P83 PERCUTANEOUS INTERVENTION FOR AORTIC COARCTATION IN YOUNG ADULTS: A CASE SERIES

Introduction

Aortic coarctation is one of the most frequent misdiagnosed congenital heart diseases and the most commonly missed foetal congenital heart disease. In adulthood the treatment of this pathology is primarily percutaneous.

Case Presentation

We present a case series of two young patients. The formers was a 37–years–old male with recent onset of heart failure symptoms due to misdiagnosed congenital aortic coarctation. The latter was a 39–years–old woman with exertional dyspnoea and a previous operated bicuspid aortic valve; in this case the intervention for the aortic defect was made in a second time, in order to avoid a huge demolishing surgical procedure. The execution of a diagnostic multimodality imaging allowed to detect the aortic coarctation, which received indication to percutaneous correction of the aortic defect after the multidisciplinary “Heart Team” discussion (image 2 and 3). In the cath–lab, the use of novel digital techniques, integrating the angiographic images with previously acquired angio–CT, allowed a safe stent delivery with minimum amount of contrast injection (image 1).

Conclusion

Percutaneous treatment of aortic coarctation in young adult is safe and effective. Fusion imaging tools could be very useful to optimize procedural results and sparing contrast dye, suggesting their possible implementation in different percutaneous procedures.

Stress cardiac MRI for the evaluation of CCS patients in a real-world tertiary care center

Background

The MR INFORM trial demonstrated that myocardial perfusion Magnetic Resonance Imaging (MRI) is non-inferior to Invasive Coronary Angiography (ICA) with measurement of Fractional Flow Reserve (FFR) in guiding the management of patients with stable coronary artery disease with respect to major adverse cardiac events, despite a reduced rate of revascularized patients. We sought to evaluate if a MRI-based strategy performed well also in patients with Chronic Coronary Syndrome (CCS) with intermediate coronary plaques observed by Coronary Computed Tomography Angiography (CCTA).

Methods

At our tertiary care center, patients with suspicion of CCS at intermediate risk first underwent CCTA. Subsequently, those showing intermediate coronary plaques underwent dipyridamole stress cardiac MRI. Revascularization was recommended for patients showing ischemia in at least two consecutive left ventricular segments or 6% of the myocardium. ICA and instantaneous FFR was performed in all of these patients, in order to confirm the indication for revascularization. The endpoint was a composite of death, non-fatal myocardial infarction, and target-vessel revascularization within 1 year.

Results

55 patients at intermediate risk underwent CCTA. 15 patients with no or only minimal plaques (stenosis <30%) and those with obstructive plaques (stenosis >70%) were excluded. 40 patients showed intermediate plaques (30–70% stenosis): 102 plaques total were classified as: non calcified n=9 (9%), calcified n=48 (47%), and mixed n=45 (44%). These patients underwent stress MRI, on the basis of which n=12 (30%) patients met criteria to recommend revascularization, whereas n=28 (70%) did not. The indication for revascularization was confirmed by ICA plus iFFR in 10 patients, and excluded in 2 (sensitivity = 100%, 95% CI 69%-100%; specificity = 93%, 95% CI 78%-99%; NPV = 100%, 95% CI 88%-100%; PPV = 83%, 95% CI 57%-95%; accuracy = 95%, 95% CI 83%-99%). Revascularization was obtained through PCI in 9 patients and through CABG in the remaining patient. All patients, regardless of revascularization, received optimal medical therapy (OMT), including high-dose statins. Throughout a 1-year follow-up, the composite endpoint occurred in only 1 patient belonging to the revascularized group, who was admitted to our hospital for NSTEMI. No adverse events were observed among the negative-MRI patients and the positive-MRI not-revascularized patients. All patients remained free from angina.

Conclusions

According to current European guidelines, in our tertiary care center patients with CCS at intermediate risk first underwent CCTA. A stress MRI-based strategy for the evaluation of intermediate plaques led us to refine the selection of patients needing coronary revascularization. No events occurred in patients with negative MRI, highlighting the accuracy of CCTA plus stress MRI strategy in these patients. In all patients, OMT may have contributed to freedom from angina.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of myocardial reperfusion in patients undergoing cangrelor supported primary PCI for STEMI

Background

Optimal myocardial reperfusion is the main goal of pharmaco-invasive treatment in STEMI patients. Cangrelor is a new intravenous P2Y12 inhibitor, mainly used in intra-procedural PCI setting of STEMI patients. Intracoronary cangrelor bolus application results in high local drug concentrations and may be more effective than a standard intravenous bolus.

Aim

This study aims to investigate the potential benefits of intracoronary versus intravenous cangrelor bolus in STEMI patients undergoing to primary PCI (p-PCI).

Materials and methods

Overall, 71 consecutive STEMI patients undergoing p-PCI were treated with intracoronary (n=37) or intravenous (n=34) bolus cangrelor administration with subsequent 2-hour intravenous infusion. The primary end point was ST-elevation reduction (STR) ≥50% at 30 minutes and at 24 hours after p-PCI. Secondary end points were STR ≥70% at 30 min after p-PC, TIMI frame count, and the QT dispersion (QTd). Moreover, stent thrombosis, bleeding events according to BARC classification, and 30-day mortality have been evaluated as safety explorative end points.

Results

STEMI patients treated with intravenous Cangrelor bolus had a higher rate of STR ≥50% either at 30 minutes (72% vs. 45%; p=0.033) or at 24 hours after p-PCI (87.1% vs. 63.6%; p=0.030) as compared to patients treated with intracoronary Cangrelor bolus; similarly, STR ≥70% at 30 minutes was more frequent in the intravenous bolus group as compared to intracoronary one (67% vs. 29% p=0.02). Furthermore, multivariable analysis demonstrated that intravenous Cangrelor bolus administration was an independent predictor of STR ≥50% (OR 3.586; 95% CI 1.134 to 11.335; p=0.030). No differences according to the TIMI frame count and the QTd were found. No stent thrombosis were observed at 30 days. The incidence of mortality and bleeding events (BARC 3–5) were comparable among study groups (30 days-death: 2.9% vs 5.4%, p=0.606; BARC 3–5 bleedings: 17.6% vs 13.5% p=0.630).

Conclusion

Intravenous coronary bolus administration of cangrelor in primary PCI is superior to intracoronary treatment with respect to extent of microvascular obstruction, and perfusion.

Funding Acknowledgement

Type of funding sources: None.