1,721,214 research outputs found
Dynamic modulation of coronary arterio-venous communications
No full textA 62 year-old man with multiple coronary risk factors – including uncontrolled hypertension, smoking habit, abdominal obesity and family history of ischemic heart disease – was admitted to our Emergency Department for a prolonged episode of chest pain occurring at rest. He had no relevant past medical history except recently diagnosed chronic obstructive pulmonary disease; however, in the last year he suffered from sporadic episodes of effort angina (Canadian Class II–III) with spontaneous regression after few minutes of rest. During the last week he experienced worsening angina, with daily episodes of chest pain, mainly occurring during mild exertion but with some episodes occurring even at rest in the last two days. On admission the patient was symptomatic for angina. Physical examination was unremarkable, except for rhonchi and wheezing sounds in the chest, the blood pressure was 200/95 mmHg and the ECG revealed sinus tachycardia with ST segment elevation and QS waves in V1–V4 leads. Pharmacological treatment was immediately started with loading doses of Aspirin and Clopidogrel, iv. morphine, i.v. nitroglycerin and i.v. beta-blockers, with partial pain resolution. Cath lab team was promptly alerted for urgent coronary angiography. In the meantime, a trans-thoracic echocardiogram was performed, showing a hypertrophic and mildly dilated left ventricle with regional wall motion abnormalities in the left anterior descending (LAD) coronary artery territory: apical and mid septal akinesia, anterior wall hypokinesia. The estimated left ventricular ejection fraction was 35–40%. No other relevant findings. Fifteen minutes after the admission the patient was still mildly symptomatic for angina and ST segment elevation was still present on the ECG, although reduced, thus the patient was transferred directly to the cath lab to undergo coronary angiography. The selective right coronary angiography revealed significant stenosis of the posterolateral branch of the right coronary artery (RCA) and, more importantly, the presence of collaterals to the LAD and three artero-venous fistulae, which allowed the RCA to communicate with the pulmonary artery, the coronary sinus and a posterolateral branch of the cardiac venous system (Fig. 1A ). Prior to the selective angiography of the left coronary artery, the patient's chest pain resolved together with the concomitant resolution of the ST segment elevation. The left coronary angiography (Fig. 2C ) was performed and showed the presence of significant proximal LAD stenosis, likely representing the culprit lesion, which appeared spontaneously reperfused. Angiography also revealed sub-occlusion of the first diagonal and significant stenosis of the first obtuse marginal (OM) branch. Due to these findings, a new right coronary angiography was performed, which documented the disappearance of both arterial and venous communications (Fig. 1 B). Because of the spontaneous reperfusion of the culprit lesion, together with the total regression of symptoms and ST segment elevation, urgent revascularization was not deemed necessary. Furthermore, considering the presence of multivessel disease, a joint clinical case meeting with cardiac surgeons and invasive cardiologists was arranged and a staged PCI was felt to be the best treatment option and thus was scheduled the following day. A successful revascularization procedure was performed with the implantation of two everolimus eluting stents (EES), 2.75×23 mm on LAD and 2.75×32 mm on OM, and a POBA of the first diagonal branch with a 2.5×25 mm balloon. The patient was discharged with the indication to complete the percutaneous revascularization later. The pre-discharge echocardiogram confirmed global left ventricular dysfunction (LVEF 35–40%) with the above described regional wall motion abnormalities. One month later the revascularization was completed with an elective PCI of the posterolateral branch of the RCA with the implantation of another EES 2.75×16 mm and the angiography confirmed the complete disappearance of collateral circulation and arterio-venous fistulae (Fig. 2 D,E)
Limitations of noninvasive measurement of fractional flow reserve from coronary computed tomography angiography
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Physiological assessment after percutaneous coronary intervention: the hard truth
No full textPhysiologically guided revascularization, using fractional flow reserve (FFR) or instantaneous wave free ratio (iFR) has been demonstrated to be associated with better long-term outcomes compared to an angiographically-guided strategy, mainly avoiding inappropriate coronary stenting and its associated adverse events. On the contrary, the role of invasive physiological assessment after percutaneous coronary intervention (PCI) is much less well established. However, a large body of evidence suggests that a relevant proportion of patients undergoing PCI with a satisfying angiographic result show instead a suboptimal functional product with a potentially negative prognostic impact. For this reason, many efforts have been focused to identify interventional strategies to physiologically optimize PCI. Measuring the functional result after as PCI, especially when performed after a physiological assessment, implies that the operator is ready to accept the hard truth of an unsatisfactory physiological result despite angiographically optimal and, consequently, to optimize the product with some additional effort. The aim of this review was to bridge this gap in knowledge by better defining the paradigm shift of invasive physiological assessment, from a simple tool for deciding whether an epicardial stenosis must be treated, to a thoroughly physiological approach to PCI with the suggestion of a practical flow chart. coronary intervention: the hard truth. Panminerva Med 2021;63:519-28. DOI: 10.23736/S0031-0808.21.04363-9
Coronary Physiology Guidance vs Conventional Angiography for Optimization of Percutaneous Coronary Intervention: The AQVA-II Trial
No full textBackground: The debate surrounding the efficacy of coronary physiological guidance compared with conventional angiography in achieving optimal post–percutaneous coronary intervention (PCI) fractional flow reserve (FFR) values persists. Objectives: The primary aim of this study was to demonstrate the superiority of physiology-guided PCI, using either angiography or microcatheter-derived FFR, over conventional angiography-based PCI in complex high-risk indicated procedures (CHIPs). The secondary aim was to establish the noninferiority of angiography-derived FFR guidance compared with microcatheter-derived FFR guidance. Methods: Patients with obstructive coronary lesions and meeting CHIP criteria were randomized 2:1 to receive undergo physiology- or angiography-based PCI. Those assigned to the former were randomly allocated to angiography- or microcatheter-derived FFR guidance. CHIP criteria were long lesion (>28 mm), tandem lesions, severe calcifications, severe tortuosity, true bifurcation, in-stent restenosis, and left main stem disease. The primary outcome was invasive post-PCI FFR value. The optimal post-PCI FFR value was defined as >0.86. Results: A total of 305 patients (331 study vessels) were enrolled in the study (101 undergoing conventional angiography-based PCI and 204 physiology-based PCI). Optimal post-PCI FFR values were more frequent in the physiology-based PCI group compared with the conventional angiography-based PCI group (77% vs 54%; absolute difference 23%, relative difference 30%; P < 0.0001). The occurrence of the primary outcome did not differ between the 2 physiology-based PCI subgroups, demonstrating the noninferiority of angiography- vs microcatheter-derived FFR (P < 0.01). Conclusions: In CHIP patients, procedural planning and guidance on the basis of physiology (through either angiography- or microcatheter-derived FFR) are superior to conventional angiography for achieving optimal post-PCI FFR values. (Physiology Optimized Versus Angio-Guided PCI [AQVA-II]; NCT05658952
Superiority of fractional flow reserve versus intravascular ultrasound for intermediate coronary stenoses
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Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Ischemia with non-obstructive coronary artery (INOCA): Non-invasive versus invasive techniques for diagnosis and the role of #FullPhysiology
No full textIschemia with non-obstructive coronary arteries (INOCA) is an increasingly recognized entity. It encompasses different pathophysiological subtypes (i.e., endotypes), including coronary microvascular dysfunction (CMD), vasospastic angina (VSA) and mixed entities resulting from the variable combination of both. Diagnosing INOCA and precisely characterizing the endotype allows for accurate medical treatment and has proven prognostic implications. A breadth of diagnostic technique is available, ranging from non-invasive approaches to invasive coronary angiography adjuvated by functional assessment and provocative tests. This review summarizes the strength and limitations of these methodologies and provides the rationale for the routine referral for invasive angiography and functional assessment in this subset of patients
Glycoprotein Ia C807T gene plymorphism and increased cardiac risk of recurrent acute coronary syndromes: a five year follow up
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Granulocyte colony-stimulating factor for the treatment of cardiovascular diseases: An update with a critical appraisal
No full textHeart failure and acute myocardial infarction are conditions that are associated with high morbidity and mortality. Significant dysfunction of the heart muscle can occur as the consequence of end-stage chronic cardiovascular diseases or acute ischemic events that are marked by large infarction area and significant tissue necrosis. Despite the remarkable improvement of conventional treatments, a substantial proportion of patients still develops severe heart failure that can only be resolved by heart transplantation or mechanical device implantation. Therefore, novel approaches based on stem-cell therapy can directly modify the disease process and alter its prognosis. The ability of the stem-cells to modify and repair the injured myocardium is a challenging but intriguing concept that can potentially replace expensive and invasive methods of treatment that are associated with increased risks and significant financial costs. In that sense, granulocyte colony-stimulating factor (G-CSF) seems as an attractive treatment approach. Based on the series of pre-clinical experiments and a limited amount of clinical data, it was demonstrated that G-CSF agents possess the ability to mobilize stem-cells from bone marrow and induce their differentiation into cardiomyocytes or endothelial cells when brought into contact with injured regions of the myocardium. However, clinical benefits of G-CSF use in damaged myocardium remain unclear and are the topic of expert discussion. The main goal of this review is to present relevant and up-to-date evidence on G-CSF therapy use in pre-clinical models and in humans and to provide a rationale for its potential clinical applications in the future
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