P69 LONG–TERM OUTCOMES WITH DRUG–ELUTING BALLOONS FOR THE TREATMENT OF IN–STENT RESTENOSIS AND DE NOVO LESIONS

Introduction

Drug coated balloons (DCB) have emerged for percutaneous coronary interventions (PCI) and mainly for in–stent restenosis or particular anatomies. However, the indications and the predictors of long–term failure of DCB have been poorly evaluated besides small–sized randomized clinical trials. Therefore, the aim of the present study was to provide a real–world analysis of the prognostic determinants and long–term outcomes among patients treated with DCB for any type of lesion and included in a comprehensive multicenter registry.

Methods

We included patients undergoing coronary angiography and PCI with DCB for in–stent restenosis or de novo lesions in 3 centers. Quantitative parameters for coronary lesions were calculated by an automatic edge–detection system. The primary study endpoint was the occurrence of major cardiovascular events (a composite of death, MI and target vessel revascularization) at the longest available follow–up. Secondary endpoints were the individual components of the primary endpoint, target lesion failure (TLF) or any acute coronary syndrome.

Results

Out of 281 patients treated with DCB, the 267 displaying a follow–up > 12 months were included, of whom 196 treated for in–stent restenosis and 71 with de novo lesions. At a median follow–up of 616 [368–1025] days, MACE occurred in 70 (26.2%) of the patients. No difference in clinical, demographic of angiographic features was observed between patients with or without an event, with the exception of a higher rate of in–stent restenosis (p = 0.04), longer and more type C lesions (p = 0.05 and p = 0.04) related with MACE. At multivariate Cox–regression, type C lesions emerged as the only independent predictor of MACE (adjusted OR[95%CI]= 1.83[1.13–2.97], p = 0.014), mainly driven by target vessel revascularization (adjusted OR[95%CI]= 1.78[1.05–2.95], p = 0.03) although not conditioning survival. However, in–stent restenosis emerged as a major determinant of TLF (adjusted OR[95%CI]= 2.59[1.17–5.75], p = 0.02).

Conclusion

The present registry shows that drug–coated balloons represent a potential treatment strategy even for de–novo lesions, especially in less complex cases. In fact, we observed an increased risk of MACE and target lesion failure in case of type C and restenotic lesions.

Left atrial function after standalone totally thoracoscopic left atrial appendage exclusion in af patients with absolute contraindication to oral anticoagulation therapy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left atrial appendage (LAA) is the source of more than 90% of thrombi in patients with atrial fibrillation (AF).  The Totally Thoracoscopic (TT) LAA exclusion with epicardial clip has become a safe and effective procedure, but the effect on left atrial (LA) function remains unknown.

Purpose

The aim of this study was to assess the effect of TT LAA exclusion on LA function.

Methods

20 patients (15 males) with non-valvular AF and contraindication to oral anticoagulation therapy (OAT) or antiplatelet therapy underwent standalone TT LAA exclusion with the Atriclip Pro II device. All patients were screened preoperatively with 3D CT scan, trans-esophageal echocardiography, spirometry and cerebrovascular doppler ultrasound. Intraoperative Atriclip Pro II positioning and LAA exclusion were guided and confirmed by trans-esophageal echo. To objectify LA function, transthoracic echocardiography with 2D Speckle tracking was performed before surgery, at discharge and at 3-month follow-up. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit.

Results

Baseline characteristics are reported in Table I. There were no major complications during the procedures. One non cardiovascular death, one minor stroke and 4 hospitalizations occur at 1-year follow up. The reservoir LA function considering the strain measurements dramatically decreased few days after the procedure and it recovered at 3-month follow-up compared to baseline, even though the LA volume is augmented (Table II). Furthermore, NT pro-BNP increased and ventricular strain decreased significantly after the procedure recovering over time.

Conclusion

TT LAA exclusion with Atriclip Pro II device is a safe and effective procedure in preventing AF related stroke in patients with contraindication to OAT. Our findings suggest that the LAA epicardial clip impairs immediately the reservoir LA function that recovers over time. Abstract Table I  Abstract Table II

Excimer laser technology in percutaneous coronary interventions: Cardiovascular laser society's position paper

Excimer Laser Coronary Atherectomy (ELCA) is a well-established therapy that emerged for the treatment of peripheral vascular atherosclerosis in the late 1980s, at a time when catheters and materials were rudimentary and associated with the most serious complications. Refinements in catheter technology and the introduction of improved laser techniques have led to their effective use for the treatment of a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non-crossable or non-expandable lesions, chronic occlusions, and stent under-expansion. The gradual introduction of high-energy strategies combined with the contrast infusion technique has enabled us to treat an increasing number of complex cases with a low rate of periprocedural complications. Currently, the use of the ELCA has also been demonstrated to be effective in acute coronary syndrome (ACS), especially in the context of large thrombotic lesions.

An heart team stroke prevention decision-making process comparing percutaneous endocardial and thoracoscopic epicardial left atrial appendage occlusion

Introduction

Left atrial appendage occlusion (LAAO) is a validated therapeutic option in patients with atrial fibrillation (AF) at high thrombo-embolic risk and contraindication to oral anticoagulation. Large clinical trials have demonstrated excellent efficacy of percutaneous LAAO, but also stand-alone thoracoscopic LAAO has shown promising results with the advantage of absence of antiplatelet therapy. No direct comparison of both strategies has been published yet.

Purpose

To evaluate an Atrial Fibrillation Heart Team guided approach to percutaneous or thoracoscopic left appendage exclusion in patients with non valvular atrial fibrillation (NVAF).

Methods

Forty patients with a contraindication to oral anticoagulation (OAC) were evaluated in the AF Heart Team for LAA exclusion. Contraindication for OAC was based upon a history of cerebral hemorrhages (n=17), non-cerebral life-threatening hemorrhages (n=9), repetitive bleeding (n=8) and having underlying diseases associated to high bleeding risk (n=6). The 20 patients included in the LAAO-Percutaneous group (LAAO-P) were on low molecular weight heparin pre-procedure, whereas in the LAAO-thoracoscopic group (LAAO-TT) none were on low molecular weight heparin nor antiplatelet therapy since the bleeding risk was estimated too high. The LAAO-P group were 70% male, with a mean age of 72.3±7.5 (range 57–82), mean CHA2DS2VASc 4.2 (range 1–6) and a mean HASBLED 3.5 (range 1–5) with an expected risk of bleeding between 3.7–8.7% per year. The LAAO-TT were 72.5% male, with a mean age of 74.9±8 (range 53–87 years), mean CHA2DS2-VASc 6.05 (range 4–8), HASBLED mean 5.4 (range3–8) expected risk of bleeding >12.5% per year. Variables considered were CHA2DS2VASc, HASBLED, documented blood transfusions, comorbidities related risk of bleeding, anatomy of the LAA, lung function, patient quality of life. LAAO-P patients were on dual antiplatelet therapy (DAT) at discharge for the first three months and aspirine 100mg/day thereafter, whereas the LAAO-TT patients were not. Follow up included TEE at 1 months and CT scan at 3 months.

Results

Mean duration of procedures for LAAO-P was 54.4 minutes, for LAAO-TT 52.01 minutes, mean post procedural ventilation time was respectively 11.2±6.4 and 15.8±16.4 minutes. No major complications occurred in both groups. One patient in the LAAO-P crossed over because of an unsuitable anatomy which became apparent intra-operatively. Mean hospital stay were comparable in both groups, 3.4±0.7 and 3.8±0.9 days respectively. At mean follow up of 24.3±10.1 months (range 5–36) all patients had complete exclusion of the appendage, no neurological events were reported.

Conclusions

The Heart Team can improve decision making in complex stroke prevention where LAAO is a therapeutic option, percutaneous and thoracoscopic occlusion seem to be comparably safe and effective. An epicardial LAAO could be advised in patients were the bleeding risk is estimated too high for AP therapy.

Funding Acknowledgement

Type of funding sources: None. Appendage closure: CT scan viewAppendage closure: surgical view

Standalone totally thoracoscopic left appendage exclusion for stroke prevention and absolute contraindication to anticoagulation: a referral centre experience

Introduction

Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). ESC guidelines state as class IIB indication left appendage exclusion in patients with contraindication to oral anticoagulation. Here we give our contribute to the issue of safety and efficacy of standalone totally thoracoscopic left appendage exclusion (TT-LAE) for stroke prevention in patients with contraindication to oral anticoagulant or at risk of life threatening hemorrhage on antiplatelet therapy: a large single Centre experience.

Materials and methods

60 patients with non valvular AF and contraindication to oral anticoagulation (25 cerebral hemorrhages,8 GI bleeding, 18 non cerebral/Gi bleeding requiring multiple transfusions, 2 myelodysplastic syndrome, 7 anatomy unsuitable for percutaneous closure, 75%male, patients age ranged 53–87 years,mean CHAD-VASC 6.4,mean HASBLED range 4.7, type of AF permanent 76.6%, 23.4% longstanding persistent), underwent stand alone totally thoracoscopic appendage exclusion. All patinets enrolled after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography, spirometry and cerebrovascuar doppler ultrasound. Intraoperative appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Follow up (range 35–1 months) included outpatient visit and CT scan or TEE at 3–6-12 month in all patients to document LAA exclusion. Perioperative mortality and early and late morbidity in addition to freedom from neurological events at follow up were analyzed by chart evaluation and full outpatient neurological examination including including the Questionnaire for Verifying Stroke Free Status (QVSFS) as validated screening tool.

Results

Mean duration of surgery “skin to skin” was 52.4 minutes; all patients were extubated shortly after the procedure. There were no deaths nor need for blood transfusion or pulmonary procedure related morbidities, only three casea of pericarditis treated with colchicine till complete resolution was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with minimal residual stumps and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit and questionnaire filling.

Conclusion

Standalone totally thoracoscopic left appendage clipping is a safe and effective procedure for stroke prevention in patients with permanent and longstanding persistent atrial fibrillation with contraindication to oral anticoagulation. Longer follow up and an European registry are needed to, possibly, confirm this preliminary results.

Funding Acknowledgement

Type of funding source: None

3050Non valvular atrial fibrillation, contraindication to anticoagulation or antiplatelet therapy and heart team approach: a single centre experience

Introduction

Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). Protect-AF and Prevail trials have tested the non inferiority of left appendage percutaneous closure to warfarin for stroke prevention but contraindication to anticoagulation was an exclusion criteria for enrollment. On the surgical side recent studies have shown the efficacy of left appendage exclusion concomitant to open chest cardiac surgery or totally thoracoscopic Maze. In these studies all patients were on anticoagulation or antiplatelet regime at discharge and follow up. Here we give our contribute to the issue of safety and efficacy of stand alone totally thoracoscopic left appendage clipping for non valvular AF related stroke prevention in patients with contraindication to oral anticoagulant or antiplatelet therapy.

Materials and methods

20 patients with non valvular AF and cerebral hemorrhages (16 males, patients age range 53–87, CHAD-VASC range 4–8, HASBLED range 4–7), underwent stand alone totally thoracoscopic appendage exclusion with a clipping device. All patients, after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography and cerebrovascular doppler ultrasound. Intraoperative device positioning and atrial appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy from the time of surgery to the control visit. Follow up (range 6–21 months) included outpatient visit, CT scan or TEE. Perioperative mortality and early and late morbidity were analyzed by chart evaluation and full outpatient neurological examination including the Questionnaire for Verifying Stroke Free Status.

Results

Mean duration of surgery “skin to skin” was 62 minutes; all patients were extubated shortly after the procedure. There were no deaths or pulmonary procedure related morbidities, only one case of pericarditis treated with colchicine was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with residual stumps less than 1 cm and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit.

Conclusion

Totally thoracoscopic left appendage exclusion is a safe, expeditous and effective procedure in preventing non valvular AF related strokes in patients with contraindication to oral anticoagulation or antiplatelet therapy. The efficacy of the procedure is comparable to open chest surgery and this procedure may be considered as valid therapeutic option in patients at high risk of hemorrhage if on anticoagulant or antiplatelet therapy. Clearly further data, longer follow up and possibly an European registry are needed to confirm this preliminary results.

Coronary artery narrowing after aortic root reconstruction with resorcin-formalin glue

Severe stenosis of right and left main coronary artery ostia developed after aortic root reconstruction with gelatin-resorcin-formol glue for correction of acute type A aortic dissection. Surgical treatment of this condition required grafting of the right and left anterior descending arteries with bilateral mammary arteries on the beating heart.

[Intramural aortic hematoma]

Aortic dissection is a medical and/or surgical emergency that is usually catastrophic if not diagnosed and treated promptly. Transesophageal Doppler echography provides an accurate method of diagnosing and evaluating dissection of aortic aneurysm. Due to the high resolution of transesophageal echocardiography, special subtypes of aortic dissection such as intramural hemorrhage can be diagnosed. The purpose of this paper is to report a case and review the anatomical, clinical and transesophageal echocardiography aspects of aortic dissection without intimal rupture (intramural hematoma).

[Tricuspid insufficiency with rupture of the chordae tendineae caused by closed thoracic trauma: evaluation by transesophageal echocardiography. Description of a case]

A case of severe tricuspid insufficiency with ruptured chordae tendineae due to nonpenetrating major chest trauma caused by a car accident is described. Electrocardiographic signs of complete right bundle branch block and olosystolic murmur were present and not observed before. Transthoracic echocardiography showed a significant prolapse of the septal tricuspid leaflet with severe tricuspid regurgitation and severe right heart overload, which progressively worsened. Transesophageal echocardiography confirmed the transthoracic echocardiographic findings. It also demonstrated the presence of ruptured chordae tendineae and the coexistence of a severe prolapse of the tricuspid anterior leaflet with flail movement. Although the patient remained asymptomatic, these findings prompted us to refer the case to the surgeon. The patient underwent valvuloplasty with excellent late result. In presence of traumatic tricuspid insufficiency the use of transesophageal echocardiography can be helpful to optimize the anatomic evaluation of the valvular apparatus allowing adequate therapeutic decision.

[Familial dissecting aortic aneurysm]

A family is described in which two brothers (44 and 48 years old) had aortic dissecting aneurysms (the first one died, the other one underwent surgical treatment and is still living) in the absence of clinical features of Marfan syndrome and of systemic hypertension. Two of the six living siblings have aortic dilation on echocardiography. Histologic examination of the aortic wall at autopsy or surgery revealed a loss of elastic fibers, deposition of mucopolysaccaride-like material and medionecrosis. We can postulate a genetically-determined disease of connective tissue usually described as "Marfan's forme fruste".

[The Italian Group for the Study of Streptokinase in Myocardial Infarct: Echocardiographic study]

Seventeen of the centres participating to the G.I.S.S.I. trial performed also, before discharge from the Hospital, an echocardiographic examination of patients (pts) included in the study. 561 pts were included, 280 assigned to the streptokinase (SK) treatment, and 281 to the control (CT) group. The echocardiographic asynergic area score index was lower in the SK pts than in the CT group (p less than 0.01). The difference was more evident in pts treated within 6 hours from the onset of symptoms (p less than 0.005), in pts without previous infarct (p less than 0.005), and in pts aged over 65 (p less than 0.005). The end diastolic (EDV) and the end-systolic (ESV) volumes were lower in SK pts (p less than 0.01 and p less than 0.025 respectively) than in the CT group; the ejection fraction (EF) did not differ. The reduction of EDV and ESV was more evident in pts treated within 6 hours, in pts without previous infarct, in pts aged over 65, and in anterior infarcts. At the 6-month follow-up examination, in SK pts the asynergic area score index, the EDV, the ESV and the EF were unmodified; in CT pts, on the contrary, the EDV and the ESV were significantly increased (p less than 0.05 and p less than 0.025 respectively).