PCSK9 inhibitors: effectiveness of treatment and changes in background lipid-lowering therapy in a real world Italian population. The AT-TARGET-IT study

Introduction

PCSK9 inhibitors (PCSK9i) significantly decrease LDL cholesterol (LDL-C), either as monotherapy or in addition to the maximally tolerated dose of statin and/or ezetimibe. Yet, few data are available on efficacy and background lipid-lowering therapy (LLT) adjustment in patients treated with PCSK9i in real-world observations.

Purpose

AT-TARGET-IT is an Italian multicenter registry involving 9 Italian centers, designed to assess efficacy, adherence, and persistence of PCSK9i, as well as prescribing doctors' behavior in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH). The aim of the present analysis was to assess efficacy and changes in background LLT therapy in patients on PCSK9i in a real-world single country observation.

Methods

From June through November 2021, we enrolled patients with PCSK9i first prescription from 6 months before inclusion through starting of PCSK9i use. Clinical and demographic characteristics, concomitant therapies, blood chemistry, were recorded at the time of first prescription and at the latest observation preceding inclusion in the study. Background therapy was assessed at baseline and during follow-up, evaluating treatment withdrawal, reduction of doses, or changes from statin-ezetimibe association to single drug therapy.

Results

We enrolled 798 patients (27% with FH) receiving either alirocumab or evolocumab and followed for a median time of 19.3 months. At the time of PCSK9i first prescription LDL-C was 147.6 mg/dl and reached 51.5 mg/dl at the time of latest observation (64% reduction), and 129 patients (16%) were not receiving any LLT, 669 patients received background LLT, of them 246 (31%) were taking ezetimibe alone and 423 (53%) were taking statins with or without ezetimibe. At the end of the observation period, 785 patients (98%) were still receiving PCSK9i and 550 (69%) did not change background LLT. Of 248 patients changing background LLT, 116 (47%) withdrew therapy, 132 (53%) changed dose or type of LLT. After stratification by achievement of LDL-C target according CV risk class, 483 patients achieved the target (60%). Target was achieved at the end of the observation period in 63% of patients taking triple therapy, 65% patients receiving PCSK9i plus statins, 62% of patients receiving PCSK9i plus ezetimibe and 55% receiving PCSK9i alone (Figure 1). No significant differences in terms of percentage of patients changing background LLT during PCSK9i treatment were found between patients at target for LDL-C and those not at target.

Conclusion

AT-TARGET-IT study shows that PCSK9i therapy is effective in reaching LDL-C target in the majority of patients, yet a sizable number of them (40%) remains undertreated. LLT background therapy is either reduced or withdrawn in 31% of patients, being responsible for not reaching target. Reasons for inappropriate LLT changes in patients receiving PCSK9i should be identified and removed to optimize lipid control.

Funding Acknowledgement

Type of funding sources: None.

C34 INDIRECT MITRAL ANNULOPLASTY USING THE CARILLON CONTOUR SYSTEM, SINGLE CENTER EXPERIENCE

Mitral Regurgitation (MR) is both the most common and the most underdiagnosed valvulopathy in Western countries. When MR’s entity is moderate to severe it is highly burdened by incident heart failure causing an important impact on prognosis, in terms of mortality and re–hospitalization. Unfortunately a lot of symptomatic patients are not elegible to reparative or replacement surgery also due to the high procedural risks. Hence, the need for a less invasive treatment has grown, so endovascular repair techniques have been developed such as the CARILLON Mitral Contour System, a percutaneous procedure for reshape the mitral annulus reducing its dilation and mitral regurgitation. This technique is indicated for patients with secondary mitral regurgitation. The CARILLON is a simple and fast procedure with a right jugular approach that requires neither general anesthesia nor anticoagulant/antiplatelet therapy. Four patients including 3 men, aged 37–64 years, suffering from heart failure and moderate to severe secondary mitral regurgitation who were symptomatic in optimal medical therapy, NYHA II – III class, were admitted to our Cardiological Intensive Care Unit from April to September 2021. All patients underwent coronary angiography and three patients had no obstructive coronary artery disease (CAD). All patients underwent transthoracic and transesophageal echocardiography showing severely dilated left ventricles (DTD 70 ± 10mm, DTS 46 ± 21mm, VTD 264 ± 6ml, VTS 204 ± 6ml), severe reduction in ejection fraction (mean EF 24 ± 5%), severely dilated left atrium, mean volume values 47 ± 13ml/m2, moderate to severe mitral regurgitation (vena contracta 6 ± 2mm, EROA 34 ± 9mm2, regurgitation volume 37 ± 12 ml, regurgitation fraction mean 54 ± 4%). After implantation of the Carillon no complications were observed. In the 3–month follow–up, patients reported improvement in symptoms, exercise capacity and NYHA class. At the echocardiographic evaluation we saw improvement in contractile function and left ventricular size, reduction in the degree of mitral regurgitation to mild–moderate. There were no further hospitalizations for heart failure during the follow–up. The data, albeit limited to our little experience, show how the Carillon reduces mitral regurgitation and improves clinical outcomes in terms of exercise tolerance, quality of life and reduction of hospital admissions, which have social and economic relevance.

P310 CARDIAC AMYLOIDOSIS: INITIAL MONOCENTRIC EXPERIENCE

 

Cardiac amyloidosis is a group of diseases characterized by the accumulation in the interstitial space of amorphous material consisting of amyloid fibrils and, until recently, considered rare, with poor therapeutic prospects and burdened by a poor prognosis. However, both for amyloidosis from immunoglobulin light chains (AL) and for transthyretin amyloidosis in its wild type and mutated forms, there has been a significant increase in diagnostic capabilities. The aim of this work is to show the characteristics found in our population affected by cardiac amyloidosis.

Materials and Methods

We enrolled 18 patients observed over 12 months. The mean age was 63 ± 5, 14 patients were male. 8 patients in NYHA Class I – II, 10 patients in NYHA Class II – III. On the ECG in 88% of cases low QRS voltages in the peripheral leads. Among the conduction disturbances: 1st degree AV block in 45%, EAS in 33%, BBSn in 17%, occurrence of isolated BEV and BESV in 90%; 1 patient presented with AF. Defibrillator was implanted in 3 patients for detection of TVS and TNnS. In the whole population, the echocardiogram showed concentric parietal hypertrophy with a granular sparkling appearance; the mean FE was 55 ± 3%, the diastolic filling pattern was altered in type I in 42%, type II in 33% and type III in 25% of patients, respectively. In 92% of cases the left atrium was dilated. In 87% of cases there was an involvement of the valves in particular in 64% of cases we found calcifications of the aortic valve and in 66% mitral insufficiency. In 42% of patients there was an increase in the thickness of the atrial septum as well as the free wall of the right ventricle. Finally, signs of non–buffering pericardial effusion were found in 33% of patients.

Results

In our study population, 15 patients had multiple myeloma and presented with cardiac AL–type amyloidosis; among these 3 also presented renal involvement. In 3 patients, on the other hand, after positive bone scan and genetic screening, we diagnosed cardiac amyloidosis due to transthyretin mutation for which therapy with Tafamidis was undertaken. 3 patients died.

Conclusions

Our population presented echographic and echocardiographic characteristics comparable to those reported in the literature.

P78 AN ANTEGRADE RECANALIZATION OF LEFT ANTERIOR DESCENDING CHRONIC TOTAL OCCLUSION WITH ORBITAL ATHERECTOMY IN PATIENT WITH SEVER LEFT VENTRICULAR DISFUNCTION

We share the case of a 71–year old man, affected by hypertension, presented in Emergency Room (ER) with chest pain. No clinical evidence of heart failure. EKG showed fast atrial fibrillation with QS complex and ST elevation in precordial leads. Echocardiogram confirmed sept and apex akinesia. Troponin I peak was 72pg/ml. In ER electrical cardioversion was efficacy performed. He was referred for invasive coronary angiography, that showed a left anterior descending (LAD) chronic total occlusion (CTO), with Rentrop grade 2 collaterals providing retrograde flow from the right coronary artery (RCA), a severe stenosis of ramus intermedius (RI) and a moderate stenosis of circumflex. A stress–echocardiogram demonstrated vitality of medio–basal anterior wall. Subsequent, recanalization procedure of LAD CTO was planned. J–CTO score was 1 (tapered calcific, lesion, <20mm). double radial access and ante grade approach was chosen. An EBU3.5 guiding catheter was engaged in the left coronary artery, and 8000 units of heparin administered. The iFR of Cx was 0.99, indicative of non significant myocardial ischemia. During hemodynamic evaluation of RI, a ventricular fibrillation occurred, treated by DC–SHOCK and PCI with stenting with no polymer, eluted with Biolimus A9 (3.0x24mm) with good result. The occlusion was crossed via an antegrade approach with an Asahi Gaia II wire and with microcatheter support. Gaia II was changed in favor of Asai Sion blu, and the IVUS catheter was enable of cross the lesion. Efficacy orbital atherectomy with Diamondback 260 was performed (5 ante and retro grade run at 80Krpm and a retro grade run at 120 Krpm. Ivus was able to cross the lesion. Efficacy pre–dilatation with semi and non compliant balloon (2.5–3.5mm) was performed and then stented with a 3.0 × 36 mm Bioloimu A9–eluting stent. Finally, IVUS confirmed correct stent expansion, achieving an excellent angiographic result. Patient was discharged with triple anti–thrombotic therapy, with indication to “life jacket” till the assessment at 1 month.

P163 BOTALLO ARTERIAL DUCT SURGICALLY TREATED IN URGENCY

The Botallo arterial duct connects the pulmonary artery and the aorta during fetal life; after birth there is a progressive fall in pulmonary resistance mediated by the increase in oxygen concentration and the decrease in prostaglandins with a vasodilating action. In these physiological conditions, spontaneous closure of the duct is observed within the first 48–72 hours of life. In the preterm infant the patency of the Botallo duct is very frequent due to the peculiar anatomical and physiological characteristics of the preterm infant. The incidence of PDA is higher the lower the birth weight and gestational age are.

We report a case of Manuel, a baby born at 32 weeks of gestational age from elective CT due to transverse presentation with difficulty in extraction and anhydrosis. 37–year–old mother hospitalized for reduction of amniotic fluid (AFI 85 index) with no apparent rupture of the membranes, for which she began a cycle of glucocorticoids 12mg twice a day. At birth, the weight of the child was 1,780 g, length 42 cm, skull circumference 28 cm, absence of valid respiratory activity, bradycardia (78 bpm) APGAR index of 4. At 5 ‘of life he was intubated with a 3 Fi rush tube fixed to 8 cm from the buccal rim with neopuff with PIP 20 cmH2O, PEEP 5 cmH2O, FiO2 0.40, transferred to the NICU, placed in the incubator, connected to the ventilator and ventilated with A/C mode with PIP 23 cmH2O, PEEP 5 cmH2O, FiO2 0, 40 –> 0.60, given surfactant alfa 200 mg/kg. Anemic, plasma and red blood cells were administered multiple times; infectious disease tests (aerobic–anaerobic haemocolutre, umbilical culture, culture of OT tubes, BAL, ear and throat swabs) were negative. After 3 days, systolic heart murmur appeared 2–3/6 radiated to the axilla. The echocardium showed the persistence of the Duct of Botallo, with a mosaic jet in the pulmonary artery and a “growing” ductal flow pattern. He started treatment with indomethacin 0.2 mg/kg every 12 hours x 3 doses, but on echocardiographic control the picture remained unchanged. At 16 days of age, the newborn was transferred to the Bambin Gesù in Rome and underwent cardiac surgery via the left posterolateral thoracotomy to close the arterial duct with a Weck clip. The post–operative course was regular. Manuel was discharged 2.5 months after birth in good general conditions, good growth–weight, with a weight of 2460 g.

P62 LEFT ANTERIOR DESCENDING CACIFIED LESION IN A PATIENT WITH RECENT INFERIOR STEMI SUPPORTED WITH VENTRICULAR ASSISTANCE FROM IMPELLA 2.5, TREATED WITH ORBITAL ATHERECTOMY AND DRUG ELUTING STENT AND OPTIMIZED WITH IVUS CO–REGISTRATION

We present a case of a 65 years old patient with hypertension.He comes to our cath lab with an inferior STEMI treated with primary PCI of right coronary artery and we found a sub–occlusive and severly calcified lesion on proximal left anterior descending artery (LAD) and a diffused disease of its middle and distal portion (Fig 2). After collegial discussion on Heart Team we decided to proceed with a staged percutaneous revascularization on LAD. After an accurate planning we decided to proceed with a single femoral access a 14f femoral sheat was positioned on femorl artery, so we put the ventricular assistance catheter and then on the same sheat we put our 7 f guiding catheter to use only a single access for IMPELLA and for the guiding catheter (Fig. 1).The IVUS catheter doesn’t be able to cross the calcified lesion on LAD so we go on with a debulking using the orbital atherectomy of Diamond Back, with several passages antegrade and retrograde.At this point we are able to perform an IVUS Co–registration that demostrated also a critical lesion on ostial LAD.After multiple pre–dilatation to prepare the lesion we put three big drug eluting stent till 5 mm of diameter.The IVUS shows us a little malapposition so we proceed with a big non compliant balloon of 6mm with optimal result (Fig 3).In conclusion we go on with a reduction of ventricular assistance and final removal of IMPELLA catheter and closure of 14f vascular access with a single Pro–glide previously implanted.This procedure has some discussion points, first of all the possibility to treat a sub–occlusive lesion of an important non culprit artery after a few days of an acute coronary syndrome in safe mode with a ventricular assistance, that allowed us to work peacefully, being able to carry out all the maneuvers we considered appropriate (multiple balloon dilatations, IVUS evaluations, orbital atherectomy).An other point of discussion is the use of this new orbital atherectomy easy to use because with a single device,6f guiding catheter compatible, we are able to treat artery from 2.5 till 4mm only setting the rotational speed and removing not only the intraluminal calcium but also the deeper one and this allows a better stent expansion.The procedure is IVUS guided associated with angiographic images on Co–registration that allow us to obtain even more informations.The last comment is for the new stent Megatron, the only stent that are able to treat coronary artery till 6 mm.

P238 CARDIAC CONTRACTILITY MODULATION THERAPY: INITIAL MONOCENTRIC EXPERIENCE

 

Cardiac contractility modulation therapy consists in the delivery, by a device implanted in the patient at the level of the subclavicular region and connected to the heart through leads that send high intensity electrical impulses within the absolute refractory period of the potential of myocardial action. These pulses are delivered in cycles of 1 hour 7 times a day, each interspersed with pauses of 2–3 hours. CCM has been shown to be able to improve myocardial contractility through better management of intracellular calcium by the cardiomyocyte, exerting short and long–term effects, even managing to induce a positive remodulation of the gene expression of cardiac cells. The recent ESC 2021 guidelines indicate that cardiac contractility modulation therapy (CCM) was evaluated in patients with heart failure, FE 25%–45% and normal QRS duration (<130 ms) considering pVO2, QoL, 6MWT. The modulation of cardiac contractility improves symptoms and exercise tolerance and reduces re–hospitalization for heart failure (HF).

The purpose of this work is to show our little experience on the use of CCM in patients suffering from heart failure.

Materials and methods

4 male patients, aged 38–75 years, with heart failure, on optimal medical therapy, NYHA class III – IV, QRS <130 msec, FE 25–45%, hospitalized for implantation by CCM. NYHA, FE and BNP rated. The device was implanted in 4 patients without significant complications.

Results

In the 3 and 6 month follow–up, patients reported an improvement in symptoms, better exercise capacity and consequently a transition to a lower NYHA class (II – III). BNP values were lower than baseline. Upon checking the defibrillator, the trend of fluid accumulation using the optivol algorithm did not show significant levels of accumulation. No further hospitalizations for heart failure exacerbation.

Conclusion

The data limited to our little experience show how CCM produces similar results to those demonstrated in previous studies in subjects with 25% ≤LVEF≤45% and QRS <130 ms; CCM therapy improves clinical outcomes in terms of exercise tolerance and quality of life, long–term survival and reduces hospitalizations.

P57 SPONTANEOUS DISSECTION OF THE DISTAL MARGINAL BRANCH IN A YOUNG WOMAN IN THE PERIPARTUM WITH NO FLOW LIMITATION AT THE PRESENTATION EVOLVED INTO SEVERE DISSECTION OF THE ANTERIOR CIRCUMFLEX AND DESCENDING ARTERY COMPLICATED BY CARDIOGENIC SHOCK

We describe the case of a 39–year–old woman with a history of recent natural birth, who came to our observation for an episode of oppressive chest pain while breastfeeding her baby at night. At the entrance, the electrocardiographic and echocardiographic findings and myocardiocitonecrosis enzymes were normal; after three hours the second enzymatic determination was clearly increased, so the patient was admitted to our ICU with a diagnosis of SCA / NSTEMI. She was therefore subjected to coronary angiography with a small hematoma in the distal tract of the marginal branch without flow limitation; it was therefore decided, in accordance with the AHA and ESC guidelines, for a conservative medical therapy. On the third day of hospitalization, the patient presented recurrence of chest pain with electrocardiographic evidence of ST segment elevation in the anterolateral site. A new angiographic evaluation was therefore performed urgently, showing a complete retrograde dissection from the marginal branch to the circumflex branch and to the anterior descending branch with TIMI 0–1 flow. During the procedure the patient underwent a prolonged hypotensive episode associated with frequent polymorphic ventricular ectopic beats, with rapid evolution towards a picture of overt cardiogenic shock. Therefore we proceeded quickly to perform PTCA with placement of medicated stents on all branches involved in the dissection, with rapid improvement of the haemodynamic picture. Spontaneous coronary dissections represent for a hemodynamist a condition of great technical difficulty where the margins of error are very high. Thanks to the technological evolution of materials, an experienced hemodynamist is able, more and more easily, to be successful in the revascularization procedure and to resolve extremely serious clinical pictures. This case report describes a spontaneous coronary dissection that most often occurs in young women in good health and without risk factors for coronary heart disease, particularly in the peripartum period. The presentation was similar to an acute coronary syndrome. According to AHA and ESC guidelines, therapy was conservative if dissection / hematoma is not a flow restriction with coronary angiography after a few days to demonstrate vessel restoration.

P63 OPTICAL COHERENCE TOMOGRAPHY–ANGIO CO–REGISTRATION (OCT–ACR) OF LEFT ANTERIOR DESCENDING IN PATIENT WITH ONGOING ANIGNA

We share the case of a 50–year old man, with no cardiovascular risk factor, presented in ER with ongoing angina and positive exercise stress testing. No clinical evidence of heart failure. EKG and echocardiogram was negative. He was referred for invasive coronary angiography, that showed severe stenosis of mid–LAD and moderate ostial LAD stenosis. Subsequent Optical Coherence Tomography–Angio Co–Registration (OCT–ACR) of Left Anterior Descending was performed. An EBU3.5 guiding catheter was engaged in the left coronary artery, and 8000 units of heparin administered. After a pre–dilatation with a semi–compliant balloon of mid LAD, a plaque rupture with thrombus was documented at mid–LAD and a fibro–lipidic plaque with a severe flow limitation (MLA<4mm2) at the ostium, with no involvement of left main (Fig. 1b). Pre–dilatation with SC and NC balloon (2.5–3.5mm) was performed and then stented with a 4.0 × 26 mm DES. Finally, OCT confirmed correct stent expansion, achieving an excellent angiographic result, without carina shifting and compromise of the circ. Patient was discharged, asymptomatic. OCT–ACR guided PCI, taking advantage of its high spatial resolution, permits to plain better the PCI, establish correct stent size, evaluate early complications especially if left main or bifurcation are involved and thanks to co–registration also measurement of long axis of the vessel are facilitated.

P334 RARE CASE OF PAPILLIFEROUS FIBROELASTOMA ON AORTIC VALVE

Cardiac tumors are rare neoplastic processes that can arise from any tissue in the heart. They are divided into primitive (benign or malignant) and metastatic (always malignant). The prevalence of cardiac tumors ranges from 0.002% to 0.28%, of which most are benign. Papillary fibroelastoma is the third most common heart cancer and the most frequent heart valve cancer. We describe the case of a 50–year–old ex–smoker patient with a recent history of recurrent right popliteal – tibial femoral thrombectomy and subsequent percutaneous angioplasty. He arrived in the emergency room for ischemic ulcers and fistulization of the right lower limb, for which he was admitted to the Vascular Surgery Department. The patient came to our observation for appearance during the hospitalization of episodes of chest pain at rest with irradiation to the left upper limb and spontaneous regression. The physical examination, blood pressure, blood chemistry tests, chest X–ray and ECG were normal. Transthoracic and transesophageal echocardiography showed a left ventricle with good contractile function, a tricuspid aortic valve with cusp movement preserved with an oval mass, hypoechoic, with well–defined margins, adhering to the ventricular surface of the right coronary cusp, conditioning insufficiency of mild degree. This image was suggestive for papillary fibroelastoma. In addition, in anticipation of cardiac surgery, a coronary CT was performed which confirmed the presence of an oval, hypodense mass and the absence of significant coronary lesions. The absence of fever, increased inflammation and leukocytosis indices made it possible to exclude an endocarditic origin of the lesion, just as the echocardiographic and radiological characteristics eliminated the suspicion of thrombosis. The patient underwent cardiac surgery via longitudinal median sternotomy, in normothermic extracorporeal circulation (CEC). The mass was then excised, preserving the native aortic valve. Postoperative follow–up with transesophageal echocardiography showed no signs of aortic insufficiency. The postoperative course was uneventful. The histological examination of the lesion confirmed the diagnosis of papillary fibroelastoma. At the follow–up after about 3 years the patient was asymptomatic and without echocardiographic signs of local recurrence.

P198 ACUTE CORONARY SYNDROME COMPLICATED BY LEFT VENTRICULAR THROMBOSIS AND ISCHEMIC STROKE IN YOUNG WOMAN WITH ACUTE LYMPHOBLASTIC LEUKEMIA IN CHEMOTHERAPY TREATMENT

Acute lymphoblastic leukemia (ALL) is the most common cancer in children and accounts for 75% of all leukemias. In ALL, very immature leukemia cells build up in the bone marrow, destroying and replacing normal cells. Thrombotic events are a complication of acute leukemia induction therapy, particularly acute lymphoblastic leukemia (ALL) treated with L – asparaginase. We present the case of a 23–year–old girl suffering from acute lymphoblastic leukemia from pediatric age, undergoing chemotherapy treatment. In August 2021 she was admitted to ICU for acute myocarditis in shock which resolved after specific therapy. In September 2021 he came to our observation again for chest pain, fever, pulmonary thickening, but with normal echocardiography and echocardiography. The next day, the patient presented a worsening of symptoms, with the appearance of an elevated ST in the anterior to the ecg trace and apical, SIV and anterior wall akinesia with severely reduced FE on the echocardiogram. After collegial discussion also with fellow haematologists for the presence of thrombocytopenia, antithrombotic therapy was administered and an urgent coronary examination was carried out. The examination showed acute thrombotic occlusion of the middle–distal VAT. In the same session we proceeded to thrombus aspiration and implantation of medicated stents, procedure concluded in the absence of complications. The following morning the patient complained of paresthesia and weakness in the right side. On the echocardiogram, the presence of a thrombus in the apical area of about 2 cm. Skull CT was performed in urgency which showed cortical–subcortical hypodensity area in the left frontal–parietal site, referring to a recent ischemic lesion. In agreement with colleagues from Stroke Unite and hematology, heparin was infused intravenously in an attempt to dissolve the thrombus, but three episodes of VF were treated with effective DC shock during the hospital stay. On the same day, the girl was transferred intubated to resuscitation for respiratory arrest; in the following hours we witnessed the exitus. Our patient presented acute thrombosis both in the heart and in the brain, although she was being treated with antiplatelet and antithrombotic drugs and in the presence of thrombocytopenia. This case highlights the strong procoagulative role of haematological disease and of the chemotherapy indicated for it.

P224 PRIMITIVE DILATED CARDIOMYOPATHY IN YOUNG MAN NOT ELIGIBLE FOR CARDIAC TRANSPLANTATION: COMBINED USE OF DEFIBRILLATOR, CARDIAC CONTRACTILITY MODULATION (CCM) AND CARILLON

Acute heart failure refers to rapid or gradual onset of symptoms and/or signs of chronic heart failure due to precipitating factors. Many patients with heart failure progress into a phase of advanced heart failure, characterized by persistent symptoms despite maximal therapy. Prognosis remains poor, with high 1–year mortality. Prognostic stratification is important to identify the ideal time for referral to an appropriate center capable of providing advanced therapies. We present the case of a 36–year–old black homeless man was admitted to Cardiological intensive care unit for acute heart failure complicated by intermediate–high risk bilateral subsegmentary pulmonary embolism, left endoventricular thrombosis, severe biventricular systolic dysfunction and secondary severe mitral insufficiency. After infusional diuretic and anticoagulant therapy, coronary angiography was performed documenting non–obstructive epicardial coronary arteries. Thereafter the therapy with sacubitril/Valsartan was falled, due to marked hypotension. Due to the high risk of sudden cardiac death, a single–chamber ICD was implanted in primary prevention. He was not eligible for long–term mechanical assistance (VAD) implantation and/or heart transplantation from referral centers, because of the patient‘s precarious psychosocial background. Furthermore, in the fullness of his faculties, the patient refused this possibility for religious reasons. Discharged in fair compensation, after resolution of pulmonary embolism and intracavitary thrombosis, he was again hospitalized for an exacerbation of chronic heart failure. Once labile hemodynamic compensation was reached, a cardiac contractility modulation device (CCM) was positioned, with the aim of improving symptoms. After optimization of therapy, with persistence of severe symptoms despite optimal medical and device therapy, options for intervention on the mitral valve were evaluated before further deterioration of the clinical conditions. Since this is a highly symptomatic patient at high risk for surgery, we opted for a coronary sinus mitral annuloplasty repair with Carillon, performed in the absence of complications. At the follow–up there was a mitral regurgitant volume reduction, improvement symptoms, in the absence of further hospitalizations.

Thromboxane and prostacyclin biosynthesis in heart failure of ischemic origin: effects of disease severity and aspirin treatment

SUMMARY BACKGROUND

Thromboembolism is a relatively common complication of chronic heart failure (HF) and the place of antiplatelet therapy is uncertain.

OBJECTIVES

We characterized the rate of thromboxane and prostacyclin biosynthesis in chronic HF of ischemic origin, with the aim of separating the influence of HF on platelet activation from that of the underlying ischemic heart disease (IHD).

PATIENTS AND METHODS

We compared urinary 11-dehydro-thromboxane (TX)B(2), 2,3 dinor 6-keto-PGF(1alpha,) 8-iso-prostaglandin (PG)F(2alpha), and plasma N-terminal pro-brain natriuretic peptide (NT-pro-BNP), asymmetric dimethylarginine (ADMA), and soluble CD40 ligand (sCD40L), in 84 patients with HF secondary to IHD, 61 patients with IHD without HF and 42 healthy subjects.

RESULTS

HF patients not on aspirin had significantly higher urinary 11-dehydro-TXB(2) as compared with healthy subjects (P < 0.0001) and IHD patients not on aspirin (P = 0.028). They also showed significantly higher 8-iso-PGF(2alpha) (P = 0.018), NT-pro-BNP (P = 0.021) and ADMA (P < 0.0001) than IHD patients not on aspirin. HF patients on low-dose aspirin had significantly lower 11-dehydro-TXB(2) (P < 0.0001), sCD40L (P = 0.007) and 2,3-dinor-6-keto-PGF(1alpha) (P = 0.005) than HF patients not treated with aspirin. HF patients in NYHA classes III and IV had significantly higher urinary 11-dehydro-TXB(2) than patients in classes I and II, independently of aspirin treatment (P < 0.05). On multiple linear regression analysis, higher NT-pro-BNP levels, lack of aspirin therapy and sCD40L, predicted 11-dehydro-TXB(2) excretion rate in HF patients (R(2) = 0.771).

CONCLUSIONS

Persistent platelet activation characterizes HF patients. This phenomenon is related to disease severity and is largely suppressable by low-dose aspirin. The homeostatic increase in prostacyclin biosynthesis is impaired, possibly contributing to enhanced thrombotic risk in this setting.

Direct coronary stenting versus stenting with balloon pre-dilation: incidence of enzyme release and follow-up results of a multicentre, prospective, randomized study. The CK and Troponin I Estimation in direct STenting (CK TEST) trial

AIM

The aim of this study was to assess the safety of direct coronary stenting, its influence on costs, duration of the procedure, radiation exposure, clinical outcome and the incidence of periprocedural myocardial damage as assessed by enzyme release determination.

METHODS

We randomized 103 patients (109 lesions) to direct stent implant or stent implant following balloon predilatation. Patients with heavily calcified lesions, bifurcations, total occlusions, left main lesions and very tortuous vessels were excluded. Three samples of blood were drawn; before, 12 and 24 h after the procedure and total CK, CK MB mass and troponin I determination was carried out in a single centralized laboratory.

RESULTS

Direct stenting was successful in 62/62 lesions (100%). No single loss or embolization of the stent occurred. All stents in the group with predilatation were effectively deployed. The immediate post procedure angiographic results were similar with both techniques. Contrast media consumption and procedural time were significantly lower in direct stenting (150+/-82 cc and 30+/-13 min) than in pre-dilated stenting (184+/-85 cc and 36+/-14 min) (P=0.04 and P=0.036 respectively) while fluoroscopy time was similar (9.1+/-12 vs 9.19+/-15 min, P=0.97). The incidence of enzyme release was similar in the groups with only three non Q MI all in the pre-dilated group (P=0.149). Any elevation of CK MB and troponin I occurred in 7% of direct stent vs 12% of pre-dilated group (P=0.66), isolated troponin I elevation in 21% of both groups. Major adverse cardiac events during hospitalization were 0 in direct and 3 in pre-dilated stenting (P=0.66), but there were no significant differences at follow-up at 1, 6 and 12 months between the 2 groups (target lesion revascularization at 12 months 11 vs 14% in the 2 groups respectively).

CONCLUSION

Direct stenting is as safe as pre-dilated stenting in selected coronary lesions. Acute results and myocardial damage as assessed by enzyme release determination are similar, but procedural costs (as measured by resource consumption) and duration of the procedure are lower in direct stenting. Overall success rate and mid-term clinical outcome are similar with both techniques.

High preprocedural non-HDL cholesterol is associated with enhanced oxidative stress and monocyte activation after coronary angioplasty: possible implications in restenosis

OBJECTIVE

To investigate whether enhanced oxidant stress in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) is associated with a higher concentration of non-high density lipoprotein (HDL) cholesterol at baseline, and whether this contributes to the inflammatory reaction and luminal renarrowing after PTCA.

DESIGN

An ex vivo and in vitro study of 46 patients who underwent PTCA and who had repeat angiograms after six months. Blood samples were collected immediately before PTCA, and at 24 hours, 48 hours, and 15 days after.

SETTING

Tertiary referral centre.

SUBJECTS

46 patients (30 male, 16 female; mean (SD) age, 62 (5) years) with stable or unstable angina who underwent elective PTCA.

MAIN OUTCOME MEASURES

Continuous variable luminal loss as defined by change in minimum lumen diameter during follow up, normalised for vessel size; lag phase of low density lipoprotein to in vitro oxidation; plasma fluorescent products of lipid peroxidation (FPLP); plasma vitamin C and E; interleukin (IL) 1beta secretion from unstimulated monocytes; plasma C reactive protein (CRP).

RESULTS

Restenosis occurred in 12 patients (26%). Oxidant stress after PTCA was greater (p < 0.0001 at 15 days) in the patients with restenosis and showed a significant correlation with the preprocedural concentration of non-HDL cholesterol (p < 0.001). Inflammatory reaction (as reflected by IL-1beta production and CRP) and late lumen loss were linearly correlated (p < 0.001) with lag phase and FPLP throughout the study, and inversely (p < 0.05) with vitamin C and E measured at two and 15 days after PTCA.

CONCLUSIONS

This study provides evidence for the critical role of cholesterol dependent oxidant stress in the pathophysiology of restenosis after PTCA. The findings raise the possibility that drugs capable of modulating oxidant status might provide a novel form of adjuvant treatment in patients with hypercholesterolaemia undergoing PTCA.

Elevated circulating levels of monocyte chemoattractant protein-1 in patients with restenosis after coronary angioplasty

Inflammation plays a pathogenic role in the development of restenosis after percutaneous transluminal coronary angioplasty (PTCA). Monocyte chemoattractant protein-1 (MCP-1) is a potent chemoattractant of monocytes; however, its role in the pathophysiology of restenosis is still unclear. We set out to investigate the role of MCP-1 in restenosis after PTCA. In addition, we tested the hypothesis that MCP-1 exerts its effect, at least in part, by inducing O(2)(-) generation in circulating monocytes. Plasma levels of MCP-1 were measured before and 1, 5, 15, and 180 days after PTCA in 50 patients (30 males and 20 females, aged 62+/-5 years) who underwent PTCA and who had repeated angiograms at 6-month follow-up. Restenosis occurred in 14 (28%) patients. The MCP-1 level was no different at baseline between patients with or without restenosis. However, after the procedure, restenotic patients, compared with nonrestenotic patients, had statistically significant (P<0.0001) elevated levels of MCP-1. In contrast, plasma levels of other chemokines, such as RANTES and interleukin-8, did not differ between the 2 groups after PTCA. Higher MCP-1 throughout the study was correlated with restenosis. Moreover, increased MCP-1 was significantly correlated with increased monocyte activity, as reflected by enhanced O(2)(-) generation. Finally, multivariate regression analysis showed that the MCP-1 plasma level measured 15 days after PTCA was the only statistically significant independent predictor of restenosis (beta=0.688, P<0.0001). This study suggests that MCP-1 production and macrophage accumulation in the balloon-injured vessel may play a pivotal role in restenosis after PTCA. MCP-1 may induce luminal renarrowing, at least in part, by inducing O(2)(-) release in monocytes. Further understanding of the mechanism(s) by which MCP-1 is produced and acts after arterial injury may provide insight into therapies to limit the progression of atherosclerosis and restenosis after balloon angioplasty.

Angiographic anatomy of the grafted left internal mammary artery

BACKGROUND

The hypothesis that persistence of undivided branches is a common finding after myocardial revascularization using the left internal mammary artery was explored.

METHODS

Three hundred seven consecutive postoperative angiographies of the left internal mammary artery were considered. Seven were excluded because of occlusion or malfunction of the conduit or the anastomosis. Of the remaining 300, 150 were harvested through a left anterior small thoracotomy (group A) and 150 through a median sternotomy (group B). The persistence of undivided branches was recorded for each group.

RESULTS

Common origin with other branches of the subclavian artery was present in 55 patients in group A and 54 in group B (p = not significant); the persistence of lateral costal branch was also equally distributed in both groups (15 and 17; p = not significant). The first intercostal artery was present in 5 patients in group A and in none in group B (p = not significant). Branches of 1 mm or more were more frequent in group A (34 versus 4, p < 0.001), as well as branches of less than 1 mm (140 versus 67; p < 0.001). Only 2 patients in group A had no branches versus 48 patients in group B (p < 0.001).

CONCLUSIONS

Common origin with other branches of the subclavian artery and persistence of the lateral costal branch are common aspects in the angiographic anatomy of the grafted left internal mammary artery. Moreover, new branches, sometimes wider than 1 mm, develop with time. These findings are independent from the harvesting technique, the left anterior small thoracotomy, or the median sternotomy. If flow competition between the coronary and noncoronary territories was a reality, coronary artery grafting with the left internal mammary artery would be unsuccessful since the beginning.

Integrated left anterior small thoracotomy and angioplasty for coronary artery revascularization

BACKGROUND

The minimal access surgical technique of a left anterior small thoracotomy (LAST) for coronary artery bypass grafting is now well established. This procedure however, does not allow multivessel revascularization. We present our early experience of an integrated approach using LAST and percutaneous transluminal coronary angioplasty (PTCA), either staged or simultaneous.

METHODS

Eighteen patients (14 men and 4 women), mean age 63 (range 35-87 years) were treated. Four patients underwent simultaneous LAST and PTCA revascularization. The remaining 14 patients were first treated with the LAST procedure, followed 1-3 days later by angioplasty. Angiographic assessment was carried out before PTCA and at 6 months after.

RESULTS

The 14 patients who underwent the staged procedure all had patent left internal mammary artery/left anterior descending coronary artery grafts. Angioplasty was performed on 21 vessels (10 stented) with good early angiographic results. All patients were extubated early, mean intensive care stay was 14.7 + 9.4 hours, mean hospital stay was 5 + 1.5 days. All patients were symptom free at 18 months follow-up.

CONCLUSIONS

Staged LAST and angioplasty is a safe and effective approach suitable for patients in whom there are contraindications to the use of extracorporeal circulation. The simultaneous approach is limited by the risk of bleeding associated with the use of anticoagulation when coronary stenting is required.

Multiple arterial conduits without cardiopulmonary bypass: early angiographic results

BACKGROUND

Lack of angiographic results and technical difficulty in grafting the vessels in the lateral and posterior walls have reduced interest in myocardial revascularization without cardiopulmonary bypass (CPB). We describe our experience to demonstrate the feasibility of coronary surgical intervention without CPB in multivessel disease.

METHODS

From May 21, 1997, through February 1998, 227 patients underwent revascularization with two or more arterial conduits as the first operation: 122 without CPB (group A) and 105 with CPB (group B). Group A included a greater number of high-risk patients.

RESULTS

Mean +/- SD anastomoses per patient were 2.5 +/- 0.6 in group A and 2.8 +/- 0.8 in group B (p = NS). No patient died in group A, whereas 1 patient (0.9%) died in group B. The postoperative complication rate was low in both groups, but intensive care unit and in-hospital stays were shorter in group A than in group B (14.1 +/- 7.1 versus 27.3 +/- 36 hours, p < 0.001, and 4.1 +/- 1.6 versus 5.4 +/- 2.4 days, p < 0.001, respectively [group A versus group B]). Sixty-seven patients in Group A (54.9%) underwent postoperative angiography 33 +/- 35 days after operation. The patency rate was 98.9% (98.2% for the marginal branches).

CONCLUSIONS

Arterial revascularization of the coronary arteries without CPB is feasible, with results similar to those obtained with CPB. The two techniques, in our opinion, are complementary, not antagonistic.

Midterm results after minimally invasive coronary surgery (LAST operation)

BACKGROUND

Our experience with a left internal thoracic artery graft to the left anterior descending artery via a left anterior small thoracotomy is reviewed to evaluate midterm results.

METHODS

From November 1994 to April 1997, four hundred sixty patients were scheduled to undergo a left internal thoracic artery graft to the left anterior descending coronary artery via a left anterior small thoracotomy; 26 of these patients (5.7%) were converted and 434 of them had the operation. Two hundred fourteen patients (49.3%) had isolated disease of the left anterior descending artery, and 220 patients (50.7%) had multiple vessel disease. A sufficient length of the left internal thoracic artery was harvested to reach the left anterior descending artery.

RESULTS

Three hundred nine patients (71.2%) underwent extubation by hour 2. Mean intensive care unit stay was 4.2 +/- 4.5 hours; mean postoperative hospital stay was 66 +/- 29 hours; the 30-day mortality rate was 1.1%; the late mortality rate was 1.4%. Eighteen patients underwent reoperation early (< or = 30 days), and eight patients underwent reoperation late (> 30 days) because of conduit/anastomotic malfunction. Four patients underwent reoperation with patent anastomosis for progression of disease (n = 3) or pericarditis (n = 1). Three patients had a percutaneous transluminal coronary angioplasty. Cumulating angiographic and stress Doppler flow assessment results, a patent anastomosis was obtained in 417 patients and a nonrestrictive anastomosis in 404 patients. Twenty-nine months after surgery, survival was 97.1% +/- 0.7% (95% confidence interval 90.5% to 100%) and event-free survival 89.4% +/- 1.2% (95% confidence interval 78.2% to 100%). In the last 190 patients, with our increased experience and better instruments, we obtained a patent anastomosis in 188 patients (98.9%) and a nonrestrictive anastomosis in 185 (97.4%).

CONCLUSIONS

Left anterior small thoracotomy gives acceptable midterm results. Incidence of patent and nonrestrictive anastomoses was satisfactory, especially in the most recent part of our experience, when the learning curve ended.

Left internal mammary elongation with inferior epigastric artery in minimally invasive coronary surgery

OBJECTIVE

Sometimes the left internal mammary artery (LIMA) is not long enough to reach a too lateral LAD when a left anterior small thoracotomy (LAST operation) is the surgical approach to graft the LAD. LIMA elongation with an inferior epigastric artery (IEA) can be an useful surgical option.

METHODS

From November 1994 to June 30, 1996, out of 289 patients who underwent LAST operation; 28 patients had a LIMA elongation with an IEA, 20 patients had single vessel disease, 4 had two vessel disease, and 4 three vessel disease. Mean age was 62 +/- 22 (48-84) and mean EF was 57 +/- 86. The IEA was used only when the LAD was totally or nearly occluded with no transmural myocardial infarction (high expected run off).

RESULTS

All patients had an uneventful recovery. After 315 +/- 104 days from surgery all were asymptomatic. A late doppler flow assessment, performed in 28 patients, showed a high velocity diastolic flow in 27. One patient was reoperated on because of graft occlusion 84 days after surgery. An angiography was performed after 87.5 +/- 23.3 days in 22 patients. All conduit and anastomoses were patent but one, (patency rate 21/22, 95.4%); another showed mild anastomotical stenosis at the LIMA-IEA junction without clinical signs (perfect patency rate 20/22, 90.9%).

CONCLUSIONS

IEA elongation of LIMA is an alternative strategy to reach a lateral LAD in selected cases; a satisfying patency rate can be expected, when correct surgical indications are used.

Persistence of mammary artery branches and blood supply to the left anterior descending artery

BACKGROUND

Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery.

METHODS

Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 microg) was injected and the average peak velocities before and after injection were calculated.

RESULTS

The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 +/- 7 and 26 +/- 5 cm/sec, respectively, in group A versus 27 +/- 5 and 25 +/- 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 +/- 0.3 in group A versus 0.69 +/- 0.3 cm/s in group B; p = NS), but not distally (1.72 +/- 0.1 in group A versus 0.97 +/- 0.3 in group B; p < 0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 +/- 0.6 and 2.5 +/- 0.3 cm/s, respectively, in group A versus 2.6 +/- 0.5 and 2.6 +/- 0.3 cm/s, respectively, in group B; p = NS).

CONCLUSIONS

The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.

Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass

BACKGROUND

We explored the possibility of anastomosing the left anterior internal mammary artery (LIMA) to the left anterior descending artery in a beating heart via a left anterior small thoracotomy.

METHODS

This procedure was performed in 155 of 162 scheduled patients; in 7 (4.3%) the left anterior descending artery was not suitable or was too small. The chest was opened in the fourth intercostal space (mean wound length, 10.5 cm) and the LIMA was harvested for about 4 cm. The left anterior descending artery was occluded by means of two 4/0 Prolene (Ethicon, Somerville, NJ) sutures, and the proximal suture was snared. The anastomosis was performed with two 8/0 Prolene sutures while the heart was beating. Early postoperatively all patients underwent repeat angiography or a Doppler flow assessment of the LIMA or both.

RESULTS

The LIMA was connected directly to the left anterior descending artery in 144 patients and with interposition of an inferior epigastric artery in 11. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. One patient (0.6%) died 38 days after the operation due to multiorgan failure. Nine patients (5.8%) had failure requiring a redo operation: 7 (4.5%) early and 2 (1.3%) late. One additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean 5.6 months of follow-up, 143 patients (92.2%) were alive, asymptomatic with or without medical treatment, and without cardiac events.

CONCLUSIONS

Left internal mammary artery-to-left anterior descending artery anastomosis performed on a beating heart via a left anterior small thoracotomy is a safe procedure. In selected patients the operation has good early and midterm results.

[Myocardial revascularization with the internal mammary artery. The indications, technics and results]

This report reviews 218 patients who underwent internal mammary artery (IMA) grafting alone or with vein graft between 1986-1989. Our experience with IMA started with a single attached graft for proximal left anterior descending lesions in young patients affected from stable angina. After that our indications became more extensive. One IMA was utilized in 209 cases, both two IMAs in the remaining 9. Sequential IMA graft was performed in 16 patients and free IMA graft in 8. There were 242 IMA anastomosis and 295 associated vein by-passes. The overall operative mortality was 2.3%. Perioperative complications include myocardial infarction in 3 (1.4%), reoperation for bleeding in 4 (1.8%) and sternal wound complication in 4 (1.8%). These results are comparable to those of patients having only saphenous vein by-pass during the same period. At the follow-up actuarial survival rate at 42 months was 94 1.8% and 90% of these patients were completely asymptomatic. We include that IMA grafting shows low operative risk and provide excellent short term results. Our findings and the high long term patency rate of this conduit encourage us to extend the indication to IMA and to perform those surgical techniques that make possible multiple mammary coronary anastomosis.

[Infectious endocarditis. Role of surgical therapy]

The problem of infectious endocarditis (IE) is approached through a review of personal experience. The series examined consists of patients, 17 with active and 21 dormant infection. Furthermore 12 in the first group, 18 in the second had natural heart valves, while 5 in group I, 3 in group II had been given artificial ones. After an analysis of the aetiopathogenic, clinical and diagnostic aspects of the condition with emphasis on the fact that Staphylococcus aureus is currently more responsible for infections in natural valves and the epidermidis for acute prosthesis infections which have a higher early and late mortality rate (40% in hospital, 33.3% long-term), the paper discusses the criteria for surgical intervention. In line with opinions expressed in the literature, it is pointed out that, while the patient's haemodynamic status is certainly the main criterion for any decision, other factors such as embolism, impaired conduction, kidney failure and expansion of the infection to contiguous tissues, should not be under-estimated.

[Reversibility of left ventricular functional damage after valve replacement in patients with chronic aortic valve insufficiency]

The authors study retrospectively some preoperative echocardiographic findings and their importance as predictors of reversible myocardial dysfunction. The functional status of 57 survivors after isolated aortic valve replacement was evaluated with exercise testing and on this ground the patients, were divided into three groups: A (28 pts) greater than 60%; C (10 pts) less than 40%; B (19 pts) from 40% to 60%. The authors conclude that the postoperative improvement in functional status is strictly correlated with some preoperative echocardiographic indexes (end-diastolic dimension, end-systolic dimension, shortening fraction, mean end-systolic radius/thickness ratio, end-systolic wall stress, myocardial mass, ejection fraction) with are also predictive of operative mortality. The authors consider the principal values of beginning left ventricular impairment: a) end-systolic dimension greater than or equal to 5.5 cm; b) shortening fraction less than 27%; c) mean end-systolic radius/thickness ratio greater than 2.5; d) end-systolic wall stress greater than 240 mmHg.

Valve replacement with the tilting disc Sorin prosthesis in patients with narrow aortic annulus

The Authors summarize their 5-year experience of the clinical use of the Sorin tilting disc prosthesis in 40 patients (group A) with narrow aortic annulus, compared with a control group (group B: 116 patients) where a larger Sorin prosthesis was implanted. Follow-up lasted from 1 to 60 months, with a mean of 25.6 +/- 12.3 in group A and 20.4 +/- 11.9 in group B. Early and late mortality were low: 1/40 and 2/39 (2.5 and 5.1%) in group A and 4/116 and 9/112 (3.4 and 8.0%) in group B (p = NS): only two deaths, one in each group, were prosthesis-related. Actuarial survival was comparable: 91.2% (CL: 96.3-86.1%) in group A and 78.0% (CL: 87.6-68.4%) in group B, as were probability of being event-free and alive, non-reoperated and with few or no symptoms [group A: 61.7% (CL: 72.4-51.0%) and 77.4% (CL: 85.9-68.9%) respectively; group B: 78.8% (CL: 83.4-74.2%) and 61.1% (CL: 85.9-68.9%) respectively]. The Authors conclude that the Sorin tilting disc prosthesis is a reliable valve substitute in the narrow aortic annulus; they recommend that enlargement procedures should be confined only to patients with annulus size less than 19 mm.

[Risk of obstruction of secondary vessels in coronary angioplasty]

To define the risk of side branch occlusion during percutaneous transluminal coronary angioplasty (PTCA), 99 consecutive procedures, performed on 92 patients, were examined. In 77 of them side branches existed, originating from the stenosed segment; analysis was performed on 65 successful procedures (success rate = 84.4%). The 121 side branches were divided as follows: 53 (43.8%) originating from the stenosis itself (group A), of which 32 small in size (less than 1 mm) and 21 "moderate" (greater than or equal to 1 mm); 68 (56.2%) originating in the immediate vicinity of the stenosis (group B) of which 23 small and 45 moderate. After PTCA 3 side branches were occluded (2.5%): a small 1 of group A and 2 (1 small and 1 moderate) of group B. Three side branches (2.5%) all of group B, 1 small and 2 moderate, became stenotic in their take-off. In one only patient who had a side branch occlusion a slight CK-MB elevation (25 mU/ml) occurred together with a Q wave appearance in the aVL lead. In conclusion, side branches at risk are frequently present (in our population they account for 83.7% of the patients) but the real incidence of damage of these branches after PTCA is quite low, without any considerable difference between groups A and B, and significant clinical consequences are usually rare.

[Occult pre-excitation. Differential diagnosis between latent Wolf-Parkinson-White syndrome and concealed atrial pre-excitation (endocavitary electrophysiological study)]

Sixty patients (pts) with very disabling symptoms during supraventricular tachycardia (SVT) underwent electrophysiological study to determinate the mechanism of arrhythmia. 20 pts had, during normal sinus rythm (NSR), ECG pattern of ventricular pre-excitation (V-P); 40 pts, instead, had ECG pattern within normal limits (WNL). In V-P pts, circus movement tachycardia by overt accessory pathway (AP) was initiated. Among ECG-WNL pts group: 10 pts showed ectopic atrial rythm; 22 pts had SVT due to A-V nodal reciprocation; and 8 pts revealed the participation of concealed AP in the reentrant circuit of tachycardia. Among these latter, atrial stimulation at various sites and drugs-administration discovered extranodal by-pass liable for concealed V-P in 2 pts; in the remaining 4 pts it was possible to demonstrate concealed atrial preexcitation by ventricular stimulation, during NSR and SVT, and by atrial mapping during ventricular stimulation and SVT. Our report confirms the significative incidence of concealed AP at the basis of numerous cases of SVT (26%) and outlines the distinction between the latent W.P.W. syndrome and the atrial preexcitation, due to anomalous by-pass with anterograde block.