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Item does not contain fulltext BACKGROUND: In 10% to 15% of patients with ST-segment elevation myocardial infarction (STEMI), concurrent coronary chronic total occlusion (CTO) in a non-infarct-related artery is present and is associated with increased morbidity and mortality. OBJECTIVES: The EXPLORE (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Elevation Myocardial Infarction) trial evaluated whether patients with STEMI and concurrent CTO in a non-infarct-related artery benefit from additional percutaneous coronary intervention (PCI) of CTO shortly after primary PCI. METHODS: From November 2007 through April 2015, we enrolled 304 patients with acute STEMI who underwent primary PCI and had concurrent CTO in 14 centers in Europe and Canada. A total of 150 patients were randomly assigned to early PCI of the CTO (CTO PCI), and 154 patients were assigned to conservative treatment without PCI of the CTO (no CTO PCI). Primary outcomes were left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) on cardiac magnetic resonance imaging after 4 months. RESULTS: The investigator-reported procedural success rate in the CTO PCI arm of the trial was 77%, and the adjudicated success rate was 73%. At 4 months, mean LVEF did not differ between the 2 groups (44.1 +/- 12.2% vs. 44.8 +/- 11.9%, respectively; p = 0.60). Mean LVEDV at 4 months was 215.6 +/- 62.5 ml in the CTO PCI arm versus 212.8 +/- 60.3 ml in the no-CTO PCI arm (p = 0.70). Subgroup analysis revealed that patients with CTO located in the left anterior descending coronary artery who were randomized to the CTO PCI strategy had significantly higher LVEF compared with patients randomized to the no-CTO PCI strategy (47.2 +/- 12.3% vs. 40.4 +/- 11.9%; p = 0.02). There were no differences in terms of 4-month major adverse coronary events (5.4% vs. 2.6%; p = 0.25). CONCLUSIONS: Additional CTO PCI within 1 week after primary PCI for STEMI was feasible and safe. In patients with STEMI and concurrent CTO, we did not find an overall benefit for CTO PCI in terms of LVEF or LVEDV. The finding that early CTO PCI in the left anterior descending coronary artery subgroup was beneficial warrants further investigation. (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Segment Elevation Myocardial Infarction; NTR1108).

Contains fulltext : 81893.pdf (Publisher’s version ) (Closed access) OBJECTIVES: This study sought to comprehensively identify predictors of stent thrombosis (ST). BACKGROUND: Given the devastating consequences of ST, efforts should be directed toward risk stratification to identify patients at highest risk for ST. METHODS: Consecutive patients with angiographic ST were enrolled. Patients who did not suffer from a ST were randomly selected in a 2:1 ratio and were matched for: 1) percutaneous coronary intervention (PCI) indication; 2) same date of index PCI; and 3) same interventional center. RESULTS: Of 21,009 patients treated with either a bare-metal or drug-eluting stent, 437 patients (2.1%) presented with a definite ST. A total of 140 STs were acute, 180 were subacute, 58 were late, and 59 were very late. Undersizing of the coronary stent, Thrombolysis In Myocardial Infarction flow grade or=50% to

Contains fulltext : 53226.pdf (Publisher’s version ) (Closed access) BACKGROUND: In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI, few data exist on the magnitude of platelet activation, aggregation and dosing of glycoprotein (GP) IIb/IIIa receptor inhibitors. METHODS : Sixty STEMI patients were randomised to abciximab, to high-dose tirofiban or to no additional GP IIb/IIIa inhibitor treatment. Platelet activation (P-selectin expression) was measured using flow cytometry and the level of inhibition of platelet aggregation was assessed using the Plateletworks assay. Additionally, the PFA-100 with the collagen/adenosine-diphosphate cartridge (CADP) was used to compare the levels of platelet inhibition. All measurements were performed at baseline (T(0)), immediately after (T(1)), 30 minutes (T(2)), 60 minutes (T(3)) and 120 minutes (T(4)) after primary PCI. RESULTS : The level of platelet activation in both GP IIb/IIIa receptor inhibitor treated groups was significantly lower compared with the control group at all time points after primary PCI (p=0.04). Also the administration of the currently recommended dose of abciximab resulted in significantly lower levels of inhibition of aggregation compared with high-dose tirofiban (p

Interventional cardiology is an expanding field within cardiovascular medicine and today it is generally accepted that cardiologists require specific training, knowledge and skills. Hospitals where coronary interventions are performed must be properly equipped and able to provide specialised care. Percutaneous coronary interventions are frequently used for coronary revascularisation. The public should have confidence in the uniformity of high quality care. Therefore, such quality of care should be maintained by certification of the individual operators, general guidelines for institutional requirements and formal audits. The Netherlands Society of Cardiology (NVVC) will be implementing a new registration system for cardiologists with a subspecialisation that will include registration for interventional cardiology. The NVVC asked the Working Group of Interventional Cardiology (WIC) to update the 1994 Dutch guidelines on operator and institutional competence, and requirements for training in interventional cardiology in order to incorporate them into the official directives. The present guidelines represent the expert opinion of the Dutch interventional cardiology community and are in accordance with international regulations. After two rounds of discussion, the NVVC approved the guidelines in November 2004 during the autumn meeting.

Item does not contain fulltext OBJECTIVES: The goal of this research was to study the effect of planned angiography on late clinical outcome after percutaneous coronary intervention. BACKGROUND: It is still largely unknown whether planned follow-up angiography after coronary angioplasty influences late outcome. METHODS: Randomization assigned 527 patients to clinical follow-up alone and 531 to clinical and six-month angiographic follow-up. The effect of planned angiography on clinical outcome at one and three years after coronary angioplasty was studied. RESULTS: The two groups were well matched. At one year, more events occurred in the angiographic group than in the clinical group: 122 (23.2%) versus 88 (16.7%) (p = 0.01). While the incidence of death or myocardial infarction (MI) was similar at one year, the revascularization rate was higher in the angiographic group: 113 (21.3%) versus 67 (12.7%) (relative risk = 1.7, 95% confidence interval: 1.3 to 2.3, p = 0.0003). At three years, still more events had occurred in the angiographic group (146 [34.5%] vs. 114 [26.3%], p = 0.03). More reinterventions did not improve late survival. However, there was a nonsignificant reduction in MI (7 [1.3%] vs. 13 [2.5%], p = NS) and a significant improvement in functional class at the end of follow-up (freedom from angina 81% vs. 74%, p = 0.03). The effect of follow-up angiography on the reintervention rate was similar for stented and nonstented patients. CONCLUSIONS: Planned follow-up angiography to evaluate the late results of coronary intervention led to a 1.7 times higher reintervention rate. This effect was similar for stented and nonstented patients. More reinterventions did not improve survival but tended to reduce the incidence of MI and led to a significantly better functional class at follow-up.

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This thesis reports the efficacy and safety of different devices in percutaneous patent foramen ovale- (PFO) and atrial septal defect (ASD) closure during long-term follow-up. A PFO is a tunnel-like opening between the left- and right atrium. During Valsalva-like maneuvers, such as coughing, a right-to-left shunt (RLS) can occur, creating the possibility for a peripheral embolus to access the systemic circulation resulting in a stroke. Percutaneous PFO closure has proven to be safe and effective for several devices during long-term follow-up, whereas other devices have been taken off market because they proved to be ineffective and less safe. Migraine is a common neurological disease with an immense disability burden. Patients with migraine with aura (MA) are known to have a higher risk for strokes. This seems to be related to the presence of a PFO, especially in combination with an atrial septal aneurysm (ASA). An ASD is a congenital defect of the atrial septum. A left-to-right shunt (LRS) is present in these patients due to the higher left atrial pressure compared to the right atrial pressure. An LRS causes right ventricle pressure- and/or volume overload. Percutaneous ASD closure is safe and effective in these patients using different devices. Image guiding during these procedures is essential. Transesophageal echocardiography (TEE) is the gold standard for these procedures, but has some important downsides such as general anesthesia, inconvenience of the patient and possible complications. Micro-TEE has proven to be safe and effective during these procedures as well, but less downsides. An important downside however is that micro-TEE does not have three-dimensional view possibilities. The aims of this thesis were to study the safety and efficacy for different devices in percutaneous ASD- and PFO closure during long-term follow-up. Further, comparing TEE and micro-TEE guiding during these procedures. Also, to study the association between migraine, presence of a PFO and septal anatomy.

Chronic total coronary occlusions (CTO) remain the most complex lesions for percutaneous revascularization. Historically, percutaneous coronary intervention of CTO was hampered by high rates of restenosis and reocclusions. The introduction of drug-eluting stents significantly improved the treatment of CTO-PCI by reducing the rate of restenosis and reocclusions. In this thesis we investigated bare metal stents and first, second -and third-generation drug-eluting stents (DES) in CTO. In the first part we focus on the efficacy and clinical safety of these stents in three multi-centre randomized clinical trials. In Chapter 2 , we showed that intima proliferation is continuous at the long-term with first generation and not halted by DES. In Chapter 3 and 4 we showed worse angiographic outcome with second-generation Endeavor zotarolimus-eluting stents compared to first-generation Sirolimus-eluting stents (SES). On the other hand, non-inferiority could be established with second-generation Resolute zotarolimus-eluting stent compared to SES. In Chapter 4-8 we compared the second-generation thin-strut everolimus-eluting stent (EES) to the third-generation ultra thin-strut sirolimus-eluting stent (Hybrid SES). At 9-month, primary non-inferiority angiographic endpoint was not met for Hybrid SES with higher rate of binary restenosis compared to EES. The difference in outcome was mostly attributed in the sub-group of smaller stent diameters. EES showed higher rates of uncovered stent struts, on the other hand Hybrid SES demonstrated higher rates of malapposition and evaginations. In the last part Chapter 9 and 10 , we showed that residual distal stenosis behind the CTO could be safely deferred from immediate stenting and that continuous thermodilution is a promising technique to investigate the coronary physiology.

This thesis describes the strategy of the management and treatment of patients with concomitant significant carotid and coronary artery disease. The short and long term outcome of a single centre experience is reported and compared with general common practise. The author conducted different observational trials in order to provide more information to justify the institutional policy. More particularly, the use of embolic protection devices in asymptomatic patients is questioned, the optimal antiplatelet therapy is investigated and the use of CT perfusion to better understand individual cerebral hemodynamics is examined. Patients with asymptomatic carotid stenosis undergoing CAS-CABG have a decreased stroke and death rate compared to those undergoing isolated CABG or CEA-CABG. CAS may be a safer carotid revascularization option for patients with asymptomatic carotid stenosis requiring CABG in terms of postoperative stroke prevention. In patients with symptomatic carotid stenosis available data are confounding, therefore the preferred strategy remains unclear, however carotid revascularization will result incontestably in higher periprocedural complication rates. Although level I evidence would be ideal to determine the best treatment strategy for patients who require combined treatment of carotid and coronary arterial disease, the design and implementation of a multicenter randomised clinical trial has been proven impractical and unrealistic. The heterogeneity of patients with varying degrees of coronary and carotid artery disease and the preference of carotid intervention are the main limitations for such a trial. Nevertheless, when conceived, such a trial should compare isolated CABG (including on and off pump surgery) with CAS-CABG and CEA-CABG in symptomatic and asymptomatic patients separately. Optimal treatment of patients with concurrent carotid and coronary artery disease remains unresolved despite extensive publications during the last 30 years. Although only 40% to 50% of strokes after CABG are ipsilateral to an existing carotid lesion, carotid revascularization is one of the few available options to reduce the excessive stroke and death rates in patients with combined disease.

This thesis reports on the application of several new devices for percutaneous treatment of structural heart disease. A patent foramen ovale (PFO) is a tunnellike communication between the right and the left atrium and has been associated with the occurrence of cryptogenic stroke. PFO closure has proven its efficacy in preventing recurrent TIA or stroke. An atrial septal defect (ASD) occurs when a part of the interatrial septum is missing and is characterized by a left-to-right shunt, resulting in volume overload of the right heart. Percutaneous closure has become common practice. New devices for PFO and ASD closure are being constructed to facilitate the procedure and to lower the complication rate. Mitral valve regurgitation (MR) is an important clinical issue. Less invasive transcatheter techniques are proposed as an alternative treatment option in highsurgical- risk patients. The aims of this thesis were to study the safety and the efficacy if this new devices and techniques. The general discussion describes the different treatment options for PFO, ASD, and MR. We provide an overview of the literature with implementation of our study results, highlighting new techniques with recommendations for further investigation.