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Background: The Italian Society of Echography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand the volumes of activity, modalities and stressors used during stress echocardiography (SE) in Italy., Methods: We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved through an electronic survey based on a structured questionnaire, uploaded on the SIECVI website., Results: Data were obtained from 228 echocardiographic laboratories, and SE examinations were performed in 179 centers (80.6%): 87 centers (47.5%) were in the northern regions of Italy, 33 centers (18.4%) were in the central regions, and 61 (34.1%) in the southern regions. We annotated a total of 4057 SE. We divided the SE centers into three groups, according to the numbers of SE performed: <10 SE (low-volume activity, 40 centers), between 10 and 39 SE (moderate volume activity, 102 centers) and ≥40 SE (high volume activity, 37 centers). Dipyridamole was used in 139 centers (77.6%); exercise in 120 centers (67.0%); dobutamine in 153 centers (85.4%); pacing in 37 centers (21.1%); and adenosine in 7 centers (4.0%). We found a significant difference between the stressors used and volume of activity of the centers, with a progressive increase in the prevalence of number of stressors from low to high volume activity ( P = 0.033). The traditional evaluation of regional wall motion of the left ventricle was performed in all centers, with combined assessment of coronary flow velocity reserve (CFVR) in 90 centers (50.3%): there was a significant difference in the centers with different volume of SE activity: the incidence of analysis of CFVR was significantly higher in high volume centers compared to low - moderate - volume (32.5%, 41.0% and 73.0%, respectively, P < 0.001). The lung ultrasound (LUS) was assessed in 67 centers (37.4%). Furthermore for LUS, we found a significant difference in the centers with different volume of SE activity: significantly higher in high volume centers compared to low - moderate - volume (25.0%, 35.3% and 56.8%, respectively, P < 0.001)., Conclusions: This nationwide survey demonstrated that SE was significantly widespread and practiced throughout Italy. In addition to the traditional indication to coronary artery disease based on regional wall motion analysis, other indications are emerging with an increase in the use of LUS and CFVR, especially in high-volume centers., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Cardiovascular Echography.)

Background: The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand better how different echocardiographic modalities are used and accessed in Italy., Methods: We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved via an electronic survey based on a structured questionnaire, uploaded on the SIECVI website., Results: Data were obtained from 228 echocardiographic laboratories: 112 centers (49%) in the northern, 43 centers (19%) in the central, and 73 (32%) in the southern regions. During the month of observation, we collected 101,050 transthoracic echocardiography (TTE) examinations performed in all centers. As concern other modalities there were performed 5497 transesophageal echocardiography (TEE) examinations in 161/228 centers (71%); 4057 stress echocardiography (SE) examinations in 179/228 centers (79%); and examinations with ultrasound contrast agents (UCAs) in 151/228 centers (66%). We did not find significant regional variations between the different modalities. The usage of picture archiving and communication system (PACS) was significantly higher in the northern (84%) versus central (49%) and southern (45%) centers ( P < 0.001). Lung ultrasound (LUS) was performed in 154 centers (66%), without difference between cardiology and noncardiology centers. The evaluation of left ventricular (LV) ejection fraction was evaluated mainly using the qualitative method in 223 centers (94%), occasionally with the Simpson method in 193 centers (85%), and with selective use of the three-dimensional (3D) method in only 23 centers (10%). 3D TTE was present in 137 centers (70%), and 3D TEE in all centers where TEE was done (71%). The assessment of LV diastolic function was done routinely in 80% of the centers. Right ventricular function was evaluated using tricuspid annular plane systolic excursion in all centers, using tricuspid valve annular systolic velocity by tissue Doppler imaging in 53% of the centers, and using fractional area change in 33% of the centers. When we divided into cardiology (179, 78%) and noncardiology (49, 22%) centers, we found significant differences in the SE (93% vs. 26%, P < 0.001), TEE (85% vs. 18%), UCA (67% vs. 43%, P < 0001), and STE (87% vs. 20%, P < 0.001). The incidence of LUS evaluation was similar between the cardiology and noncardiology centers (69% vs. 61%, P = NS)., Conclusions: This nationwide survey demonstrated that digital infrastructures and advanced echocardiography modalities, such as 3D and STE, are widely available in Italy with a notable diffuse uptake of LUS in the core TTE examination, a suboptimal diffusion of PACS recording, and conservative use of UCA, 3D, and strain. There are significant differences between northern and central-southern regions and echocardiographic laboratories that pertain to the cardiac unit. This inhomogeneous distribution of technology represents one of the main issues that must be solved to standardize the practice of echocardiography., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Cardiovascular Echography.)

Prognosis in pulmonary hypertension is strictly linked to right ventricle failure, which results from uncoupling between right ventricle function and its afterload. This study sought to describe how to estimate with echocardiography right ventricular wall tension, its correlation with right ventricle haemodynamics and its prognostic role. A total of 190 patients without overt right ventricle failure but with suspected pulmonary hypertension on a previous echocardiogram underwent right heart catheterization and nearly-simultaneous echocardiography. Right ventricular wall tension was estimated according to Laplace's law as right ventricle length × tricuspid regurgitation peak gradient and it was correlated with right ventricle haemodynamic profile; its potential prognostic impact was tested along with canonical right ventricle function parameters. Right ventricular wall tension correlated significantly with invasive estimation of right ventricle end-diastolic pressure (R: 0.343, p  < 0.001) and with several other haemodynamic variables, such as mean pulmonary artery pressure, pulmonary artery compliance, transpulmonary gradient, pulmonary vascular resistance, right atrial pressure and right ventricle stroke work index (all p  < 0.001). At a mean follow-up of five years and three months, only right ventricular wall tension was associated to all-cause mortality ( p  = 0.036), while tricuspid annular plane systolic excursion ( p  = 0.536), right ventricle fractional area change ( p  = 0.383), right ventricle fractional area change ( p  = 0.076), tricuspid regurgitation peak gradient ( p  = 0.107) and tricuspid annular plane systolic excursion/tricuspid regurgitation peak gradient ( p  = 0.181) could not. We identified a novel bedside echocardiographic predictor of altered right ventricle haemodynamics, which is precociously altered in patients without overt right ventricle failure and is associated to all-cause mortality at a long-term follow-up. Further studies are needed to confirm its role in pulmonary hypertension patients., (© The Author(s) 2019.)

Objectives: To evaluate "real life" incidence and independent predictors of major bleeding defined in ACS patients treated with PCI and current standard antithrombotic therapy with prasugrel or ticagrelor., Methods and Results: The RENAMI project is a multicenter retrospective observational registry enrolling 4424 patients with ACS treated with PCI and prasugrel or ticagrelor plus aspirin. Primary endpoint was MACE (major adverse cardiovascular events). Secondary endpoints included each component of MACE, cardiovascular death (CV death), recurrence of ACS (reACS) and stroke. Eighty three (1.8%) patients developed out of hospital major bleedings after 14.1 ± 6.2 months. These patients had higher rates of MACE (14.5% vs 4.4%; p = 0.001) and of all-cause death (11% vs 2.1%; p < 0.001). Independent predictors of major bleeding were age >75 years (OR 2.00; 95% CI 1.18-3.41; p = 0.010) and female sex (OR 1.66; 95% CI 1.02-2.70; p = 0.041). BARC 3-5 bleeding was independently associated with all-cause mortality (OR 3.46; 95% CI 1.64-7.31; p 0.001)., Conclusion: In ACS patients treated with PCI and ticagrelor or prasugrel, BARC 3-5 bleedings despite being uncommon negatively impacted on prognosis. Old and female patients are at increased risk, offering clinical indications for tailoring dual antiplatelet therapy., (Copyright © 2018 Elsevier B.V. All rights reserved.)

To assess the accuracy and reproducibly of cardiovascular magnetic resonance (CMR) in the measurement of the aortic annulus and in process of valve sizing as compared to intra-operative sizing, cardiovascular computed tomography (CCT) and transesophageal echocardiography (TEE). Retrospective study on 42 patients who underwent aortic valve replacement from September 2010 to September 2015, with available records of pre surgery annulus assessment by CMR, CCT and TEE and of peri-operative assessment. In CCT and CMR, the annular plane was considered a virtual ring formed by the lowest hinge points of the valvular attachments to the aorta. In TEE the annulus was measured at the base of leaflet insertion in the mid-esophageal long-axis view using the X-plane technique. Two double-blinded operators performed the assessments for each imaging technique. Intra-operative evaluation was performed using Hegar dilators. Continuous variables were studied with within-subject ANOVA, Bland-Altman (BA) plots, Wilcoxon's and Friedman's tests; trends were explored with scatter plots. Categorical variables were studied with Fisher's exact test. The intra- and inter-operator reliability was satisfying. There were no significant differences between the annulus dimensions measured by CMR and either one of the three references. Valve sizing for CoreValve by CMR had the same good agreement with CCT and TEE, with a 78 % match rate; for SAPIEN XT the agreement was slightly better (82 %) for CCT than for TEE (66 %). MR performs well when compared to the surgical reference of intra-operative sizing and stands up to the level of the most used imaging references (CCT and TEE).

With the progressive increase in life-expectancy of human immunodeficiency virus (HIV)-positive patients in the "highly active antiretroviral therapy" (HAART) era, co-morbidities, particularly cardiovascular (CV) diseases (CVD) are emerging as an important concern. The pathophysiology of CVD in this population is complex, due to the interaction of classical CV risk factors, viral infection and the effects of antiretroviral therapy (ARV). The role of ARV drugs in HIV is double edged. While these drugs reduce systemic inflammation, an important factor in CV development, they may at the same time be proatherogenic by inducing dyslipidemia, body fat redistribution and insulin resistance. In these patients primary prevention is challenging, considering the lower median age at which acute coronary syndromes occur. Furthermore prevention is still limited by the lack of robust evidence-based, HIV-specific recommendations. Therefore we performed a comprehensive evaluation of the literature to analyze current knowledge on CVD prevalence in HIV-infected patients, traditional and HIV-specific risk factors and risk stratification, and to summarize the recommendations for primary prevention of CVD in this HIV population., (Copyright © 2016. Published by Elsevier Inc.)

Midterm outcomes for patients presenting with heart failure and functional mitral regurgitation (MR) treated with Mitraclip remain unclear. Pubmed, Medline, and Google Scholar were systematically searched for studies enrolling patients with severe-moderate MR who underwent Mitraclip implantation. All events after at least 6 months were the primary safety end point (including death, rehospitalization for heart failure, and reinterventions), whereas change in the ejection fraction, left ventricular volumes, arterial pulmonary pressure, and left atrial diameters were considered as secondary end points. Meta-regression analysis was performed to evaluate the effect of baseline clinical and echocardiographic parameters on efficacy outcomes: 875 patients were included in 9 studies; 1.48 clips (1.3 to 1.7) for patients were implanted, and after a median follow-up of 9 months (6 to 12), 409 patients (78% [75% to 83%]) were in class New York Heart Association I/II and 57 (11% [8% to 14%]) still had moderate-to-severe MR. Overall adverse events occurred in 137 (26% [20% to 31%]) of the patients and 78 (15% [1% to 17%]) of them died; 6-minute walk test improved by 100 m (83 to 111), whereas a significant reduction in left ventricular volumes and systolic pulmonary pressure was reported. At meta-regression analysis, an increase in left ventricle systolic volumes positively affected reduction of volumes after Mitraclip, whereas atrial fibrillation reduced the positive effect of the valve implantation on ejection fraction on end-diastolic and -systolic volumes. In conclusion, Mitraclip represents an efficacious strategy for patients with heart failure and severe MR. It offers a significant improvement in functional class and in cardiac remodeling, in patients with severely dilated hearts as well, although its efficacy remains limited in the presence of atrial fibrillation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Childhood cancer survivors (CCSs) have an increased risk of overweight and dyslipidaemia, but the distribution and the potential relationships between anticancer therapies and cardiovascular risk factors have been heterogeneously and not prospectively described., Methods: All consecutive CCSs with primary cancer diagnosed between 1973-2007 and subsequently referred to our outpatient clinic were enrolled. Hypercholesterolaemia (total cholesterol >200 and/or low density lipoprotein (LDL)>160 mg/dl) was the primary end point, hypertriglyceridaemia (triglycerides >200 mg/dl) and body mass index >30 kg/m(2) the secondary end points. Cox multivariate adjustments were performed to account for differences in cancer and treatments., Results: A total of 340 patients were included (197 male, 143 female; mean age at last follow-up 24.1 ± 3.2). The most common diagnosis were haematological malignancies (n = 227) and brain tumours (n = 51). After a median follow-up of 16.1 years, hypercholesterolaemia was diagnosed in 67 CCSs (20%), hypertriglyceridaemia in 20 CCSs (6%) and obesity in 28 CCSs (8%). Total body irradiation and growth hormone deficiency increased the risk of both hypercholesterolaemia (hazard ratio (HR) = 2.7; confidence interval (CI) 1.2-4.4 and HR = 2.3; CI 1.1-4.9; all p < 0.05) and hypertriglyceridaemia (HR = 6.5; CI 1.4-31 and HR = 7.2; CI 1.1-43; all p < 0.05). The risk of hypercholesterolaemia was also higher in CCSs who underwent autologous haematopoietic stem cell transplantation (HR = 3.2; CI 1.7-5.9; p < 0.001) or platinum-based chemotherapy (HR = 2.7; CI 1.5-4.9; p < 0.001), whereas a previous diagnosis of brain tumour (HR = 10; CI 1.2-45; p < 0.05) and anthracyclines exposure (HR = 1.3; CI 1.2-26; p < 0.05) significantly predicted obesity., Conclusion: CCSs show a high and variable risk for developing dyslipidaemia and obesity, depending on cancer diagnosis and treatments. Therefore, they need accurate and tailored control of their cardiovascular risk profile., (© The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

A 29-year-old woman with two mechanical valve prostheses was referred to our institution for sudden and self-resolved diplopia 2 weeks after childbirth. From the beginning of pregnancy, nadroparin was started instead of warfarin. The echocardiogram performed at hospital admission revealed a severe aortic prosthesis regurgitation due to incomplete leaflet apposition with a prosthetic aortic transvalvular gradient increase. Three-dimensional transoesophageal echocardiography revealed a thrombus located between the two prostheses, causing intermittent aortic valve malfunction. Intravenous heparin was started. Three days later, a second transoesophageal echocardiogram revealed a decreased aortic transvalvular gradient, but an oval thrombus adhered to the mitral prosthesis and fluctuating through the prosthetic valve was detected. Tissue plasminogen activator infusion was started. To reduce cerebral embolization, carotid filters used during artery angioplasty were placed in common carotid arteries, left and right. No complication occurred during and after the procedure. With thrombus absence at 30-min transoesophageal echocardiography, filters were removed. The patient continued intravenous heparin until achievement of a therapeutic international normalized ratio range and she was asymptomatic on discharge.

Transcatheter aortic valve implantation (TAVI) is sometimes associated with severe complications due to the unpredictability of such closed-chest procedures. Reported complications include atrioventricular blocks, vascular complications, aortic root rupture, aorto-right ventricular fistulas, and aortic dissections. Herein is presented the case of an 88-year-old female with a late atrioventricular septal defect that developed after TAVI.

Several clinical and procedural factors have been identified as predictors of early and midterm events after transcatheter aortic valve implantation (TAVI), but incidence and prognostic impact of diabetes mellitus (DM), especially insulin treated, on short- and midterm outcomes remain to be defined. All consecutive patients who underwent TAVI at our institutions were enrolled and stratified according to DM status. All-cause mortality at 30 days or in hospital and at follow-up was the primary end point, whereas periprocedural complications, rates of myocardial infarction, stroke, and reintervention at follow-up were the secondary ones. All end points were adjudicated according to the Valve Academic Research Consortium definitions. In all, 511 patients were enrolled: 361 without DM, 78 with orally treated DM, and 72 with insulin-treated DM. Orally treated DM patients were more frequently women, whereas insulin-treated DM patients were younger. Thirty-day Valve Academic Research Consortium mortality was not significantly higher in patients with orally treated DM and insulin-treated DM compared with patients without diabetes (6.4%, 9.7%, and 4.7%, p = 0.09). Bleedings, vascular complications, postprocedural acute kidney injury, and periprocedural strokes were not significantly different in the 3 groups. At midterm follow-up (median 400 days), patients with insulin-treated DM had a significantly higher mortality rate (33.3% vs 18.6%, p = 0.01) and higher myocardial infarction incidence (8.3% vs 1.4%, p = 0.002) if compared with patients without diabetes. Strokes and reinterventions at follow-up were similar in the 3 groups. After multivariable adjustment, insulin-treated DM was independently correlated with death (hazard ratio 2, 95% confidence interval 1.3 to 3.3) and myocardial infarction (hazard ratio 3.73, 95% confidence interval 1.1 to 13). In conclusion, DM does not significantly affect rates of complications in patients who underwent TAVI. Insulin-treated DM, but not orally treated DM, is independently associated with death and myocardial infarction at midterm follow-up and should be included into future TAVI-dedicated scores., (Copyright © 2014 Elsevier Inc. All rights reserved.)

A 60 year-old female underwent tricuspid valve replacement in 2002. Post-operative recovery was complicated by severe post-pericardiotomy-syndrome. Seven years later she underwent transcatheter valve-in-valve implantation through the right jugular vein because of early prosthesis deterioration. Moreover intra-operative transoesophageal echocardiography showed an important right-to-left shunt through the patent foramen ovale that immediately disappeared after the deployment of a 29-mm Sapien-XT. The patient had an immediate and dramatic improvement in day-by-day activities. This case shows that tricuspid valve deterioration can be safely and successfully treated through this approach., (Copyright © 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

The survival rate of heart transplant patients is increasing, underlying the need for accurate predictors of adverse events during clinical follow-up. Myocardial performance index (MPI) is a Doppler-derived index of combined systolic and diastolic function: we assessed the prognostic role of MPI in survival of patients >1 year after heart transplantation (HT). A total of 152 consecutive HT patients referred to our institution were enrolled in this prospective study. Primary endpoints were cardiac death and a composite of major adverse cardiac events (MACE). During follow-up (69 ± 22 months), 68 (44.7%) patients had an adverse event and 20 (13.15%) patients died. Patients with MACE during follow-up showed lower EF (57.3 ± 9.3 vs. 63 ± 6.1; P < 0.001) and higher MPI (0.45 ± 0.19 vs. 0.31 ± 0.13; P < 0.001) at enrolment. MPI and EF were independently related to MACE (OR = 2.2; 95% confidence interval [CI] = 1.01-5.1; and OR = 6.6; 95% CI = 3.5-11.2, respectively) and showed strong diagnostic power (MPI: receiver operating characteristic [ROC] area = 79%, with 79% sensitivity and 81% specificity; EF: ROC area = 77%, with 54% sensitivity and 91% specificity) in the subsequent year. Patients with EF > 50% and MPI < 0.45 at enrolment showed 75% event-free survival 5 years after HT. In HT patients, MPI combined with EF was an accurate means of predicting long-term adverse events., (© 2013, Wiley Periodicals, Inc.)

Objective: This study aims to assess changes in mitral regurgitation (MR) severity after transcatheter aortic valve implantation (TAVI)., Background: Existing data on MR after TAVI are contradictory., Methods: Thirty-five patients with MR graded ≥ 2+ were followed after undergoing TAVI with either the Edwards Sapien or CoreValve device. Echocardiography was performed the week before and 3 months after the procedure. MR was graded on a scale of 0 to 4+, classified as organic or functional, and the effective regurgitant orifice area (EROA) and MR index were calculated., Results: At baseline, MR was graded 4+ in 4 (11.4%) patients, 3+  in 10 (28.6%), and 2+ in 21 (60%). At follow-up, MR was graded at 3+ in 4 (11.4%) patients, 2+ in 8 (22.9%), and 1+ in 19 (54.3%); 4 (11.4%) exhibited no MR. EROA (24.4 ± 11.5 mm(2) pre-TAVI vs. 11.2 ± 10.3 mm(2) post-TAVI, P < 0.001) and MR index (1.9 ± 0.3 pre-TAVI vs. 1.3 ± 0.7 post-TAVI, P < 0.001) were reduced with TAVI, independent of the etiology. MR decreased by at least 1 grade in 28 (80%) patients, with a reduction ≥2 grades in 10 (28.6%) patients; no patient showed a worsened condition. Subgroup analyses showed that the reduction in MR was significant in patients treated with the Edwards Sapien device but not in patients treated with the CoreValve device., Conclusions: This multiparametric echocardiographic evaluation showed that MR improved significantly after TAVI and that this result may be related to the type of valve implanted., (© 2012, Wiley Periodicals, Inc.)

Objectives: Evaluate echocardiographic predictors of pulmonary artery hypertension (PAH) in a prospective cohort of patients with systemic sclerosis (SSc)., Methods: 38 patients with SSc who did not have PAH and significant left heart disease, with peak tricuspid regurgitant velocity (TRV) ≤ 2.8 m/sec and systolic pulmonary artery pressure (sPAP) < 40 mmHg on echo Doppler were enrolled. Patients underwent: clinical assessment, NT-proBNP, and DLco measurements. Echo Doppler evaluation included right ventricular (RV) dimensions, tricuspid annular plan systolic excursion, fractional area change, tricuspid DTI systolic velocity, Tei index, pulmonary flow acceleration time (AcT), ratio of TRV to RV outflow tract time-velocity integral (TVI) and a parameter of disturbed RV ejection (TRV/AcT). After a planned 12-month follow-up we evaluated the predictive value of these parameters for the development of PAH, as demonstrated by right heart catheterization (RHC). Criteria for RHC were TRV ≥ 3 m/sec or sPAP ≥ 40 mmHg., Results: Four patients developed PAH. Only TRV/TVI and TRV/AcT ratios significantly predicted PAH development (TRV/TVI ratio ≥ 0.16 [predefined and ROC confirmed]: OR 99, CI 95%: 4.865-2015, P = 0.004; TRV/AcT ratio ≥ 0.022 [predefined and ROC confirmed]: OR 12.68, CI 95% 1.163-379.3, P = 0.036). Both parameters showed a good diagnostic power (TRV/TVI ratio: ROC area 79%, sensitivity 75%, specificity 97% and diagnostic accuracy 94.74% for cutoff value of 0.16; TRV/AcT ratio: ROC area 75%, sensitivity 75%, specificity 71% and diagnostic accuracy 72% for cutoff value of 0.022)., Conclusions: This prospective study identified increased values of the two ratios TRV/TVI and TRV/AcT as predictors of PAH in SSc., (© 2011, Wiley Periodicals, Inc.)

Objective: One of the drug-eluting stents that have been introduced into clinical practice is the paclitaxel-eluting stent (PES). Several randomised, controlled clinical trials have already been conducted to evaluate the safety and efficacy of this stent, but data regarding clinical practice are still lacking. The aim of this study was to evaluate the safety and efficacy of PESs in a 'real-world' population., Methods: Two hundred and seventy-three patients with a high cardiovascular risk profile and complex coronary lesions were treated with PESs. Each patient was categorised using the following parameters: cardiovascular risk factors, clinical history, clinical presentation, angiographic pattern, and procedural characteristics. Primary endpoints were major adverse cardiac events (cardiovascular death, coronary artery bypass grafting, myocardial infarction, stroke, target vessel revascularisation, target lesion revascularisation, and remote revascularisation)., Results: A low rate of intraprocedural and periprocedural complications was observed. During the clinical follow-up period (mean 10.5 +/- 4.2 months), 78% of patients were event-free. Twenty-six patients (9.8%) underwent target vessel revascularisation, but only 11 of them (4.2%) had target lesion revascularisation. Seven patients (2.7%) had myocardial infarction, and cardiac death occurred in two patients (0.76%). Only one case (0.37%) of subacute stent thrombosis and one case of late stent thrombosis were observed., Conclusions: The present study demonstrates that the use of PESs is safe and effective also in patients with a high cardiovascular risk profile and complex coronary lesions.

Favorable early results of percutaneous drug-eluting stents in unprotected left main (LM) disease are available, but outcome data beyond 6 to 10 months are lacking. We evaluated the long-term results of sirolimus-eluting stents (SESs) in patients with LM disease. From November 2002 to December 2004, consecutive patients with LM disease, without contraindications to double antiplatelet therapy and undergoing SES implantation, were enrolled prospectively. The primary end point of the study was occurrence of major adverse cardiovascular events. In total 85 patients were treated with 118 SES and followed for 595 +/- 230 days. Event-free survival rates at 1 year and 2 years were 85.5% and 78.6%, respectively. Only 2 deaths occurred overall (2.4%), the first in-hospital in a very high-risk patient according to the European System for Cardiac Operative Risk Evaluation and the second in a patient with severe systolic dysfunction already at the index procedure). Myocardial infarction was adjudicated in 3 patients (3.6%), 2 occurring periprocedurally and 1 during follow-up for a de novo nontarget lesion. There were 7 (10.8%) target lesion revascularizations at 24 months, with all but 1 percutaneous and in a subject with bifurcation LM disease at baseline. At 9-month angiography, late loss was 0.15 +/- 0.81 mm and restenosis rate was 8.2%. An increased incidence of adverse events was noted in patients undergoing SES after dilation with extremely oversized balloons. No case of stent thrombosis was reported. In conclusion, this single-center experience suggests that percutaneous use of SESs to treat LM disease in unselected high-risk patients is safe and effective even 1 year after implantation.

Background: Studies focusing on short- and mid-term follow up support the beneficial role of sirolimus-eluting stents (SES) in the treatment of in-stent restenosis (ISR), yet no long-term safety and/or efficacy data are available., Methods: Patients with ISR following bare-metal stenting (BMS) and treated with SES were prospectively studied. Baseline, procedural, and in-hospital data were appraised. The primary endpoint was the rate of major cardiovascular events (MACE) at long-term follow up (>9 months). Secondary endpoints were the individual contributors to MACE., Results: A total of 180 SES were implanted to treat 138 consecutive patients. Procedural success was achieved in all patients without in-hospital death, acute stent thrombosis, stroke, or urgent coronary artery bypass. During follow up, MACE occurred in 5.8% of patients at 6 months, 14.3% at 12 months, and 25% at 24 months. Specifically, all-cause mortality was 1.7% at 6 months, 3.5% at 12 months, and 4.8% at 24 months, for a total of 5 deaths. Target vessel revascularization occurred at 6, 12, and 24 months in 4.2%, 11.2%, and 15.9% of patients, respectively, while target lesion revascularization (TLR) alone accounted for 3.4% at 6 months, 9.6% at 12 months, and 11% at 24 months. Three case of myocardial infarction occurred during follow up (2.2%), without any surgical revascularization or stent thrombosis., Conclusions: Treatment of ISR with SES appears safe and effective, even if a 10% annual rate of MACE can be expected, with a sizable portion of these due to apparently nontarget lesion events.

Objective: The follow-up patency rates and associated clinical and angiographic variables following stenting of very long (> or =50 mm) and chronic (>6 months) total coronary artery occlusive lesions are not well documented. The aim of the present study was to evaluate the early results and mid-term outcomes following angioplasty of such lesions., Methods: Between January 2000 and June 2002, we treated 278 chronic coronary occlusions. Of these, eighty-nine occlusions (89 patients) were with lesions > or =50 mm long; these patients constituted the study population., Results: Mean duration of occlusion was 7 +/- 2 months (range, 6-13 months). Procedural success was obtained in 81 patients. A total of 211 coronary stents (2.6 +/- 1.1 stents/patient) were implanted, and mean stent length was 59 +/- 9 mm. In 3 patients, TIMI flow 1-2 was observed after stent implantation. Thus, the angiographic success was considered to be 78/89 patients (87.6%). Periprocedural major adverse cardiac events occurred in 6 patients (6.7%). Clinical success was obtained in 74 patients (83%). During a 9.6 +/- 2 month follow-up, forty-three patients (55.1%) remained angina free, thirty-two (41%) had recurrence of angina, three patients (3.9%) had a new myocardial infarction and no deaths were reported. Target vessel revascularization was required in 34 patients (43.6%). Angiographic follow-up was obtained in 70 patients (90%) at a mean of 7.4 +/- 2 months. Restenosis was observed in 36 patients (51%), six of whom had reocclusion. A significant correlation was observed between the need for reintervention and stent length (R 0.52), residual stenosis (R 0.73) and diabetes mellitus (0.68)., Conclusion: Although coronary artery stenting for very long (> or =50 mm) chronically occlusive lesions is feasible, safe and associated with a low incidence of periprocedural adverse clinical events, these complex and expensive procedures still have a high 6-month restenosis rate. These results might be significantly improved with the advent of drug-eluting stents.