487 LEFT MAIN TRIFURCATION RESTENOSIS: A COMBINED STRATEGY FOR A COMPLEX ANATOMICAL SCENARIO

Unprotected left main trifurcations (ULMT) are highly challenging lesions for the interventionalist. There is still no evidence on the best revascularization strategy, and the risk of short-term procedural complications and long-term adverse outcomes remains high.

We report the case of a 62-years-old with multiple risk factors and a high bleeding risk attributable to severe pancytopenia. Due to an episode of unstable angina, he underwent coronary angiography showing a left main stem (LM) trifurcation with critical ostial left anterior descending (LAD) stenosis, and a proximal LAD sub-occlusive lesion extending to the ostium of the first diagonal (D1) Percutaneous coronary intervention (PCI) consisted of intravascular ultrasound (IVUS)-guided deployment of two drug-eluting stents (DES) from LM to mid-LAD.

One year later he was admitted for chest pain relapse. Coronary angiogram demonstrated critical in-stent restenosis at the proximal LAD and sub-occlusions of ostial ramus intermediate (RI) and ostial circumflex (Cx) (Figure 1).

Re-do PCI consisted of multiple pre-dilations and deployment of a DES on proximal-mid LAD within the previous stent, with two sequential triple kissing inflations on LAD-RI-Cx (Figure 2). Angioplasty on RI and Cx was accomplished with two drug-coated balloons (DCBs) kissing inflation, followed by final triple kissing, with an optimal angiographic result (Figure 3).

In our opinion, the combined use of DCBs and main branch stenting, further optimized by multiple triple kissing balloons, seems to be the most harmonious approach to treat such complex coronary lesions, where the use of multiple stenting strategies might be an overly cumbersome strategy, especially when an intrinsic bleeding risk makes long or powerful anti-thrombotic protocols not feasible.

Mitral Valve Stenosis after Transcatheter Aortic Valve Replacement: Case Report and Review of the Literature

Mitral stenosis is a rare and potentially severe complication of transcatheter aortic valve replacement (TAVR). Given the anatomic coupling and interdependence of the aortic and mitral valves, it comes by itself that procedures (either surgical or percutaneous) involving the aortic valve imply the risk of altering mitral valve function. Indeed, transcatheter aortic prostheses may impair adequate anterior mitral leaflet (AML) opening, especially when implanted in a "low" position, thus resulting in high transvalvular gradients. Hereby, we report the case of a 71-year-old male with symptomatic severe aortic stenosis and a history of previous surgical mitral valve repair who underwent TAVR with a self-expandable prosthesis. Notwithstanding an acceptable angiographic position, the prosthetic frame was shown to interfere with the AML, as evidenced by augmented transmitral gradients; nonetheless, pulmonary artery pressures remained unchanged, and the patient experienced symptomatic improvement. Therefore, a conservative approach was chosen and the patient was discharged home after medical therapy optimization. Moreover, we provide a review of the available literature regarding the incidence, predictors and possible management of this infrequent complication.

Anatomical patterns of patent foramen ovale (PFO): do they matter for percutaneous closure?

AIM

The aim of this study was to describe and classify the various anatomical pattern of patent foramen ovale (PFO) with transesophageal echocardiography (TEE) and to relate such classification to the selection of PFO closure devices.

METHODS

This study enrolled 216 PFO patients (118 females) mostly with previous cryptogenic stroke or transitory ischemic attack (TIA) who underwent percutaneous closure of PFO with deep sedation under TEE control. Anatomical patterns were classified as follows: simple: PFO characterised by central/superior eccentric shunt or with a valve mechanism (45%); reduse: widely redundant septum primum (22%); ASA: atrial septal aneurysm (11%); EASA: entire atrial septal aneurysm (1.4%); CRIB: cribriform septum primum (9%); tunnel: tunnel between septum primum and secundum >10 mm (11%). Degree of right-to-left shunt, either at basal condition or at Valsalva manoeuvre, was classified as: 1=mild (45%); 2=moderate (42%); 3=severe (13%). Additional right-atrium anatomical features are also described.

RESULTS

Procedure was successful in 100% of the cases. At follow-up recurrent TIA occurred in two patients. Residual shunts were present in 4.9% of the patients after Valsalva manoeuvre. Palpitations were reported in 4%.

CONCLUSIONS

Closing the PFO choosing the device following strict anatomical criteria based on TEE assessment allowed excellent immediate and late results minimizing residual shunts.

Bevacizumab (Bev), irinotecan (IRI), folinic acid (FA), and 5-fluorouracil (FU) every 2 weeks (BIFF regimen) as first-line treatment for metastatic colorectal cancer (MCRC) patients (pts): The SICOG experience

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Background: The IRIFAFU regimen produced in MCRC pts a consistent activity (RR, 33% [95% CI, 27–39%], PFS, 7.4 [95% CI, 6.5–8.3] mo.) in 2 consecutive randomized SICOG trials . Bev was proven to significantly improve the efficacy of IFL regimen. Here we report the safety and activity results of the BIFF regimen as first-line treatment of MCRC. Patients: From Feb 2007 to Jul 2008, 95 pts with MCRC were treated: so far, 85 pts were evaluated for safety: M/F were 47/38, median age (range) was 64 (35–78) yrs. Fifty-six pts had a colon, and 29 pts a rectal carcinoma. ECOG PS was 0 (63 pts, 74%), or 1 (22 pts, 26%). Thirty-four (40%) pts had 1 site, 33 (39%) 2 sites, and 18 (21%) pts ≥3 sites of disease. Liver was involved in 66 (78%), lung in 23 (24%) pts. Twenty-one (25%) pts had an unresected primary (colon 13, rectum 8). Bev 5 mg/kg (1-h), and IRI 180 mg/sqm (1-h) were given IV on day 1, 6S-FA 250 mg/sqm (2-h), and FU 850 mg/sqm (bolus) were given IV on day 2 biweekly for a maximum of 12 cycles. Bev was continued until progression, severe toxicity, or refusal. Results: A median of 9 (range, 1–12) cycles of BIFF were delivered. G4 hematologic toxicity was: neutropenia (21%), and febrile neutropenia (10%). G≥3 non-hematologic toxicity was: diarrhea 15%, vomiting 7%, stomatitis 4%, hypertension 1%. No severe episodes of bleeding were registered. Among 81 assessable pts, 5 CRs (3 in liver, 1 in liver & nodes, 1 in liver & lung), and 41 PRs were registered, giving a RR of 57% (95% CI, 45–68%). Overall, 71/81 (88%, 95% CI, 77–93%) pts obtained a disease control. Liver mets resection, or primary resection, was safely performed in 3 pts and in 2 pts, respectively. After a median follow- up of 12 (range, 6–24) mo., median FFS was 8.4 (95% CI, 6.8–10.0), and median PFS was 14.1 (95% CI, 9.6–18.6) mo. With only 14 deaths, OS results are still immature. Conclusions: Unexpected side effects of the BIFF regimen were not registered. Addition of Bev increased the activity without worsening the tolerability of IRIFAFU combination as compared with our previous experience. Efficacy of BIFF was comparable with that reported with other Bev plus IRI-based combinations. Updated follow-up will be presented.

No significant financial relationships to disclose.

Contrast enhanced imaging of left internal mammary artery after vasodilation improves the evaluation of the bypass graft

AIM

The aim of the study is to evaluate patency and flow reserve by echocardiography in arterial grafts using the left internal mammary artery (LIMA) to the left anterior descending coronary artery (DA). The main limitations in performing this study routinely are the weakness of the Doppler signal and the exact chest localization of the graft. The purposes of the study were: to verify the feasibility of the echo color Doppler method on LIMA; to verify which between the parasternal or supralavicular view is the better approach to obtain a clear signal; to verify the increase of systolic and diastolic flow velocity of LIMA in basal conditions and after infusion of dipyridamole, and if the visualization of the Doppler signal improves after contrast infusion.

METHODS

Twenty patients (all males, mean age 63+/-7.8 years) with previous coronary artery bypass in the last 10 years, and without any significant stenosis in the left mammary artery graft as proved by a recent coronary angiogram (within 6 months), were selected for our study. LIMA was evaluated by two echocardiographic approaches. Patients were studied at rest and after pharmacological infusion of dipyridamole using the protocol of 0.56 mg/kg in 4 minutes. Contrast enhancement was infused in order to improve the Doppler signal using Levovist contrast agent at rest and after vasodilatation. Diastolic and systolic peak flow velocities, their ratio and the diastolic and total velocity time integrals were evaluated.

RESULTS

The results showed that using the supraclavicular approach we obtained the visualization of the graft at rest in all patients (100%) and using the parasternal approach in 19 out of 20 (95%) even without contrast injection. At rest, the diastolic and systolic peak flow velocities were 0.417+/-0.133 m/s and 0.368+/-0.1291 m/s; their ratio (diastolic/systolic) was 0.882+/-0.7362. The overall and diastolic velocity time integrals were 0.1571+/-0.0645 m and 0.2232+/- 0.0701 m. After dipyridamole infusion we observed in all patients an increase in diastolic and systolic peak flow velocities as expected by 0.582+/-0.342 m/s (p<0.005) and 0.73+/-0.427 m/s (p<0.005). Contrast injection at rest and after peak dipyridamole infusion showed a better and clearer Doppler signal of the graft allowing an easier evaluation of the velocity curves in all patients. In fact using the association dipyridamole-Levovist the velocity ratio and the total and diastolic velocity time integral values were 1.268+/-0.368 (p<0.05), 0.3492+/-0.131 m (p<0.05) and 0.2309+/-0.153 m (p<0.05).

CONCLUSION

In conclusion, this new echo-color-Doppler approach seems to be valid for the evaluation of the patency rate and flow reserve of the internal mammary artery graft, and helps to better select patients who really need angiography.

Transoesophageal echocardiography in patients without arterial and major cardiac sources of embolism: difference between stroke subtypes

We studied the records of 175 consecutive patients referred to our neurologic ward between January 1994 and February 2000 with a diagnosis of ischaemic cerebrovascular disease (ICVD) (stroke or transient ischaemic attack - TIA) who underwent transoesophageal echocardiography (TEE). We excluded patients with large vessel disease, high-risk embolic cardiopathies and other rare causes of stroke. According to clinical and neuroimaging findings, patients were divided into two groups. The lacunar (LAC) group (69/175 (39.4%)) and the nonlacunar (N-LAC) one (106/175 (60.6%)). The control population consisted of 78 consecutive patients, referred to the echocardiography laboratory for TEE without history of ICVD and known heart disorders. Patent foramen ovale (PFO) frequency was significantly higher in case patients than in control subjects (55/175 (31.4%) vs. 13/78 (16.6%); p = 0.02). Among case patients, PFO was more prevalent in the N-LAC group than in the LAC one (43/106 (40.6%) vs. 12/69 (17.4%); p = 0.0005). A large degree of shunt occurred in 53.5% of N-LAC patients and in 16.7% of LAC ones (p = 0.04). Atrial septal aneurysm (ASA) was detected in 12% of case patients and 1.3% of control subjects (p = 0.003) and was more frequent in the N-LAC group than in the LAC one (16 vs. 5.8%; p = 0.05). Mitral prolapse (MP) was present in 6/175 (3.4%) ICVD patients (vs. 1/78 among controls) in most cases associated with myxomatous valve redundancy. Aortic arch atheromas (AA) were detected in 12% of ICVD patients and in 10.2% of controls. The frequency was 9.4% in N-LAC and 15.9 in LAC. No complicated AA (plaque thickness >4 mm, ulcerated atheroma, superimposed thrombus) were detected. After multivariate analysis, PFO (OR = 3.8; 95% CI = 2.7-7.9) and ASA (OR = 8.01; 95% CI = 3.0-16.1) appeared to be independent predictors of ICVD. PFO (OR = 2.24; 95% CI = 1.24-4.92) was also independently associated with N-LAC stroke subtype and its importance was even higher in younger patients. Our study provides further evidence that TEE is a helpful diagnostic tool in stroke patients without arterial and major cardiac sources of embolism. However, its utility differs according to type and localization of the ischaemic lesion being more relevant in patient with N-LAC infarctions.

Mesangial nephropathy in Sjögren's syndrome

We describe a 36-year-old woman with Primary Sjögren's Syndrome (PSS). Purpura, corneal perforation, metabolic acidosis, decreased glomerular filtration, hypokalemia, hyposthenuria, and polyuria were present. Chronic renal insufficiency and renal tubular acidosis type I were diagnosed. Kidney biopsy revealed mesangial glomerulonephritis, interstitial nephritis, and tubular atrophy. Replacement treatment with saliva, tears, and potassium citrate was started. She was given prednisone and cyclophosphamide. This would be the first description of PSS, mesangial glomerulonephritis, and chronic renal insufficiency.

Soluble HLA class I, HLA class II, and Fas ligand in blood components: a possible key to explain the immunomodulatory effects of allogeneic blood transfusions

The immunomodulatory effect of allogeneic blood transfusions (ABT) has been known for many years. However, a complete understanding of the effects of ABT on the recipient's immune system has remained elusive. Soluble HLA class I (sHLA-I), HLA class II (sHLA-II), and Fas ligand (sFasL) molecules may play immunoregulatory roles. We determined by double-determinant immunoenzymatic assay (DDIA) sHLA-I, sHLA-II, and sFasL concentrations in different blood components. sHLA-I and sFasL levels in red blood cells (RBCs) stored for up to 30 days and in random-donor platelets are significantly (P <.001) higher than in other blood components and their amount is proportionate to the number of residual donor leukocytes and to the length of storage. Blood components with high sHLA-I and sFasL levels play immunoregulatory roles in vitro as in allogeneic mixed lymphocyte responses (MLR) and antigen-specific cytotoxic T-cell (CTL) activity, and induce apoptosis in Fas-positive cells. These data suggest that soluble molecules in blood components are functional. If these results are paralleled in vivo, they should be taken into account in transfusion practice. Blood components that can cause immunosuppression should be chosen to induce transplantation tolerance, whereas blood components that lack immunosuppressive effects should be preferred to reduce the risk of postoperative complications and cancer recurrence.

In vitro synthesis of prostaglandin E2 by synovial tissue after helium-neon laser radiation in rheumatoid arthritis

This paper reports the effect of helium-neon laser radiation (power of 5 mW and 632.8 nm wave length) on the synthesis of PGE2 in vitro in synovial tissue of biopsy samples of knee joints in patients with chronic rheumatoid arthritis stages II or III. Twelve patients were studied. Each patient received 15 applications of He-Ne laser. Eleven points for He-Ne laser applications were selected in one of the affected knees. The energy density used was 8 J/cm2 per application point. The He-Ne laser therapy reduced the synthesis of PGE2. The analysis of the data revealed a statistically significant difference between the levels of the synthesis of PGE2 before treatment (17.69 +/- 2.65 ng mg-1 of dry tissue h-1) and after treatment (13.85 +/- 2.73 ng mg-1 of dry tissue h-1), with p < 0.01 comparing mean values. This was also accompanied by relief of pain (91.6%), and a favorable subjective report from the patient. We conclude that PGE2 is a quantifiable parameter that could explain what causes pain relief in patients with rheumatoid arthritis that are treated with He-Ne laser.