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Outcome data on using cangrelor in older patients are limited. This post hoc analysis of the itAlian pRospective Study on CANGrELOr (ARCANGELO) study aims to assess bleeding and ischemic outcomes with the transition from cangrelor to any oral P2Y12 inhibitors in age-stratified subgroups (≥75 years—older, <75 years—younger) of patients with acute coronary syndrome who underwent percutaneous coronary intervention (PCI). Of 995 patients, 215 (21.6%) were older, 115 of whom (11.6%) were aged ≥80 years. Presentation with ST-elevation myocardial infarction was less frequent in older than in younger patients (52.6% vs 62.1%, p = 0.0119). At 30 days after PCI, rates of the study's primary end point of overall bleeding defined according to the Bleeding Academic Research Consortium were not significantly different between the 2 age subgroups (4.6% in the younger vs 7.4% in the older, p = 0.1179). Rates of major adverse cardiac events, defined as the composite of death, myocardial infarction, ischemia-driven revascularization, and stent thrombosis, were significantly lower in younger than in older patients (0.9% vs 3.3%, p = 0.0170). Intraprocedural thrombotic events occurring in the 48 hours after PCI arose in similar proportions in the subgroups (1.4% vs 1.4%, p = 1.000). In conclusion, these data suggest that using cangrelor with transition to any oral P2Y12 inhibitor is a safe and effective antithrombotic treatment in older patients who undergo PCI for acute coronary syndrome in the setting of routine clinical practice. Clinical Trial Registration Number: NCT04471870.

The subjective perception of cardiac symptom severity is considered a main treatment target in the management of transthyretin-related cardiac amyloidosis (CA), as opposed to objective prognostic markers such as N-terminal pro b-type natriuretic peptide (NT-proBNP), which objectively reflects the severity of heart disease. Nevertheless, anxious and depressive symptoms in patients with CA might affect subjects perceptions of disease, creating a potential gap between objective and subjective parameters. We assess the impact of such bias in consecutive patients with CA. A total of 60 patients aged 62 to 88 years with CA were recruited. The level of anxiety and depression was measured by the Hospital Anxiety and Depression Scale and the subjective perception of symptoms severity by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Finally, NT-proBNP plasma levels at rest and glomerular filtration rate were measured. Nearly 1/2 of the patients (48%) reported clinically relevant levels of psychologic symptoms. Higher levels of anxious and depressive symptoms were significantly linked to lower KCCQ scores. Furthermore, the relation between NT-proBNP and KCCQ was significant only when anxious and depressive symptoms were low (β = −0.86, p = 0.002; β = −0.86, p = 0.002, respectively) and medium (β = −0.49, p = 0.004; β = −0.45, p = 0.004, respectively) but was otherwise lost. Depression and anxiety in patients with transthyretin-related CA required assessment and management. In conclusion, patients with depression/anxiety have a clear disconnect between their personal assessment and objective measures of cardiac symptoms, with a major influence on the patients’ wellbeing and on their subjective response to treatments in clinical trials.

ObjectivesDifferences in terms of safety and efficacy of percutaneous edge-to-edge mitral repair between patients with functional and degenerative mitral regurgitation (MR) are not well established. We performed a systematic review and meta-analysis to clarify these differences.MethodsPubMed, EMBASE, Google scholar database and international meeting abstracts were searched for all studies about MitraClip. Studies with <25 patients or where 1-year results were not delineated between MR aetiology were excluded. This study is registered with PROSPERO.ResultsA total of nine studies investigating the mid-term outcome of percutaneous edge-to-edge repair in patients with functional versus degenerative MR were included in the meta-analysis (n=2615). At 1 year, there were not significant differences among groups in terms of patients with MR grade≤2 (719/1304 vs 295/504; 58% vs 54%; risk ratio (RR) 1.12; 95% CI: 0.86 to 1.47; p=0.40), while there was a significantly lower rate of mitral valve re-intervention in patients with functional MR compared with those with degenerative MR (77/1770 vs 80/818; 4% vs 10%; RR 0.60; 95% CI: 0.38 to 0.97; p=0.04). One-year mortality rate was 16% (408/2498) and similar among groups (RR 1.26; 95% CI: 0.90 to 1.77; p=0.18). Functional MR group showed significantly higher percentage of patients in New York Heart Association class III/IV (234/1480 vs 49/583; 16% vs 8%; p<0.01) and re-hospitalisation for heart failure (137/605 vs 31/220; 23% vs 14%; p=0.03). No differences were found in terms of single leaflet device attachment (25/969 vs 20/464; 3% vs 4%; p=0.81) and device embolisation (no events reported in both groups) at 1 year.ConclusionsThis meta-analysis suggests that percutaneous edge-to-edge repair is likely to be an efficacious and safe option in patients with both functional and degenerative MR. Large, randomised studies are ongoing and awaited to fully assess the clinical impact of the procedure in these two different MR aetiologies.

La ricanalizzazione delle occlusioni coronariche croniche (CTO) si associa a risultati clinici favorevoli in sottogruppi selezionati di pazienti. Le probabilità di successo nella ricanalizzazione delle CTO sono incrementate notevolmente nelle ultime decadi grazie allo sviluppo di materiali e tecniche interventistiche dedicate. Tali procedure, tuttavia, restano tecnicamente impegnative dal punto di vista tecnico, sono gravate da un tasso lievemente più elevato di complicanze ed hanno un successo procedurale crescente ma ancora più basso di quello di angioplastiche coronariche in lesioni non occlusive. Queste procedure richiedono un’adeguata formazione di operatori dedicati. In questo manoscritto ci ripromettiamo di fornire uno stato dell’arte delle evidenze cliniche a favore della rivascolarizzazione delle CTO e una descrizione pratica delle principali strategie interventistiche utilizzate per la ricanalizzazione.

Coronary stents improve immediate and late results of balloon angioplasty by tacking up dissections and preventing wall recoil. These goals are achieved within weeks after angioplasty, but with current technology stents permanently remain in the artery, with many limitations including the need for long-term antiplatelet treatment to avoid thrombosis. We report a prospective multicentre clinical trial of coronary implantations of absorbable magnesium stents. We enrolled 63 patients (44 men; mean age 61·3 [SD 9·5 years]) in eight centres with single de novo lesions in a native coronary artery in a multicentre, non-randomised prospective study. Follow-up included coronary angiography and intravascular ultrasound at 4 months and clinical assessment at 6 months and 12 months. The primary endpoint was cardiac death, non-fatal myocardial infarction, or clinically driven target lesion revascularisation at 4 months 71 stents, 10–15 mm in length and 3·0–3·5 mm in diameter, were successfully implanted after pre-dilatation in 63 patients. Diameter stenosis was reduced from 61·5 (SD 13·1%) to 12·6 (5·6%) with an acute gain of 1·41 mm (0·46 mm) and in-stent late loss of 1·08 mm (0·49 mm). The ischaemia-driven target lesion revascularisation rate was 23·8% after 4 months, and the overall target lesion revascularisation rate was 45% after 1 year. No myocardial infarction, subacute or late thrombosis, or death occurred. Angiography at 4 months showed an increased diameter stenosis of 48·4 (17·0%). After serial intravascular ultrasound examinations, only small remnants of the original struts were visible, well embedded into the intima. Neointimal growth and negative remodelling were the main operating mechanisms of restenosis. This study shows that biodegradable magnesium stents can achieve an immediate angiographic result similar to the result of other metal stents and can be safely degraded after 4 months. Modifications of stent characteristics with prolonged degradation and drug elution are currently in development.

Abstract Background Patients with atrial fibrillation (AF) have a five-fold increase in stroke events, and ∼90% of the thrombi develop in the left atrial appendage (LAA). Left atrial appendage occlusion (LAAO) has emerged as a safe and feasible alternative to oral anticoagulation (OAC) for stroke prevention in selected patients with non-valvular AF and contraindications to OAC. Atrial fibrillation is closely associated with mitral disease, and there is a growing interest in combined procedures. More than half of patients undergoing a mitral transcatheter edge-to-edge repair (M-TEER) suffer of AF and many have high or unacceptable bleeding risk. Case summary We present a case of an 80-year-old woman suffering from paroxysmal AF, right carotid siphon aneurysm, and primary mitral regurgitation, with a high bleeding risk, who underwent a combined intervention of M-TEER and LAAO. Discussion The combination of these two procedures is a logical step once the access to the left atrium is obtained with a transseptal puncture (TSP) and a transesophageal echocardiography (TEE) is in place to guide both procedures. The turning point in LAAO procedure is a correct TSP allowing coaxial alignment of the sheath with the LAA neck. Steerable delivery sheaths are promising dedicated tools, particularly in challenging anatomy or during combined procedures requiring different TSP positions.

The multicenter prospective Lipid Rich Plaque (LRP) registry showed that nonculprit (NC) lipid-rich plaques identified by near-infrared spectroscopy (maxLCBI4mm >400) with an intravascular ultrasound plaque burden (PB) >70% and/or minimum lumen area (MLA) <4 mm2 within the maxLCBI4mm segment were more frequently associated with major adverse cardiac events (MACE) within 2 years. The aim of this sub-study was to report the relationship between initial clinical presentation and subsequent NC-MACE. Patients enrolled in the LRP study were stratified post hoc as having a stable angina pectoris or silent ischemia presentation versus acute coronary syndrome, excluding patients presenting with acute ST-elevation myocardial infarction. Among the 1552 patients, 717 presented with stable angina pectoris or silent ischemia. Patients presenting with acute coronary syndrome were more likely to be younger and Black, current smokers, and have less chronic kidney disease. Of the scanned nonculprit vessels, there was no difference between the 2 clinical presentation groups regarding lipidic content, and the rate of lipid-rich plaques (maxLCBI4mm >400) was 31.9% in both groups. Finally, there was no difference in NC-MACE at 2 years’ follow-up, although within each group (stable versus acute coronary syndrome), the NC-MACE rate associated with maxLCBI4mm >400 was significantly higher than maxLCBI4mm ≤400 (stable 13.8% vs 6.5%; acute patients 11.6% vs 6.3%, respectively). In conclusion, in patient groups that present with stable angina pectoris or silent ischemia versus acute coronary syndrome, the NC lipidic content was similar, as was NC-MACE, through 2 years of follow-up.

Abstract Background Sarcoidosis is a rare multiorgan inflammatory disorder of unknown aetiology, characterized by the formation of non-caseating granulomas in the affected organs. Cardiac involvement is underrecognized and observed in up to 25% of cases in autopsy studies, and is associated with a high mortality rate, especially due to sudden cardiac death due to ventricular arrhythmias. Case summary A 41-year-old man well known to our hospital because of his father’s diagnosis of cardiac amyloidosis, and carrier of transthyretin (TTR) gene mutation, was hospitalized following a resuscitated cardiac arrest. The patient was hospitalized a month before for a syncopal episode with demonstration of preserved left ventricular ejection fraction (LVEF) with akinetic basal septum at heart ultrasound and normal coronary. Chest computed tomography, performed in the emergency department, was significant for hilar lymphadenopathies and pulmonary nodules highly suggestive of sarcoidosis. A subsequent 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed multiorgan phlogistic involvement, including the myocardium. After the diagnosis of cardiac sarcoidosis, the patient was started on steroids therapy and underwent ICD implantation. A follow-up 18-FDG-PET showed a reduction of organs glucose uptake and a follow-up echo an improvement in LVEF. Despite that, he occurs occasional recording of repetitive ventricular arrhythmias and one appropriate ICD shock during the next 12 months. Discussion Cardiac sarcoidosis is an insidious disease. Its diagnosis can be challenging, with no specific finding in echocardiography. The best strategy would be multi-modality imaging involving both magnetic resonance imaging with late gadolinium enhancement and 18-FDG-PET, followed by biopsy to confirm the diagnosis. Multi-modality imaging should be further used to evaluate the response to treatment and assess prognosis. Since the patient was a known carrier of the TTR gene mutation, many efforts were made in order to come up with the correct diagnosis considering that both cardiac amyloidosis and cardiac sarcoidosis are non-ischaemic cardiomyopathy with systemic involvement.

Few data are available about the impact on outcomes of procedural strategies for percutaneous coronary intervention with thin-struts stents on unprotected left main (ULM): 792 patients with an ULM stenosis treated with percutaneous coronary intervention with thin-strut stents were enrolled in the present multicenter registry. Target lesion revascularization (TLR) was the primary end point. MACE (a composite of all-cause death, myocardial infarction, TLR, and stent thrombosis) and its single components, along with target vessel revascularization were the secondary end points. Subgroup analyses were performed according to complex versus noncomplex bifurcation lesions. After 16 months, 5.5% of patients experienced a TLR. At multivariate analysis, provisional stenting (odds ratio [OR] 0.46: 0.85 to 0.23, p = 0.006), use of imaging (OR 0.45: 0.23 to 0.98, p = 0.003) and final kissing balloon (FKB) (OR 0.41: 0.83 to 0.21, p = 0.001) reduced risk of TLR. FKB reduced risk of overall TLR only for 2 stents-strategy (6.2% vs 32.4%, p <0.05), but not for provisional strategy (3.8% vs 3.7%, p = 0.67). Intracoronary imaging reduced risk of overall TLR both for provisional (2.2% vs 5.4%) and for 2-stents strategy (7.3% vs 14.1% p <0.05 for both, all confidence interval 95%). In conclusion, TLR for ULM patients treated with thin-strut stents is infrequent. Provisional stenting was noninferior compared with 2-stents apart from complex lesions. Benefit from intracoronary imaging is consistent for different strategies, whereas that from FKB persists only for 2-stents.

Optimal dual antiplatelet therapy (DAPT) duration for patients undergoing percutaneous coronary intervention (PCI) for coronary bifurcations is an unmet issue. The BIFURCAT registry was obtained by merging two registries on coronary bifurcations. Three groups were compared in a two-by-two fashion: short-term DAPT (≤ 6 months), intermediate-term DAPT (6-12 months) and extended DAPT (>12 months). Major adverse cardiac events (MACE) (a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization and stent thrombosis) were the primary endpoint. Single components of MACE were the secondary endpoints. Events were appraised according to the clinical presentation: chronic coronary syndrome (CCS) versus acute coronary syndrome (ACS). 5537 patients (3231 ACS, 2306 CCS) were included. After a median follow-up of 2.1 years (IQR 0.9-2.2), extended DAPT was associated with a lower incidence of MACE compared with intermediate-term DAPT (2.8% versus 3.4%, adjusted HR 0.23 [0.1-0.54], p <0.001), driven by a reduction of all-cause death in the ACS cohort. In the CCS cohort, an extended DAPT strategy was not associated with a reduced risk of MACE. In conclusion, among real-world patients receiving PCI for coronary bifurcation, an extended DAPT strategy was associated with a reduction of MACE in ACS but not in CCS patients.