Patients who suffer from diabetes mellitus and present coronary artery disease are at a higher risk of cardiovascular events. The coronary arteries of diabetic patients present a diffuse process of atherosclerosis with frequent distal involvement, being prone to acute cardiovascular events. Diabetics present an increased rate of developing coronary artery remodeling, negative remodeling being representative for this class of patients; this process is characterized by vessel shrinkage and an increased rate of coronary calcium accumulation that is a predictor for cardiovascular risk. Currently, it is desired to improve the treatment of diabetic patients with bioresorbable vascular scaffolds (BVS), because of their reduced risk of restenosis and the ability to restore coronary function, including vasomotion, adaptive shear stress, and expansive remodeling. Optical coherence tomography, intravascular ultrasound and multi-slice computed tomography are imaging techniques used for a high accuracy of diagnosis in coronary artery disease. This manuscript is a review that aims to highlight imaging techniques used for evaluating the functional impact of coronary lesions in diabetic patients who underwent coronary PCI with bioresorbable scaffolds and to describe the functional markers that show the specificity for predicting coronary artery disease.
Radiofrequency catheter ablation of parahisian accessory pathways in pre-excitation syndrome is a challenging task, due to the extremely high risk of complete atrioventricular block. In this brief report we describe the case of a 32 year-old man presenting a parahisian accessory pathway, who has been successfully treated by radiofrequency ablation. Radiofrequency catheter ablation using low-power radiofrequency current is considered to be the most appropiate method of ablation in adult patients.
Background: Epicardial fat has been recently identified as a major player in the development of the atherosclerotic process.
Study aim: The aim of this study was to correlate the epicardial fat volume (EFV), determined by Multisclice CT, and the severity of the coronary lesions, expressed by the Coronary Calcium Score (CCS) and Syntax Score (SxS) in patients with established coronary artery disease (CAD).
Material and methods: One-hundred-twenty-six patients underwent Multisclice 64 CT assessment of coronary lesions and epicardial fat quantification. Calculation of CCS was performed on all the three coronary vessels and was followed by determination of SxS according to guidelines. The patients were divided into 2 groups: Group 1 – patients with CCS >400 (n = 26), and Group 2 — patients with CaS <400 (n = 100).
Results: The mean age of the study population was 65.32 years for Group 1 and 54 years for Group 2 (p <0.0001). However, patients >65 years of age had a high CCS in a more significant extent than younger patients (50% in Group 1 vs. 17% in Group 2, p = 0.0115). Female gender was recorded in 48% of cases in Group 2 and in 19% of cases in Group 1 (p = 0.008). Several factors were identified in a higher extent in the group with high CCS as compared with the group with low CCS, such as the presence of significant stenosis (>50%) of the left anterior descending artery (LAD) (46% vs. 9%, p <0.0001), the presence of multi-vessel coronary disease (50% vs. 5%, p <0.0001) and a high SxS, above 23 (23% vs. 4%, p = 0.006). The epicardial fat volume was 117.81 ± 40.4 ml (95% CI: 97.98–138.2 ml) in Group 2 and 89.77 ± 37.7 ml (95% CI: 80.4–101.5 ml) in Group 1 (p = 0.0033).
Conclusions: Epicardial fat volume could represent a new imaging-derived biomarker, useful for classification of the severity of coronary artery disease, increased values of EFV being associated with other biomarkers of disease severity, such as calcium score.
Introduction: Peripheral artery disease, a frequent consequence of atherosclerosis, is usually associated with concomitant ischaemic coronary artery disease and with a high rate of cardiovascular mortality.
Material and methods: The study population consisted of 24 patients, admitted to our clinic with peripheral artery disease, 10 of them with critical limb ischaemia. In all cases, cardiovascular risk factors, left ventricular dysfunction and ejection fraction were analyzed. Peripheral Multislice Angio CT examination was used to determine the TASC class and to assess the peripheral arterial lesions. The Coronary Calcium Score and the Syntax Score were determined with angio CT of the coronary arteries.
Results: Patients were between 39 and 84 years of age, and 54% were in Fontaine class 2B, 21% in Fontaine class 3 and 25% in Fontaine class 4. 12.5% of patients presented TASC class A, 33.3% TASC class B, and 54.2% TASC class C. Coronary Calcium Scores were between 0 and 100 in 16.6% of patients, between 100 and 400 in 41.8%, and >400 in 41.6% of patients. The SYNTAX Score was <22 in 54% of patients, between 22 and 32 in 37.5%, and >32 in 8.5% of patients. A significant correlation was found between the Coronary Calcium Score and the SYNTAX Score (r = 0.82, p = 0.03). The Syntax Score was 22.43 ± 3.2 in TASC A patients, 26.2 ± 5.4 in TASC B patients, 32.1 ± 2.3 in TASC C patients (p = 0.005).
Conclusions: The severity of coronary artery disease characterized by the Syntax Score, by the presence of left main stenosis and segmental left ventricular hypokinesis presents significant correlation with the severity of peripheral artery disease, characterized by the TASC classification.
Introduction: Coronary artery disease (CAD) is the leading cause of death worldwide and is associated with a significant socio-economic impact. In many cases, patients are treated with implanted coronary stents that carry a significant risk for reobstruction. The aim of our study was to evaluate the importance of coronary computed tomography angiography (CCTA) in evaluating the significance of in-stent restenosis lesions and for establishing the indication for reintervention in these cases.
Materials and methods: We evaluated 25 patients who underwent CCTA examination. We determined the contrast density, expressed in Hounsfield units at two levels, proximal and distal to the stent.
Results: There were no statistically significant differences between the study groups in terms of gender (41.17% females in Group 1 vs. 37.5% in Group 2, p = 1), presence of hypertension (41.17% in Group 1 vs. 62.5% in Group 2, p = 0.31), smoking status (41.17% in Group 1 vs. 37.5% in Group 2, p = 0.31), incidence of dyslipidemia (47.05% vs. 50%, p = 1) and diabetes mellitus (35.29% vs. 0%, p = 0.31). However, the age of the study population was significantly higher in the groups with significant ISR (58.94 ± 8.35 vs. 47.25 ± 11.2, p = 0.02). Patients who showed significant angiographic in-stent stenosis (more than 70%) were found to have a higher transluminal attenuation gradient, compared with those with less severe lesions (14.5 ± 5.4 vs. 5.14 ± 2.4, p = 0.02).
Conclusions: The transluminal attenuation gradient, assessed by CCTA is a non-invasive-derived parameter that can help the clinician to determine the right time for revascularization in case of in-stent restenosis.
Since the introduction of the new concepts of plaque vulnerability and patient vulnerability, many researchers have focused on different biomarkers that can represent predictors for coronary plaque instability. One of the features that characterize the vulnerable coronary plaque is positive remodeling, which can be easily identified by computed tomography angiography, a noninvasive procedure, or by other invasive methods such as intravascular ultrasound. This review aims to describe the assessment of positive remodeling as a marker of coronary plaque instability and the differences between computed tomography angiography and intravascular ultrasound in investigating this new biomarker.
Background: The acute loss of myocardium, following an acute myocardial infarction (AMI) leads to an abrupt increase in the loading conditions that induces a pattern of left ventricular remodeling (LVR). It has been shown that remodeling occurs rapidly and progressively within weeks after the AMI.
Study aim: The aim of our study was to identify predictors for LVR, and find correlations between them and the cardiovascular (CV) risk factors that lead to remodeling.
Material and methods: One hundred and five AMI patients who underwent primary PCI were included in the study. A 2-D echocardiography was performed at baseline (day 1 ± 3 post-MI) and at 6 months follow-up. The LV remodeling index (RI), was defined as the difference between the Left Ventricular End-Diastolic diameter (LVEDD) at 6 months and at baseline. The patients were divided into 2 groups, according to the RI: Group 1 – RI >15% with positive remodeling (n = 23); Group 2 – RI ≤15% with no remodeling (n = 82).
Results: The mean age was 63.26 ± 2.084 years for Group 1 and 59.72 ± 1.267 years for Group 2. The most significant predictor of LVR was the female gender (Group 1 – 52% vs. Group 2 – 18%, p <0.0001). Men younger than 50 years showed a lower rate of LVR (Group1 – 9% vs. Group 2 – 20%, p = 0.0432). In women, age over 65 years was a significant predictor for LVR (Group 1 – 26% vs. Group 2 – 9%, p = 0.0025). The CV risk factors associated with LVR were: smoking (p = 0.0008); obesity (p = 0.013); dyslipidemia (p = 0.1184). The positive remodeling group had a higher rate of LAD stenosis compared to the no-remodeling group (48% vs. 26%, p = 0.002). The presence of multi-vessel disease was shown to be higher in Group 1 (26% vs. 9%, p = 0.0025). The echocardiographic parameters that predicted LVR were: LVEF <45% (p = 0.048), mitral regurgitation (p = 0.022), and interventricular septum hypertrophy (p <0.0001).
Conclusions: The CV risk factors correlated with LVR were smoking, obesity and dyslipidemia. A >50% stenosis in the LAD and the presence of multi-vessel CAD were found to be significant predictors for LVR. The most powerful predictors of LVR following AMI were: LVEF <45%, mitral regurgitation, and interventricular septum hypertrophy.
Introduction: In patients with out-of-hospital cardiac arrest (OHCA) complicating an ST-segment elevation myocardial infarction (STEMI), the survival depends largely on the restoration of coronary flow in the infarct related artery. The aim of this study was to determine clinical and angiographic predictors of in-hospital mortality in patients with OHCA and STEMI, successfully resuscitated and undergoing primary percutaneous intervention (PCI).
Methods: From January 2013 to July 2015, 78 patients with STEMI presenting OHCA, successfully resuscitated, transferred immediately to the catheterization unit and treated with primary PCI, were analyzed. Clinical, laboratory and angiographic data were compared in 28 non-survivors and 50 survivors.
Results: The clinical baseline characteristics of the study population showed no significant differences between the survivors and non-survivors in respect to age (p=0.06), gender (p=0.8), the presence of hypertension (p=0.4), dyslipidemia (p=0.09) obesity (p=1), smoking status (p=0.2), presence of diabetes (p=0.2), a clinical history of acute myocardial infarction (p=0.7) or stroke (p=0.17). Compared to survivors, the non-survivor group exhibited a significantly higher incidence of cardiogenic shock (50% vs 24%, p=0.02), renal failure (64.3% vs 30.0%, p=0.004) and anaemia (35.7% vs 12.0%, p=0.02). Three-vessel disease was significantly higher in the non-survivor group (42.8% vs. 20.0%, p=0.03), while there was a significantly higher percentage of TIMI 3 flow postPCI in the infarct-related artery in the survivor group (80.% vs. 57.1%, p=0.03). The time from the onset of symptoms to revascularization was significantly higher in patients who died compared to those who survived (387.5 +/- 211.3 minutes vs 300.8 +/- 166.1 minutes, p=0.04), as was the time from the onset of cardiac arrest to revascularization (103.0 +/- 56.34 minutes vs 67.0 +/- 44.4 minutes, p=0.002). Multivariate analysis identified the presence of cardiogenic shock (odds ratio [OR]: 3.17, p=0.02), multivessel disease (OR: 3.0, p=0.03), renal failure (OR: 4.2, p=0.004), anaemia (OR: 4.07, p=0.02), need for mechanical ventilation >48 hours (OR: 8.07, p=0.0002) and a duration of stay in the ICU longer than 5 days (OR: 9.96, p=0.0002) as the most significant independent predictors for mortality in patients with OHCA and STEMI.
Conclusion: In patients surviving an OHCA in the early phase of a myocardial infarction, the presence of cardiogenic shock, renal failure, anaemia or multivessel disease, as well as a longer time from the onset of symptoms or of cardiac arrest to revascularization, are independent predictors of mortality. However, the most powerful predictor of death is the duration of stay in the ICU and the requirement of mechanical ventilation for more than forty-eight hours.
Pulmonary embolism (PE) remains a common and potentially life-threatening cardiovascular emergency. Systemic thrombolysis with intravenous infusion of a thrombolytic agent is generally recommended for treatment of high risk PE. However, this method has known limitations in the presence of high bleeding risk. Catheter-directed thrombolysis has the potential to achieve the same benefits as systemic thrombolysis, with a lower risk of haemorrhage. The case presented is of a 67-year-old male patient with a high risk of pulmonary embolism and contraindications for systemic thrombolysis, in whom the presence of severe comorbidities presented an increased risk of surgical embolectomy, who was successfully treated by catheter-directed thrombolysis.
Introduction: In-stent restenosis (ISR) is traditionally associated with neointimal hyperplasia. However, recent studies have suggested that an underlying progression of the atherosclerotic process called neoatherosclerosis, different from intimal proliferation, could be involved in ISR development. In this study the aim was to compare the characteristics of the neoatheromatous plaque evidenced by Multislice Angio Computed Tomography, Optical Coherence Tomography (OCT) and Virtual Histology Intravascular Ultrasound (VH-IVUS) with the characteristics of de-novo lesions in native coronary vessels of patients with ISR. Material and methods: This is a prospective single-center pilot study in which patients presenting with acute chest pain and having at least one symptomatic bare-metal stent (BMS) restenosis at six months to one year after BMS implantation, were enrolled. The characteristics of the neointimal tissue developed within the implanted stents using Acio CT, OCT and VH-IVUS were studied. Results: In total, 27 patients with 38 coronary BMS were included in the study, in whom 27 ISR lesions and 43 lesions in native coronary vessels were identified. Angio CT examination revealed that atheromatous plaques responsible for ISR tend to have a larger volume compared with native lesions located in the same coronary vessel (plaque volume 91.2 mm3 for ISR vs. 60.4 mm3 for native vessels, p <0.0001). Additionally, they show more low density plaques compared to native coronary lesions located in the same coronary vessel (33.9 mm3 vs. 18.2 mm3 for the volume of the plaque with density <30 HU, p <0.0001). Plaques responsible for ISR exhibit a higher lipid content than native ones (41.1% vs. 22.9%, p = 0.05). OCT analysis indicated an irregular shaped vascular lumen in 44.4% of ISR lesions compared to 25.6% of de-novo lesions (p = 0.1). Conclusions: Neoatherosclerosis within the implanted coronary stents is associated with signs of plaque vulnerability to a significantly higher extent than the atheromatous plaques in native coronary arteries in patients with ISR presenting with an acute coronary syndrome.