr). Their combination seems to be more harmful than their single use. Importantly, the risk of azithromycin-mediated QT prolongation is higher in males and in elderly groups,4 that represent a large proportion of the COVID-19 population. Data from a recent Chinese report showed that 16.7% of hospitalized COVID-19 patients and 44.4% of those in intensive care units had arrhythmias.5 The two main mechanisms involved could be hypoxia and electrolyte abnormalities, common features in the acute phase of severe illness. These factors may further enhance the risk of arrhythmic toxicity associated with hydroxychloroquine or azithromycin. Therefore, strategies to mitigate this potential risk have been proposed. The American College of Cardiology suggested QT monitoring in order to discontinue azithromycin (if used) and/or reduce the hydroxychloroquine dose in the case of QT prolongation. While drugs currently used against COVID-19 may seem crucial to treat the infection (in the absence of better options), it is imperative to mitigate toxicity to guarantee the maximum possible safety. According to 2019 international guidelines by the American Thoracic Society and Infectious Diseases Society of America, in pneumonia patients with QT prolongation, macrolides should be replaced by tetracyclines. While providing a broad-spectrum antibiotic activity, compared with other antibiotics tetracyclines also display additional properties that can be advantageous in COVID-19. In particular, the tetracycline derivative minocycline exerts anti-inflammatory effects by suppressing proinflammatory cytokines, including interleukin-6 (IL-6), which plays a key role in COVID-19, and may inhibit poly(ADP-ribose) polymerase-1 (PARP-1) which seems to be implicated in SARS-CoV-2 replication.6,7 Moreover, minocycline displays a synergistic effect when added to hydroxychloroquine.8 Compared with azithromycin, minocycline does not prolong the QT interval, and experimental evidence suggests that it may even be beneficial in conditions associated with increased risk of QT prolongation or arrhythmia. In an experimental model of epilepsy, intrathecal administration of minocycline, by antagonizing the action of microglia, reduced autonomic nervous system activity and seizure-induced QT prolongation.9 In other murine models, treatment with minocycline attenuated ischaemia-induced arrhythmias by blocking the mitochondrial K-ATP channel and inhibiting the PI3K/Akt signalling pathway mediated by L-type calcium channels both involved in myocardial ischaemia-induced arrhythmias.10 Although not proven in humans yet, it is reasonable to believe that minocycline may prevent (or at least mitigate) the increased risk of QT prolongation, and potentially fatal arrhythmias, due to hydroxychloroquine/azithromycin combination therapy, while having the same efficacy as azithromycin but a lower arrhythmogenic effect. For these reasons, until clinical trials prove the efficacy of azithromycin alone or in combination with hydroxychloroquine, we suggest that, whenever antibiotic prophylaxis is needed, azithromycin should be replaced by minocycline.

Introduction: Whether duration of chronic total occlusion (CTO) affects lesion and procedural characteristics remains largely unknown. Aim: To investigate whether CTO duration influences lesion characteristics and revascularization success. Material and methods: EuroCTO Registry data on patients who had CTO percutaneous coronary intervention between January 2015 and April 2017 were analyzed. Three groups were created based on occlusion age: 3 to 6 months (n = 1415), 7 to 12 months (n = 973), > 12 months (n = 1656). Results: Patients with greater CTO duration were older (63.0 (56.0–70.0); 63.0 (56.0–71.0); 66.0 (59.0–73.0) years respectively; p < 0.001), had more 3-vessel disease (32.2%; 30.9%; 46.1% respectively; p < 0.001) and more frequent prior coronary artery bypass grafting (8.2%; 9.9%; 29.4% respectively; p < 0.001). In multivariate analysis, occlusion duration was associated with moderate/ severe calcification (OR = 1.52; 95% CI: 1.28–1.80; p < 0.001), lesion length > 20 mm (OR 1.77; 95% CI 1.49–2.10; p < 0.001), and collateral circulation Werner type 2 (OR = 1.20; 95% CI: 1.01–1.43; p = 0.041). The CTO duration was associated with lower procedural success (OR for success 0.60; 95% CI: 0.46–0.79; p < 0.001). In multivariate analysis in-hospital adverse events did not differ according to duration of CTO. Conclusions: Coronary artery CTO duration is associated with greater extent of calcification, lesion length, development of collateral circulation and, most importantly, with lower procedural success.

© 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.

Atrial Fibrillation is the most common cardiac arrhythmia affecting people of all ages, principally the elderly. Cognitive decline and dementia are also prevalent diseases in elderly. The scientific community always showed interest in the possible association between these two pathological entities, both implicating social and economic burden. This has been confirmed by several longitudinal population-based studies. Some studies also revealed that the association between atrial fibrillation and dementia may be not related to history of stroke. Therefore, other pathophysiological mechanisms are likely implicated, so far unclear or undefined. The aim of the present review is to analyse the possible mechanisms underlying the frequent association between atrial fibrillation and cognitive impairment.

Background: The study focuses on the evolution of practice, procedural outcomes, and in-hospital complications of chronic total occlusion percutaneous coronary intervention in Europe. Methods and Results: Data from 17 626 procedures enrolled in European Registry of Chronic Total Occlusion between January 2008 and June 2015 were assessed. The mean patient age was 63.9±10.9 years; 85% were men. Procedural success increased from 79.7% to 89.3% through the study period. Patients enrolled during the years had increasing comorbidities and lesion complexity (J-CTO score [Multicenter CTO Registry of Japan] increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015; P for trend, P for trend, P for trend, P for trend, 0.390). Conclusions: Chronic total occlusion percutaneous coronary intervention has shown a steady increase in procedural success rate over time, with unchanged complication rates, despite the increasing complexity of the lesions attempted. The J-CTO score predictive value for procedural success was low for the entire registry and had no predictive ability for the retrograde approach.

Aims: The clinical value of percutaneous coronary intervention (PCI) for chronic coronary total occlusions (CTOs) is not established by randomized trials. This study should compare the benefit of PCI vs. optimal medical therapy (OMT) on the health status in patients with at least one CTO.Method and results: Three hundred and ninety-six patients were enrolled in a prospective randomized, multicentre, open-label, and controlled clinical trial to compare the treatment by PCI with OMT with a 2:1 randomization ratio. The primary endpoint was the change in health status assessed by the Seattle angina questionnaire (SAQ) between baseline and 12 months follow-up. Fifty-two percent of patients have multi-vessel disease in whom all significant non-occlusive lesions were treated before randomization. An intention-to-treat analysis was performed including 13.4% failed procedures in the PCI group and 7.3% cross-overs in the OMT group. At 12 months, a greater improvement of SAQ subscales was observed with PCI as compared with OMT for angina frequency [5.23, 95% confidence interval (CI) 1.75; 8.71; P = 0.003], and quality of life (6.62, 95% CI 1.78-11.46; P = 0.007), reaching the prespecified significance level of 0.01 for the primary endpoint. Physical limitation (P = 0.02) was also improved in the PCI group. Complete freedom from angina was more frequent with PCI 71.6% than OMT 57.8% (P = 0.008). There was no periprocedural death or myocardial infarction. At 12 months, major adverse cardiac events were comparable between the two groups.Conclusion: Percutaneous coronary intervention leads to a significant improvement of the health status in patients with stable angina and a CTO as compared with OMT alone.Trial registration: NCT01760083.

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.

Objectives The aims of this study were to describe the 10-year experience of a single operator dedicated to chronic total occlusion (CTO) and to establish a model for predicting technical failure. Background During the last decade, the interest in percutaneous coronary interventions (PCIs) of chronic total occlusions (CTOs) has increased, allowing the improvement of success rate. Methods One thousand nineteen patients with CTO underwent 1,073 CTO procedures performed by a single CTO-dedicated operator. The study population was subdivided into 2 groups by time period: period 1 (January 2005 to December 2009, n = 378) and period 2 (January 2010 to December 2014, n = 641). Observations were randomly assigned to a derivation set and a validation set (in a 2:1 ratio). A prediction score was established by assigning points for each independent predictor of technical failure in the derivation set according to the beta coefficient and summing all points accrued. Results Lesions attempted in period 2 were more complex in comparison with those in period 1. Compared with period 1, both technical and clinical success rates significantly improved (from 87.8% to 94.4% [p = 0.001] and from 77.6% to 89.9% [p < 0.001], respectively). A prediction score for technical failure including age ≥75 years (1 point), ostial location (1 point), and collateral filling Rentrop grade

The OAT trial and its angiographic substudy TOSCA-2, along with a number of published commentaries, represents examples of over-interpretation of clinical study results. A study that achieved no statistically significant result for any of the study endpoints can only claim to have proven that their null hypothesis cannot be rejected. The lack of power due to a reduction of patient numbers by one third, and an unexpected low event rate, makes it not unlikely that another trial would be able to disprove the null hypothesis. These statistical facts should be accepted by the authors and commentators. Instead, the inconclusive results were interpreted in such a way that they might apply to patient populations which had not been represented in the original trial (like CTOs without prior MI, or with viable myocardium), or for patients who could have been included, such as multivessel high risk patients, but had not been so by the investigators choice. Furthermore, major problems of the study are ignored, such as accepting TIMI 2 flow as a procedural success.

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 < 0.001), myocardial infarction (2.3% vs. 5.4%, respectively; p = 0.001), further revascularization (8.6% vs. 23.6%, respectively; p < 0.001), and major adverse cardiac and cerebrovascular events (8.7% vs. 23.9%, respectively; p < 0.001). Female sex (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.33 to 3.18; p = 0.001), prior PCI (HR: 1.73; 95% CI: 1.16 to 2.60; p = 0.011), low left ventricular ejection fraction (HR: 2.43; 95% CI: 1.22 to 4.83; p = 0.011), J-CTO (Multicenter CTO Registry in Japan) score >= 3 (HR: 2.08; 95% CI: 1.32 to 3.27; p = 0.002), and procedural failure (HR: 2.48; 95% CI: 1.72 to 3.57; p < 0.001) were independent predictors of major adverse cardiac and cerebrovascular events at long-term follow-up. 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. (C) 2015 by the American College of Cardiology Foundation.

We describe a case of a chronic proximal in-stent CTO extending up to the ostium of a right coronary artery where successful achievement of guidewire passage through the CTO was performed with a retrograde approach. Guidewire trapping into the right guiding catheter was performed thereafter and procedure was completed by retrograde balloon crossing and antegrade stenting. © 2009 Elsevier Ireland Ltd.

We report a case of apical thrombus formation among a group of 15 patients with takotsubo cardiomyopathy who were referred for a suspected acute coronary syndrome over a 2.5-year period. To the best of our knowledge, no data are available regarding the treatment of this syndrome. According to current literature and our reported experience, the use of anticoagulant therapy administered until complete resolution of wall motion abnormalities appears to be appropriate to treat apical thrombus formation and any possible subsequent embolism. © 2008 Italian Federation of Cardiology.

Objectives: To evaluate the prognostic value of exercise myocardial scintigraphy in patients undergoing incomplete revascularization by means of percutaneous coronary intervention (PCI) with at least a residual chronic total occlusion (CTO) left untreated. Methods: Of 569 consecutive patients with multivessel disease undergoing myocardial scintigraphy after incomplete revascularization by PCI between March 1997 and December 2004, 126 (79% male, 64 ± 10 years) with ≥ 1 residual CTO fulfilled the eligibility criteria and entered in the study. Hard events defined as cardiac death and myocardial infarction, soft events defined as incidence of unstable angina and PCI procedures, and their composite were assessed at a median follow-up period of 44 months. Results: Hard events were observed in six patients (4.8%). All of them had severely abnormal perfusion defects detected by myocardial scintigraphy. Soft events occurred in 0 (0%), 10 (7.9%), and 15 (11.9%) patients with normal, mildly abnormal, and severely abnormal perfusion, respectively. In the Kaplan-Meier analysis, the log-rank test was statistically significant across patients stratified by summed stress score either in terms of hard, soft and hard, or soft events. Univariate and multivariate Cox proportional-hazards showed an incremental significant information when the scintigraphic variables were added to clinical, angiographic, left ventricular ejection fraction, and Duke treadmill score, for prediction of the composite of hard and soft cardiac events (P < 0.006). Conclusions: Among patients with a residual CTO left untreated after PCI, myocardial perfusion imaging provides significant independent information concerning the subsequent risk of cardiac events. (J Interven Cardiol 2010;23:139-148) © 2010, Wiley Periodicals, Inc.

Chronic total occlusions (CTOs) are frequently encountered during diagnostic coronary catheterisation. However, there is still confusion regarding the indication for percutaneous coronary intervention (PCI) in this lesion subset, mainly because it is cumbersome and the prognostic impact of revascularisation in these patients remains unclear. Many studies have now shown the long term clinical benefits after CTO PCI1-3; still, with procedural complexity, high radiation exposure to both the patient and the operator, high costs and lower procedural success rates, most patients with CTO are managed medically or referred for bypass graft surgery – regardless of the severity of symptoms and extent of ischaemia4.

Background: Several studies have illustrated the safety and the procedural outcome of high-frequency vibrational energy in guidewire refractory chronic total occlusions (CTOs). Aim: To evaluate the advantage of high-frequency vibrational energy device (CROSSER Catheter) use in coronary complex CTO revascularization as primary strategy. Methods: CROSSER was used as a primary approach if four or more unfavorable angiographic features were observed in the CTO lesions. Results: From May 2007 to February 2009, a CTO percutaneous intervention attempt was performed in 178 lesions of 171 patients (60.1 ± 8.9 age with 49.4 ± 7.2% in ejection fraction). Among these, the CROSSER was used in 46 complex CTO lesions of 45 patients (25.8% of cases) and in the remaining cases, typical CTO percutaneous coronary intervention techniques were employed. Clinical success was 84.8% in CROSSER group. Moreover, in the CROSSER group, no periprocedural myocardial infarction, perforation, or 30 days MACE was observed. In addition, the use of CROSSER was associated with lower time of procedure, time of fluoroscopy, and contrast load administration as compared with conventional techniques [88 ± 27 minutes vs 109 ± 38 minutes (P = 0.045), 39 ± 12 minutes vs 50 ± 27 minutes (P = 0.032), and 334 ± 122cc vs 408 ± 198cc (P = 0.05), respectively]. Conclusion: In the present study, the CROSSER System was safe and obtained a high rate of success in complex CTO similar to conventional dedicated guidewire techniques for noncomplex CTO; however, the CROSSER Catheter obtained CTO recanalization with lower contrast load administration, less time of procedure, and lower fluoroscopy exposure. (J Interven Cardiol 2010;23:130-138)

Background: Conventional two-dimensional angiography lacks the ability to properly image the true bifurcation geometry, and its percutaneous coronary intervention-induced changes in the clinical setting. Methods and Results: A novel three-dimensional reconstruction system was investigated by retrospectively analyzing 39 lesions in 35 consecutive patients with coronary bifurcation disease treated with the mini-crush technique. At baseline, significant correlations were proved between two- and three-dimensional systems in terms of either reference vessel diameter (R 2 = 0.68 and 0.29 for main and side branches, respectively), minimum lumen diameter (R 2 = 0.73 and 0.36), stenosis diameter (R 2 = 0.69 and 0.29), and lesion length (R 2 = 0.48 and 0.58). These results were consistent with those observed after the procedure and at 8-month follow-up. Lesion length was significantly longer with the three-dimensional compared to the two-dimensional system for both main and side branches (P < 0.001, and P = 0.007, respectively). Conclusions: The three-dimensional quantitative reconstruction system may provide accurate evaluation of the complex curvilinear structure of bifurcation lesions when using a double stent technique. © 2009, Wiley Periodicals, Inc.

Objective: To investigate long-term outcomes of unprotected left main coronary artery (ULMCA) disease treatment using drug-eluting stents (DES). Background: In several studies, DES implantation in ULMCA appeared safe and effective at mid-term; however, to date, there is limited long-term data. Methods: All consecutive patients undergoing sirolimus- or paclitaxel-eluting stent implantation in ULMCA disease at a single institution were evaluated. The primary endpoint was long-term major adverse cardiac events (MACE) defined as cardiac death, nonfatal myocardial infarction, or target lesion revascularization (TLR). Stent thrombosis (ST), according to Academic Research Consortium definitions, was also evaluated. Results: A total of 210 patients were assessed. In-hospital MACE rate was 1%. During a mean follow-up of 28.0 ± 14.5 months, MACE occurred in 26 patients (12.5%): cardiac death in nine patients (4.3%) and TLR in 17 patients (8.2%). The cumulative MACE-free survival rate was 89.0, 87.4, and 85.4% at 1, 2, and 3 years, respectively. ST occurred in three patients (1.4%): one case was definite and the other two were probable/possible ST; there were no cases of very late ST. Binary restenosis occurred in 8.3%. The EuroScore >6 was the only independent predictor of MACE [hazard ratio (HR) 2.24, 95% confidence interval (CI) 1.05-4.77, P = 0.04]. There was a trend toward an increased risk of MACE associated with distal ULMCA location (HR 2.14, 95% CI 0.87-5.29, P = 0.10). Conclusions: Our study showed DES implantation in ULMCA to be feasible, safe, and effective at long term. Randomized trials comparing percutaneous versus surgical revascularization are warranted to define the treatment of choice for ULMCA disease. © 2009 Wiley-Liss, Inc.

Objectives: We sought to evaluate the safety and performance of the Janus Tacrolimus-Eluting stent (TES) in an unselected population of patients, without application of restrictive clinical or angiographic criteria. Background: Continued attention to the safety, efficacy, and deliverability of first-generation drug eluting stents has led to the development of new antiproliferative agents with alternative stent platforms and different drug carrier vehicles. Methods: The TEST (Tacrolimus Eluting STent) registry is a prospective, nonrandomized single-center registry in which 140 consecutive patients who underwent single- or multi-vessel percutaneous coronary intervention between February 2005 and August 2005 were enrolled. Results: The composite rate of major adverse cardiac events (MACE) at 22 months clinical follow-up was 40.9%. The rate of mortality, myocardial infarction, and target lesion revascularization (TLR) were 5.5%, 11%, and 31.5%, respectively. Angiographic follow-up at 8 months was achieved in 74% of patients; binary restenosis occurred in 39.4% of lesions. Most restenosis lesions (94.6%) had a diffuse pattern, while focal restenosis was observed in 5.4% of cases. Definite or probable stent thrombosis was observed in 2.4% of patients. Conclusions: The present prospective, nonrandomized, TEST registry indicated high MACE and restenosis rates, and thereby rather discouraging long-term outcomes with use of the Janus TES in an unselected “real world” population of patients who underwent single- or multi-vessel percutaneous coronary intervention. © 2009 Wiley-Liss, Inc.

Aims: Trifurcation lesions, which are mostly observed in distal left main (LM), represent a technical challenge for interventional cardiologists. We sought to determine the feasibility and long-term clinical outcome of drug eluting stent (DES) implantation in patients with LM coronary trifurcation lesions. Methods and results: All patients with clinically significant de novo LM trifurcation lesions, who refused coronary artery bypass surgery and were considered eligible for percutaneous coronary intervention (PCI), were consecutively enrolled in this study from November 2005 to February 2007. Eleven patients (65±9 years, 91% men) met all the inclusion criteria and underwent LM trifurcation stenting with DES. Angiographic success was 100%. Clinical follow-up in all patients and angiographic follow-up in 91% of patients was available at 32±7 and 8±2 months, respectively. The primary endpoint, defined as the composite of cardiac death or acute myocardial infarction, occurred in one patient (9%). No cases of stent thrombosis were recorded. Three patients (27%), experienced a clinically-driven target lesion revascularisation (TLR). Conclusions: PCI with DES implantation in patients with LM trifurcation seems feasible and safe, with acceptable TLR rates. Large scale multicentre registries are warranted to reliably address clinical outcome of this subset of patients. © Europa Edition. All rights reserved.

Background: Percutaneous closure of the left atrial appendage (LAA) is a novel alternative for the treatment of patients with atrial fibrillation (AF) and with a high risk of stroke who are not eligible for long-term anticoagulation therapy. The aim of this study was to asses the safety, feasibility, and long-term efficacy of this procedure. Methods: From July 2004 to June 2007, 20 patients (13 male, mean age 69 ± 8 years) with non–valvular AF (NV-AF) underwent LAA percutaneous closure using the PLAATO™ system, implanted through a transeptal access. All patients had contraindications to anticoagulant therapy and were at high risk for cardioembolic stroke (mean CHADS2 score 3 ± 1.2). A trans-thoracic echocardiogram was performed at 1, 3, and every 6 months after the procedure, whereas a trans-oesophageal echocardiogram (TOE) was scheduled at 6 months. After 24 months, a phone interview was obtained. Results: All procedures were successfully performed in 18 patients. In two patients, LAA closure was not feasible for the presence of a multilobed LAA. Two patients underwent percutaneous closure of patent foramen ovale in the same session. In one patient, the procedure was complicated by cardiac perforation with pericardial effusion, treated with pericardiocentesis. At a mean follow up of 40 ± 10 months, no embolic events occurred. One patient died, after 36 months, for gastric cancer. TOE examination showed the complete exclusion of the LAA in all patients. Conclusions: Percutaneous closure of LAA is safe and efficacious to prevent stroke in patients with NV-AF at high risk for cardioembolic events, with contraindications to anticoagulant therapy. © 2009 Wiley-Liss, Inc.

Objectives: This retrospective study sought to assess the clinical and angiographic long-term outcome after implanting drug-eluting stents in bifurcation lesions with the T-provisional (T-prov) technique and mini-crush (MC) technique. Background: The best option on the treatment of coronary bifurcation lesions is a subject of considerable debate. However, recent evidence suggests that bifurcation lesions might be treated by drug-eluting stent on both branches using the MC technique with a low rate of major adverse cardiac event and restenosis. Methods: From April 2004 to July 2006, 457 patients were consecutively treated with either MC technique (n = 199) or T-prov technique (n = 258). Of these latter, 170 patients were treated with 1 stent and 88 patients with 2 stents. The 9-month angiographic follow-up was completed in 188 of 229 (82.1%) bifurcation lesions of MC patients and in 207 of 266 lesions (77.8%) of T-prov patients. Results: After a propensity score adjustment, 2-year cumulative major adverse cardiac events were similar between groups (p = 0.16). The MC group compared with the T-prov 1-stent group had significantly lower main and side branches restenosis (hazard ratio [HR]: 0.52, 95% confidence interval [CI]: 0.27 to 0.99; p = 0.047; and HR: 0.41, 95% CI: 0.20 to 0.85; p = 0.016, respectively). However, the MC group compared with the T-prov-only group had significantly lower side branch restenosis (HR: 0.55, 95% CI: 0.37 to 0.82; p = 0.004). Conclusions: Both techniques of bifurcation treatment met high procedural success with low complication rates and similar major adverse cardiac event long-term outcome. However, the MC technique yields a lower restenosis rate at both main and side branches. These results may confirm the advantage of using prescheduled 2-stent technique to give a complete coverage of the side branches' ostium. © 2009 American College of Cardiology Foundation.