Ping-pong guide catheter technique for facilitating antegrade crossing of a chronic total occlusion

A 60-year-old man was referred for percutaneous coronary intervention of a proximal left circumflex (Cx) chronic total occlusion (CTO) with distal filling via epicardial collaterals from the left anterior descending (LAD) artery.

HEMOSTASIS DISORDERS IN CORONARY ARTERY DISEASE: A PROSPECTIVE COMPARATIVE STUDY OF 130 PATIENTS

The laboratory detection of factors that participate in coagulation mechanisms in patients with coronary heart disease may lead to important findings regarding the contribution of endothelial function to atherosclerotic lesions of coronary arteries. The main purpose of this study was to investigate the role of high-sensitivity C-reactive protein (hs-CRP), von Willebrand factor (vWF) activity, thrombomodulin (TM), ADAMTS13 activity and myeloperoxidase (MPO) in patients undergoing coronary angiography due to non-ST-elevation myocardial infarction (NSTEMI), unstable angina (UA) and stable angina pectoris with positive stress testing-induced myocardial ischemia (controls). Furthermore, the measured biomarkers were examined among patients with classical cardiovascular risk factors. 50 NSTEMI patients, 50 UA patients and 30 controls referred to coronary angiography were included in the study. The blood samples were collected before the catheter procedure. MPO, TM and ADAMTS13 activity were measured by enzyme-linked immunosorbent assay (ELISA), while vWF activity was calculated with INNOVANCE vWF Ac. When the laboratory results were compared between the three study groups, hs-CRP was found to be higher in NSTEMI patients compared to UA patients (p=0.0015) and controls (p<0.0001). ADAMTS13 activity was higher in NSTEMI (p=0.0035) and UA patients (p=0.0102) compared to controls and TM was lower in NSTEMI patients compared to UA patients (p=0.0307) and controls (p=0.0002). Moreover, MPO was higher in UA patients compared to the control group (p=0.0227). Finally, each of the aforementioned biomarkers was compared in the presence of the following cardiovascular risk factors: smoking, diabetes mellitus, arterial hypertension, dyslipidemia, chronic kidney disease (CKD) and peripheral artery disease (PAD). The results of this study add more data to the current medical literature concerning the role of coagulation disorders, endothelial damage and immunothrombosis in patients with coronary artery disease and their correlation with traditional risk factors for cardiovascular disease.

Organization of intensive cardiac care units in Europe: Results of a multinational survey

Background:

The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe.

Methods:

A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14).

Results:

A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries.

Conclusion:

More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Organization of intensive cardiac care units in Europe: Results of a multinational survey

Background:

The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe.

Methods:

A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14).

Results:

A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries.

Conclusion:

More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece

Objectives

The coronavirus disease 2019 (COVID-19) outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece has affected hospital visits and admissions. We aimed to investigate trends of cardiac disease admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures.

Study design

This is a retrospective observational study.

Methods

Data for 4970 patients admitted via the cardiology emergency department (ED) across 3 large-volume urban hospitals in Athens and 2 regional/rural hospitals from February 3, 2020, up to April 12 were recorded. Data from the equivalent (for the COVID-19 outbreak) time period of 2019 and from the postlockdown time period were also collected.

Results

A falling trend of cardiology ED visits and hospital admissions was observed starting from the week when the restrictive measures due to COVID-19 were implemented. Compared with the pre–COVID-19 outbreak time period, acute coronary syndrome (ACS) [145 (29/week) vs. 60 (12/week), −59%, P < 0.001], ST elevation myocardial infarction [46 (9.2/week) vs. 21 (4.2/week), −54%, P = 0.002], and non-ST elevation ACS [99 cases (19.8/week) vs. 39 (7.8/week), −60% P < 0.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the postlockdown period were significantly higher than in the COVID-19 outbreak time period (1511 vs 660; P < 0.05).

Conclusion

Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak time period. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation.

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The coronavirus disease 2019 (COVID-19) outbreak has led to an unprecedented health system overload.

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The restrictive measures in Greece resulted in a low number of COVID-19 cases.

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Hospital visits and cardiovascular events have diminished after implementation of restrictive measures.

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Acute coronary syndromes reduced by approximately 55%, despite limited incidence of COVID-19.

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The multifactorial etiology of this finding should be thoroughly investigated.

P1321 A case of multiple levels of ventricular obstruction

Subaortic stenosis (SAS) is a rare entity in adults with unclear etiology and variable presentation. SAS may be presented with symptoms mimicking Hypertrophic Cardiomyopathy (HCM). Often a combination of imaging modalities is needed to distinguish SAS from HCM with obstruction.

A 53 years old man, smoker, was referred to our medical center suffering from shortness of breath on exertion. He first presented at another facility with a 2 month history of shortness of breath and chest discomfort during brisk physical activity and the possible diagnosis of HCM was made. On physical examination, a 3/6 systolic murmur was audible along the left sternal border, that became louder with standing and the Valsalva maneuver. The patient had non distended jugular veins, clear lung fields and no ankle edema. The results of laboratory exams did not reveal any pathological sign.

The transthoracic echocardiogram revealed significant left ventricular hypertrophy (Interventricular septum 21 mm, Posterior wall 16 mm) with normal left ventricular systolic performance (ejection fraction &gt;70%). The aortic valve was tricuspid and calcified whereas mitral valve was morphologically normal, with systolic anterior motion and mild posterolaterally directed regurgitation. Two systolic gradients, one dynamic, late peaking of 85mmHg and another fixed of 70mmHg were detected in left ventricular outflow track (LVOT).

Transesophageal echocardiography was performed for the better evaluation of aortic valve and showed a three level obstruction caused by the systolic motion of the mitral valve towards the hypertrophic septum at LVOT, the presence of a membranous subaortic membrane and the calcified aortic valve respectively. The aortic valve was calcified with a moderate stenosis (0.8cm2 / m2) from 3D planimetry. A Cardiac Magnetic Resonance exam was ordered and confirmed the significance of hypertrophy and the presence of circumferential subaortic membrane. No late enhancement after the administration of Gadolinium was observed. Coronary angiography was performed and demonstrated normal coronary arteries.

We hypothesized that the presence of subaortic membrane led to marked myocardial wall thickness and to the destruction of the aortic valve due to turbulent flow in the LVOT. The patient was referred for surgical management

Extended septal myectomy combined with complete resection of orbital subaortic membrane were performed. he calcified aortic valve was replaced by bioprosthetic valve No 23mm.

The patient tolerated the procedure well with significant symptomatic improvement. TTE performed 1 month postoperatively showed no remarkable LVOT gradient. The results of histopathology and genes investigations are pending.

Subaortic membrane is a rare cause of symptoms that can mimic hypertrophic cardiomyopathy. A combination of imaging modalities is needed to distinguish subaortic stenosis from aortic valve stenosis and hypertrophic obstructive cardiomyopathy.

Abstract P1321 Figure. Three levels obstruction

Percutaneous coronary intervention for distal coronary graft anastomosis le-sions: a case series

BACKGROUND

Management of coronary artery graft failure, especially at the site of a recent distal anastomosis, is a challenging clinical situation, and literature data are scarce.

CASE SERIES

We present a case series of patients with coronary artery bypass graft failure up to six months after surgical revascularization, who were treated with percutaneous coronary intervention at the site of distal graft anastomosis through the graft or the native vessel.

CONCLUSIONS

Percutaneous coronary intervention at distal graft anastomotic lesions is challenging, it can be performed from either the graft or the native vessel, and the angiographic result may not always be optimal. HIPPOKRATIA 2019, 23(2): 87-91.

Ipsilateral radial and ulnar artery cannulation during the same coronary catheterization procedure

BACKGROUND

Switching to femoral after a failed radial approach carries an increased risk of bleeding complications since the femoral artery puncture is performed in patients already anticoagulated. Moreover, dedicated radial operators find it more and more difficult to use the femoral approach, and ulnar artery cannulation provides them with the opportunity to further reduce its use. Our objective was to evaluate the feasibility and safety of ipsilateral radial and ulnar artery cannulation during the same coronary catheterization procedure.

METHODS

We performed a retrospective analysis of all cardiac catheterizations, from January 2015 until June 2016, with initial radial approach and conversion to ipsilateral ulnar approach. Patients with sheath insertion both in radial and ipsilateral ulnar arteries were further evaluated.

RESULTS

Four thousand one hundred and two procedures were performed during the study period, and 3,876 (94.5 %) of them were performed initially through a radial approach. Radial and ipsilateral ulnar catheterization was accomplished in nine patients, resulting in successful catheterization and procedure completion, without any serious complications recorded.

CONCLUSIONS

Ipsilateral radial and ulnar artery catheterization proved to be feasible and safe, without any serious complications. Hippokratia 2016, 20(3): 249-251.

Serum interleukin-6 is elevated in symptomatic carotid bifurcation disease

INTRODUCTION

The levels of circulating proinflammatory cytokines may express the extent of the inflammatory response and their participation in plaque progression and rupture needs to be evaluated. We aimed to investigate differences in circulating levels of proinflammatory cytokines and in plaque infiltration by macrophages between patients undergoing carotid endarterectomy for symptomatic and asymptomatic carotid atherosclerotic disease.

METHODS

One hundred nineteen patients (91 men and 28 women; mean age 66 +/- 8 years; range 42-83 years) who underwent carotid endarterectomy for significant (>70%) carotid bifurcation stenosis were enrolled in this study. Patients were characterized as symptomatic (n = 62) or asymptomatic (n = 57) after neurological examination. Serum levels of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), IL-1beta, serum amyloid A (SAA), and high-sensitivity C-reactive protein (hs-CRP) were evaluated. Macrophage infiltration of the plaque was assessed quantitatively from endarterectomy specimens using the monoclonal antibody CD68.

RESULTS

Serum IL-6 levels were significantly higher in patients with symptomatic compared with those with asymptomatic carotid disease (3.3 [2.0-6.5] pg/ml vs 2.5 [1.9-4.1] pg/ml, P = 0.02). TNF-alpha, IL-1beta, SAA, and hs-CRP levels did not differ significantly between the two groups. Symptomatic patients had also more intense macrophage accumulation in the carotid plaque compared with asymptomatic patients (0.6 +/- 0.1% vs 0.4 +/- 0.1%, P < 0.001). Although there were correlations between the levels of the different inflammatory markers, there were no correlation between any of them and the extent of plaque macrophage infiltration.

CONCLUSION

Patients with symptomatic carotid atherosclerotic disease have elevated serum IL-6 levels compared with asymptomatic patients. Symptomatic patients have also more intense macrophage infiltration of the atherosclerotic plaque suggesting that inflammatory process may contribute to the destabilization of the carotid plaque.