P90 LEFT ATRIAL APPENDAGE OCCLUSION AND RIGHT CARDIAC CATHETERIZATION IN PATIENT WITH PORTO–PULMONARY HYPERTENSION AND PERSISTENT ATRIAL FIBRILLATION WITH GASTRO–INTESTINAL BLEEDING IN ORAL ANTICOAGULANT TREATMENT

62–year–old male with multiple cardiovascular risk factors.Known pre–capillary porto–pulmonary hypertension treated with Macitentan 10 mg per day, in the context of serum–negative liver disease complicated by portal hypertension and congestive gastropathy.Persistent atrial fibrillation in AVK due to high thromboembolic risk (CHA2DS2VAsc 3).At the last echocardium–TT evidence of worsening of right ventricular systolic function (TAPSE from 20 to 16 mm) and estimated pulmonary hypertension (PAPS from 45 to 65 mmHg). Subsequent hospitalization for severe anemia (Hb 6.5 g/dl), with diagnosis of bleeding angiodysplasias.In consideration of high bleeding risk (HAS–BLED 3), left atrial appendage occlusion has been indicated.The patient underwent right cardiac catheterization, via right femoral vein, with confirmation of severe pulmonary pre–capillary hypertension (mean PAP 45 mmHg, PCWP 14 mmHg); during the same session, left atrial appendage was occluded percutaneously using a Watchman device. At discharge, combination therapy with Riociguat plus Macitentan and single antiplatelet therapy with Clopidogrel 75 mg per day were undertaken. Shortly thereafter, recurrence of gastro–enteric bleeding occurred; after cardiac evaluation, Clopidogrel was discontinued and anticoagulant therapy with Edoxaban 30 mg od was started.The choice of shifting from Clopidogrel to low dose NOAC was guided by the unclear evidence of efficacy and safety of single or dual antiplatelet therapy in a population of patients with both high thrombotic and bleeding risk, such as in this case.Given that NOACs can be considered as an alternative to Warfarin after Watchman implantation (class IIB), after the second recurrence of bleeding, we opted for long–term antithrombotic strategy using a direct oral anticoagulant at reduced dose, making bleeding risk more acceptable instead of the administration of full dosage of NOAC, matter of major importance in candidates for left appendage closure, in whom long–term anticoagulant therapy itself is contraindicated; on the other hand, aiming for a better protection against thromboembolic events compared to standard antiplatelet therapy.

C69 EFFECTIVENESS AND SAFETY OF DISTINCT ANTIPLATELET REGIMENS AFTER TRANSCATHETER LEFT ATRIALE APPENDAGE OCCLUSION: A SINGLE CENTER REAL–WORLD EXPERIENCE

Transcatheter left atrial appendage occlusion (LAAO) has emerged as a reliable tool to prevent thromboembolic events, in particular ischemic stroke, in patients with atrial fibrillation (AF) in the absence of mitral stenosis/valve prosthesis and contraindication to oral anticoagulation (OAC). Antiplatelet therapy (APT) is required after device implantation to prevent device–related thrombus (DRT). Previous studies provided conflicting results on the optimal APT regimen after LAAO. Thus, herein we aimed at assessing the comparative effectiveness and safety of distinct APT regimens. We conducted a real–world single–center observational study including consecutive AF patients that underwent LAAO at the University Hospital of Parma between October 2010 and June 2021. Clinical follow–up included all successfully implanted patients. Primary endpoint was net efficacy outcome, a composite of any ischemic or hemorrhagic event. Secondary endpoints were ischemic (any of the following: ischemic stroke, transient ischemic attack [TIA], DRT, systemic embolism) and hemorrhagic (major [≥3] bleedings according to Bleeding Academic Research Consortium [BARC] classification) complications alone. We enrolled a total of 130 patients (median age 77.0 [72.7;81.0] years; 78 [60.0%] men). History of hemorrhagic stroke in OAC (74 [56.9%]) was the main indication for LAAO. Technical procedure success was achieved in 123 (94.6%) patients. According to multidisciplinary team evaluation, immediately after LAAO, 39 (31.7%) patients received short (≤ 1 month)–dual APT (DAPT) consisting of cardioaspirin and clopidogrel, 35 (28.5%) long (>1, ≤12 months)–DAPT and 49 (39.8%) single APT (SAPT). At a median follow–up of 32 months, the incidence of primary endpoint was significantly lower in short–DAPT group (3 [7.7%] vs. 7 [20.0%] in long–DAPT vs. 14 [28.6%] in SAPT, p = 0.049], mainly driven by a lower occurrence of bleeding endpoint (0 [0.0] vs. 4 [11.4%] in long–DAPT vs. 9 [18.4%] in SAPT, p = 0.020) without differences in the incidence of ischemic endpoint (p = 0.916). Finally, comparison of the Kaplan–Meier curves showed that short–DAPT group had a higher primary endpoint–free survival (p = 0.015) compared to the others. In summary, our study highlighted that short (≤ 1 month)–DAPT regimen after LAAO is associated with better outcomes, mainly driven by reduction of major bleedings. Strong evidences arising from randomized trials are warranted to support these findings.

P56 SPONTANEOUS CORONARY ARTERY DISSECTIONS: ANALYSIS OF NON TRADITIONAL RISK FACTORS

 

The etiology of spontaneous coronary dissection (SCAD) is not well defined and Non traditional risk factors (NT–RF) have assumed increasing interest, but few data are available. NT–RF include three categories: Sex–related (SR–NT–FR), Sex–predominant (SP–NT–RF) and Gender–related (GR–NT–RF). (Table 1)

Aim of the Study

The objective of our analysis was to evaluate the incidence of NT–RF in Parma SCAD registry population.

Material and methods

We reviewed 62 patients with SCAD enrolled between January 2013 through November 2021

Results

Traditional risk factors were less common: hypertension was the most prevalent (39 pts, 62.9%). When considering NT–RF, 51 patients (82%) had at least one of all, with at least one SR–RF (66%) or GR–RF (64,5%). Patients with NT–RF were younger at time of SCAD (mean age 53 vs 66; p = 0.027) and they were predominantly females (48 vs 7 pts, p = 0.004) (Table 2). No differences were found among NT–RF SCAD and nNT–RF SCAD patients by fibromuscular dysplasia, peripheral arterial disease and chronic kidney disease. Patients with SCAD more often presented with non ST–segment elevation myocardial infarction (43 pts, 72.6%) vs ST–segment elevation (17 pts, 27.4%). No differences in clinical presentation and angiographic characteristics were found among NT–RF and nNT–RF patients group. MACE occurred in 17.7% of patients of the overall study population, at a median follow–up of 23 (interquartile range: 11;57) months. When comparing the incidence of cardiovascular events in the 2 study groups there was a trend toward a higher prevalence of MACE in NT–RF group without statistical significance (NT–RF SCAD 19.6% – nNT–RF SCAD 9.1%; p = 0.4). (Table 3)

Conclusion

SCAD is an emerging cause of myocardial infarction in young and middle–aged women without the traditional cardiovascular risk profile. Although overall survival seems good, SCAD is a potentially malignant disease which can present with ventricular arrhythmias and sudden cardiac death. Risk estimation is difficult in women, due to the scarce validity of prediction models, therefore a great effort must be made by the clinical community for the widespread diffusion and use of models incorporating NT–RF. Acknowledgement of peculiar features of this disease could help clinicians and researchers to establish targeted interventions for cardiovascular primary prevention, early diagnosis and secondary prevention in women, including rehabilitation and stress management programmes.

Effects of near-infrared laser radiation on the survival and inflammatory potential of Candida spp. involved in the pathogenesis of chemotherapy-induced oral mucositis

Candida spp. usually colonize ulcerative lesions of atrophic mucosa in patients with chemotherapy-induced oral mucositis inducing severe inflammation. The spread of antifungal-resistant strains strongly encouraged the search of complementary or alternative therapeutic strategies to cure inflamed mucosa. In this paper, we studied the effects of a near-infrared (NIR) laser system with dual-wavelength emission (808 nm + 904 nm) on the survival and inflammatory potential of C. albicans, C. glabrata, and C. parapsilosis. Laser treatment was performed with a Multiwave Locked System laser. Survival and apoptosis of fungal strains were evaluated by colony-forming units (CFU) counting and annexin V staining. Cytokine production was evaluated by ImmunoPlex array. Laser treatment significantly affected the survival of Candida spp. by inducing apoptosis and induced a lower production of inflammatory cytokines by dendritic cells compared to untreated fungi. No differences in the survival and inflammatory potential were recorded in treated or untreated Saccharomyces cerevisiae cells, used as the control non-pathogenic microorganism. Laser treatment altered the survival and inflammatory potential of pathogenic Candida spp. These data provide experimental support to the use of NIR laser radiation as a co-adjuvant of antifungal therapy in patients with oral mucositis (OM) complicated by Candida infections.

Clinical applications of multi-detector computed tomography coronary angiography

Cardiac computed tomography (CT) is a fast developing technique. In 10 years it developed from investigative tool into a clinical reality. The technology drive has been the key to success for this technique which is to date the only non invasive clinical tool for coronary angiographic assessment. Technical background is quite complex and the newer solutions are aiming at reducing the scan time and the radiation dose while improving temporal resolution, contrast resolution and ultimately image quality. The key technical development has been in the late 1990, the introduction of ECG triggering/gating techniques. Spatial resolution has also been improved reaching sub-millimeter performance. The latest innovations provide fast coverage with >64 slice detectors, high spatial resolution with 0.5 mm slice thickness, high temporal resolution with <100 ms in hardware, and higher contrast resolution with the forthcoming dual-energy solutions. Recently, also dose issues have been exploited and current state of the art technology are able to perform cardiac CT with 1-2 mSv. These improvements put cardiac CT as the most promising clinical tool for the non invasive assessment of coronary arteries.

Long-term mortality in patients unsuitable for surgical revascularization undergoing elective left main coronary artery angioplasty

AIM

Elective percutaneous coronary intervention (PCI) of left main coronary artery disease remains an important challenge in interventional cardiology. Nonetheless, this procedure is useful for patients with significant left main stenosis who are candidates for revascularization but unsuitable for coronary artery bypass graft. In this study the Authors sought to evaluate the safety and long-term mortality of PCI of left main coronary artery disease. Secondary endpoints were to analyse long-term mortality in various categories (patients<75 years vs patients<75 years, males vs females, drug eluting stents [DES] vs bare metal stents [BMS]).

METHODS

Between January 2003 and December 2006, 131 patients who consecutively under-went PCI on left main stem were reviewed. The mean follow-up time was 14.0+/-10.8 months. Survival curves were plotted with the Kaplan-Meier method and compared with the Log-rank test.

RESULTS

The Kaplan-Meier curves did not show statistically significant differences in terms of all-cause mortality at follow-up between protected and unprotected left main coronary disease (12% vs 14% respectively, P=0.67). In the protected left main group, there was a significantly higher use of DES compared with unprotected left main group (59% vs 43%, P=0.02).

CONCLUSION

The data show that PCI for left main coronary disease is feasible, safe and with an acceptable long-term mortality rate in patients at high-surgical risk unsuitable for surgical revascularization.

Diagnostic accuracy of 64-slice CT in the assessment of coronary stents

PURPOSE

The purpose of this study was to assess the diagnostic accuracy of 64-slice computed tomography (64-CT) coronary angiography in the detection of coronary in-stent restenosis.

MATERIALS AND METHODS

Ninety-five patients (72 men and 23 women, mean age 58+/-8 years) with previous percutaneous coronary intervention with stenting and suspected restenosis underwent 64-CT (Sensation 64, Siemens). The mean time between stent deployment and 64-CT was 6.1+/-4.2 months. The scan parameters were: slices 32 x 2, individual detector width 0.6 mm, rotation time 0.33 s, feed 3.84 mm/rotation, 120 kV, 900 mAs. After the intravenous administration of iodinated contrast material (Iomeprol 400 mgI/ml, Iomeron, Bracco) and a bolus chaser (40 ml of saline), the scan was completed in <12 s. All coronary segments with a stent were assessed on 64-CT by two observers in consensus and judged as: patent, with intimal hyperplasia (lumen reduction of <50%), with in-stent restenosis (> or =50%), or with in-stent occlusion (100%). The consensus reading was compared with conventional coronary angiography.

RESULTS

Four patients were excluded because of insufficient image quality. In the remaining 91, we assessed 102 stents (31 RCA; 10 LM; 54 LAD; 7 CX). In 14 (13.7%) stents, in-stent restenosis (n=8) or in-stent occlusion (n=6) was found. Intimal hyperplasia was detected in 11 (10.8%) stents. The sensitivity and negative predictive value of 64-CT for in-stent occlusion were 100% and 100%, respectively, whereas for all stenoses, >50% they were 92.9% and 98.7%, respectively.

CONCLUSIONS

We found that 64-CT has a high diagnostic accuracy for the detection of in-stent restenosis in a selected patient population.