Impact of isolated non-dominant hypoplastic right coronary artery disease on cardiovascular events and mortality rates in the elderly

It is generally believed that serious events are unlikely to result from atherosclerotic disease of a non-dominant hypoplastic right coronary artery (RCA). Left dominant coronary artery system are usually associated with higher in-hospital mortality among patients undergoing percutaneous coronary intervention.[1,2] Nevertheless, clinical series or reports of right ventricle infarction, malignat arrhythmias and sudden death correlated to non-dominant RCA have been reported in the literature in the past years.[3,4] The specific contribute of non-dominant RCA disease on long-term follow-up in patients aged over 65 years has not been yet clarified.

Home-made fenestrated amplatzer occluder for atrial septal defect and pulmonary arterial hypertension

We report the management of a patient with secundum atrial septal defect （ASD） and severe pulmonary hypertension. A 65-year-old male with recently diagnosed atrial septal defect was referred to our centre for decompensated right heart failure with rest and exercise induced dispnea and severe pulmonary hypertension. Right heart catheterization confirmed a mean pulmonary pressure of about 55 mmHg and a Qp/Qs of 2.7. An occlusion test with a compliant large balloon demonstrated partial fall of pulmonary arterial pressure. The implantation of a home-made fenestrated Amplatzer ASD Occluder （ASO） was planned in order to decrease left-to-right shunt and promote further decrease of pulmonary arterial pressure in the long-term. Thus, by means of mechanical intracardiac echocardiography study with a 9F 9 MHz Ultralce catheter （Boston Scientific Corp.）, we selected a 34 mm ASO for implantation. Four millimeter fenestration was made inflating a 4 mm non-compliant coronary balloon throughout the waist of the ASO, which was successfully implanted under intmcardiac echocardiography. After six months, a decrease of pulmonary arterial pressure to 24 mmHg and full compensated right heart failure was observed on transthoracic echocardiography and clinical examination. This case suggests that Wanscatheter closure with home-made fenestrated ASD in elderly patients with severe pulmonary hypertension is feasible.

Prolonged high-pressure balloon angioplasty of femoropopliteal lesions：Impact on stent implantation rate and mid-term outcome

Objectives To assess the impact on stent implantation rate and mid-term outcomes of prolonged high pressure angioplasty of femoropopliteal lesions. Methods We retrospectively enrolled 620 consecutive patients from January 2011 to December 2011 （75.6 ±12.3 years, 355 males, 76.5%in Rutherford class 5-6）, referred for critical limb ischemia and submitted to prolonged high-pressure angioplasty of femoropopliteal lesions. The definition of prolonged high-pressure angioplasty includes dilation to at least 18 atm for at least 120 s. Proce-dural data, and clinical and instrumental follow-up were analyzed to assess stent implantation rate and mid-term outcomes. Results The preferred approach was ipsilateral femoral antegrade in 433/620 patients （69.7%） and contralateral cross-over in 164/620 （26.4%） and pop-liteal retrograde＋femoral antegrade in 23/620 （3.7%）. Techniques included subintimal angioplasty in 427/620 patients （68.8%） and endolu-minal angioplasty in 193/620 patients （31.2%）. The prolonged high pressure balloon angioplasty procedure was successful in 86.2%（minor intra-procedural complications rate 15.7%）, stent implantation was performed in 74 patients （11.9%）, with a significant improvement of ankle-brachial index （0.29 ±0.6 vs. 0.88 ±0.3, P〈0.01） and Rutherford class （5.3 ±0.8 vs. 0.7 ±1.9, P〈0.01）, a primary patency rate of 86.7%, restenosis of 18.6%on Doppler ultrasound and a target lesion revascularization of 14.8%at a mean follow-up of 18.1 ±6.4 months （range 1-24 months）. Secondary patency rate was 87.7%. Conclusions Prolonged high pressure angioplasty of femoropopliteal lesions appears to be safe and effective allowing for an acceptable patency and restenosis rates on mid-term.

Congenital coronary artery anomalies silent until geriatric age： non-invasive assessment, angiography tips, and treatment

Coronary artery anomalies （CAAs） may be discovered more often as incidental findings during the normal diagnostic process for other cardiac diseases or less frequently on the basis of manifestations of myocardial ischemia. The cardiovascular professional may be involved in their angiographic diagnosis, fimctional assessment and eventual endovascular treatment. A complete angiographic definition is mandatory in order to understand the functional effects and plan any intervention in CAAs： computed tomography and magnetic resonance imaging are useful non-invasive tools to detect three-dimensional morphology of the anomalies and its relationships with contiguous cardiac structures, whereas coronary arteriography remains the gold standard for a definitive anatomic picture. A practical idea of the possible functional sig- nificance is mandatory for deciding how to manage CAAs： non-invasive stress tests and in particular the invasive pharmacological stress tests with or without intravascular ultrasound monitoring can assess correctly the functional significance of the most CAAs. Finally, the knowledge of the particular endovascular techniques and material is of paramount importance for achieving technical and clinical success. CAAs represent a complex issue, which rarely involve the cardiovascular professional at different levels. A timely practical knowledge of the main issues regarding CAAs is important in the management of such entities.

Thin and crush: The new mantra in left main stenting?

Complex bifurcations have been suggested to be better approached by a planned double stent technique; however, recent randomized trials have shown better outcomes of provisional compared to planned twostent strategy, in terms of both short-term efficacy and safety. In left main(LM) bifurcations, double kissing(DK)-Crush has demonstrated its superiority over Culotte and provisional-T in terms of restenosis and stent thrombosis, gaining respect as one of the most performant techniques for bifurcations stenting. On the other hand, the Nano-Crush technique has recently become part of the repertoire of double stenting techniques, providing evidence that the use of ultrathin strut stents and very minimal crush would be beneficial for both the physiological and rheological properties of the complex bifurcations, even in LM scenario, leading to a lower rate of thrombosis and restenosis at both side branch and true carina. Finally, the newest generation of ultrathin strut stents are gaining a reputation for its safe and effective use in LM treatment thanks to improved design with increased expansion rate capable of LM treatment up to 5-6 mm diameter. The modern crush techniques, such as DK-Crush and Nano-Crush, are providing excellent results on mid and long-term follow up, suggesting that minimal crushing obtained using ultra-thin stents is a good way to obtain surgical-like outcomes in the treatment of complex LM bifurcation disease.

Left atrial dysfunction in elderly patients with patent foramen ovale and atrial septal aneurysm

Objective Recently it has been suggested that, in patients with large patent foramen ovale （PFO） and atrial septal aneurysms （ASA）, a certain amount of left atrial （LA） dysfunction may be active as an alternate mechanism promoting arterial embolism. Following this hypothesis, elderly patients, being more susceptible to atrial chambers stiffness, should present a more severe LA dysfunction profile. We sought to evaluate the grade of LA dysfunction in elderly patients submitted to transcatheter PFO closure. Methods We retrospectively enrolled 28 consecutive patients with previous stroke （mean age 674-12.5 years, 18 females） referred to our centre for catheter-based PFO closure after recurrent stroke. Baseline values of LA passive and active emptying, LA conduit function, LA ejection fraction, and spontaneous echocontrast （SEC） in the LA and LA appendage were compared with those of 50 atrial fibrillation patients, as well as a sex/age/cardiac risk matched population of 70 healthy controls. Results Pre-closure elderly subjects demonstrated significantly greater reservoir function as well as passive and active emptying, with reduced conduit function and LA ejection fraction, when compared to healthy and younger patients. After closure in elderly patients, LAparameters did not return completely to the levels of healthy patients, whereas LA dysfunction in younger subjects returned normal. Conclusions This study suggests that elderly patients have more severe LA dysfunction than younger patients, which affects the LA remodelling after closure.

Endovascular management of patients with coronary artery disease and diabetic foot syndrome： A long-term follow-up

Background To investigate the long-term results of global coronary and peripheral interventional treatment of diabetic foot patients. Methods We retrospectively included 220 diabetic patients （78.5 ±15.8 years, 107 females, all with Fontaine Ⅲor Ⅳclass） who were referred to our centre for diabetic foot syndrome and severe limb ischemia from January 2006 to December 2010. Patients were evaluated by a team of interventional cardiologists and diabetologists in order to assess presence of concomitant coronary artery disease （CAD） and eventual need for coronary revascularization. Stress-echo was performed in all patients before diagnostic peripheral angiography. Patients with indications for coronary angiography were submitted to combined diagnostic angiography and then to eventual staged peripheral and coronary interventions. Doppler ultrasonography and foot transcutaneous oximetry of transcutaneous oxygen pressure （TcPO2） before and after the procedure were performed as well as stress-echocardiography and combined cardiologic and diabetic examination at 1 and 6 month and yearly. Results Stress-echocardiography was performed in 94/220 patients and resulted positive in 56 patients who underwent combined coronary and peripheral angiography. In the rest of 126 patients, combined coronary and peripheral angiography was performed directly for concomitant signs and symptoms of coronary heart disease in 35 patients. Coronary revascularization was judged necessary in 85/129 patients and was performed percutaneously after peripheral interventions in 72 patients and surgically in 13 patients. For Diabetic foot interventions the preferred approach was ipsilateral femoral antegrade in 170/220 patients （77.7%） and contralateral cross-over in 40/220 patients （18.8%） and popliteal retrograde ＋ femoral antegrade in 10/220 patients （4.5%）. Balloon angioplasty was performed in 252 legs （32 patients had bilateral disease）： the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TcPO2 and ABI with ulcer healing in 233/252 legs （92.4%）. Freedom from major amputation was 82.8% at a mean follow-up of 3.1 ±1.8 years （range 1 to 5 years） whereas survival was 88%. Conclusions Global coronary and peripheral endovascular management of diabetic foot syndrome patients seems to lead to an high immediate success and limb salvage rates and increasing survival compared to historical series.

Misdiagnosed Aortic Intramural Hematoma and the Role of Intravascular Ultrasound Imaging in Detection of Acute Aortic Syndrome:A Case Report

Acute aortic syndrome includes classic aortic dissection,aortic intramural hematoma,and penetrating atherosclerotic ulcer– a group of conditions that are defined by their dynamic evolution and similar clinical manifestation.Accurate diagnosis and prompt treatment are essential as all the aforementioned conditions are a signifi cant threat to a patient’s life.However,acute aortic syndrome and especially aortic intramural hematoma may be challenging diagnostic problems.Intravascular ultrasound imaging is a diagnostic method that can be useful for more thorough evaluation of the aortic lesion and can particularly aid in discerning the different forms of acute aortic syndrome.We present a case of a patient with aortic intramural hematoma that was missed by conventional imaging studies but was successfully visualized with intravascular ultrasound imaging.

Congenital coronary artery-left ventricle direct micro-fistulas may cause effort angina and positive stress tests in Western adults

Coronary artery anomalies （CAAs） occur in 0.64 % to 5.6% of patients undergoing coronary angiography, Most pathophysiology and clinical histories involving CCAs have been fully clarified in the past 30 years. Isolated congenital coronary artery-left ventricle direct microfismlas （CVmF） have been recently described, but the clinical significance and anatomical characteristics associated with this rare type of CAA in a western population are still unclear.

Should we consider patent foramen ovale and secundum atrial septal defect as different steps of a single anatomo-clinical continuum？

1 Introduction Isolated atrial septal defects （ASD） represent 7% of all cardiac anomalies and can present at any age. Adolescents and adults with simple congenital heart disease such as isolated atrial septal defects are more likely to reach adult age without being diagnosed. Secundum ASD （sASD） is by far the most common type, occurring in 1/1500 live births, with 65% to 75% involving females, On the other hand, patent foramen ovale （PFO） represents an endemic variant in the normal population with a prevalence of 25%-27%. These two entities appear so different that is difficult to fred a conjunction ring： nevertheless we use the same philosophy for the treatment, Indeed, device-based closure has been proved to be effective in both settings.

Endovascular interventions of the femoro-popliteal disease in the elderly

In the last few years the treatment of superficial femoral artery (SFA) occlusive disease has undergone greater changes in management including more aggressive endoluminal therapy, especially in the elderly patients who are at high risk for extra-vascular comorbidities from the surgical approach. While acute and chronic arterial limb ischemia is the conditions which the interventional cardiologists frequently encounter, the elderly population represents special problematic clinical and anatomical setting due to heavy calcification and poor distal run-off. Arterial thrombolysis, rheolytic thrombectomy, mechanical thrombectomy, laser angioplasty, cryoplasty, and new flexible long stents are some of the promising techniques to improve the technical and clinical outcomes in these elderly patients.

Carotid artery angioplasty and stenting in elderly patients： the advantage of being an interventional cardiologist

Objective Carotid angioplasty and stenting （CAS） has been suggested to be the procedure of choice in patients with high risk cardiovascular profile. Unfortunately, such patients are often aged with several comorbidities, such as a high prevalence of coronary artery disease, peripheral artery disease and hostile anatomy that complicate the CAS performance. We sought to evaluate the results of CAS in elderly patients, outlining the encountered challenges and the eventual proposed global cardiovascular management. Methods We retrospectively searched the database for patients 〉 65-year-old who were referred to Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, over a 24-month period （December 2007-November 2009） for CAS. Coronary angiography and peripheral screening were performed in all patients. All eventual challenges and related solutions were analyzed. Results Totally, 160 patients were enrolled. Among which, 50 patients （31.2%, mean age 80 ~ 6.4 years） underwent CAS over a 24- month period： 24 patients （48%） had concurrent coronary artery disease （three-vessel in 7 patients, bivessel in 8 patients, single vessel in 5 patients and left main in 4 patients）; 13 patients （26%） and peripheral artery disease at the site of arterial access; 15 patients and type III aortic arch （30%）, 7 patients severe tortuosity of the common carotid artery （14%）, and 8 angulated takeoffof carotid or internal artery （16%）. Concurrent percutaneous coronary intervention was performed in 14 patients, including 3 patients with left main disease. Concurrent peripheral intervention was performed in 7 patients （ all with bilateral common or external critical disease） due to the impossibility to gain another access. Successful carotid cannulation was achieved in all patients with hostile neck. Two-wire technique has been used in 17 patients, three-wire technique in 9 patients, and four-wire technique in 4 patients. Conclusion Elderly patients submitted to CAS represent a complex and challenging subgroup in which often cardiac and peripheral technical expertise is required to gain success of the procedure： interventional cardiologists are probably the preferred performers in such complex patients （JGeriatr Cardio12010; 7：3-6）.

Transradial supra-aortic arteries interventions:a good option for elderly patients

1Introducfion Peripheral arterial disease (PAD)is the consequence of atherosclerosis in the arteries of carotid,vertebral,abdominal mesenteric,renal,and extremity arteries with a prevalence increasing with.Carotid Occlusive disease is one of the most common site for atherosclerosis development:Endoatherec- tomy and Carotid artery stenting (CAS)have been shown to achieve similar outcomes and costst[1,2]especially in high-risk patients as very often elderly patients with multiple athero- sclerotic localizations are.The performance of supraaortic diagnostic and interventional procedures via the radial artery (RA)is growing all over the world thanks to lower risk of access site complications,lower chance to embolizing de- bries by touching the aortic arch,lower costs,and increased patient comfort compared to the traditional transfemoral approach (TFA).[3,4]The aim of this paper is to describe the potentiality the TRA can offer in the peripheral interventions of supra-aortic arteries in the elderly.

Topical anaesthesia before transradial approach for supraoartic vessels angiography and stenting in the elderly： a feasible alternative

Over the years, the use of transradial approach （TRA） for carotid artery stenting （CAS） with distal embolic protection has been recognized as a valid alternative to the conventional femoral approach, improving the outcomes compared to carotid endoatherectomy.0-33 Indeed, despite the femoral artery remains the conventional access site for the endovascular treatment of supraoartic vessels, concomitant anatomical variations and/or peripheral vascular disease could complicate the cannulation of such arteries. Moreover, the TRA has been related with a lower incidence of bleeding complications and a shorter bed rest after the interventional procedure.

Hypertension and psychosocial factors: which came first,the egg or the chicken?

In this issue of the Journal of Geriatric Cardiology,the article of Yu, et al1 presents an intriguing issue in the field of hypertension treatment and pathophysiology.……

Past and present of cardiocirculatory assist devices: a comprehensive critical review

During the last 20 years, the management of heart failure has significantly improved by means of new pharmacotherapies, more timely invasive treatments and device assisted therapies. Indeed, advances in mechanical support, namely with the development of more efficient left ventricular assist devices (LVADs), and the total artificial heart have reduced mortality and morbidity in patients awaiting transplantation, so much so, that LVADs are now approved of as a strategy for destination therapy. In this review, the authors describe in detail the current basic indications, functioning modalities, main limitations of surgical LAVDs, total artificial heart development, and percutaneous assist devices, trying to clarify this complex, but fascinating topic.

Closing patent foramen ovale in cryptogenic stroke:The underscored importance of other interatrial shunt variants

Recent trials and metanalysis even not fully conclusive and still debated,at least suggested that mechanical device-based closure of patent foramen ovale(PFO)is more effective than medical therapy in prevent recurrence of stroke. In a proportion ranging from 20% to nearly 40% of patients in literature,PFO is associated to atrial septal aneurysm(ASA):ASA is a well-known entity often associated with additional fenestration. Additionally small atrial septal defects("Flat ASD") can present with signs of paradoxical embolism and cannot be easily detected by transthoracic echocardiography or even by transesophageal echocardiography and are usually discovered by intracardiac echocardiography at the moment of transcatheter closure. This evidence might change potentially the anatomical diagnosis from PFO to fenestrated ASA or as we called it to "hybrid defect",being a bidirectional flow through a small ASD or/and an additional fenestration,often present. Despite the differences in anatomy,pathophysiology and haemodynamic paradoxical embolism may occur in both entities and also may be the first appearance of fenestrated ASA. Because some overlapping do really exist between PFO and hybrid defects,which are often not clearly differentiable by standard diagnostic tools,it is likely that a proportion of patients evaluated for potential transcatheter closure of PFO had actually a different anatomical substrate. These different anatomical and pathophysiologic entities have not been address in any of the previous trials,potentially having an impact on overall results despite the similar mechanical treatment. Neurologists and general cardiologists in charge of clinical management of PFOrelated cryptogenic stroke should be aware of the role of hybrid defects in the pathophysiology of paradoxical embolism- mediated cerebral ischemic events in order to apply the correct decision- making process and avoid downgrading of patients with paradoxical embolism-related interatrial shunt variants different from PFO.

Impact of number of run-off vessels on interwoven nitinol mesh stents patency in the femoropopliteal segment

Objective To evaluate the impact of run-off vessels number on the outcomes of Supera stent(Abbott Vascular,Santa Clara,Calif,USA)for treatment of femoropopliteal occlusive disease.Methods We retrospectively evaluated the medical records of 188 consecutive patients(mean age 68.2±9.6 years,100 males)undergone angiography and woven mesh stent implantation in femoral or popliteal arteries or both arterial segments,in our institution between January 12014 and January 12018.Target lesion revascularization and major adverse limb events at 12-month were evaluated comparing patients with 1-,2-or 3-run-off vessels in the foot.Results Interventional success was achieved in 100%.Stent implantation involved in the femoral site in 56 patients(30.3%),the femoropopliteal in 92 patients(48.9%)and the popliteal site in 40 patients(21.3%).A significant improvement of ankle-brachial index(0.29±0.6 vs.0.88±0.3,P<0.001)and Rutherford class(5.3±0.8 vs.0.7±1.9,P<0.01)were observed before discharge.The median follow-up duration was 12.3 months(inter quartile range:11.0 to 13.9).During the follow-up period,52 patients(27.6%)had clinical events.Primary patency at 12 months was 72.4%.The primary patency significantly increased when the runoff status.Comparing the number of events among patients with different number of run-off vessels,a significant difference(P<0.001)was observed for patients having one(24.0%)and two run-off vessels(15.0%).Conclusions The outcomes of Supera stent in femoropopliteal occlusive disease depend strictly on the number of run-off vessels.

Patent foramen ovale closure in over-60-years old patients with diastolic dysfunction

Background Patent foramen ovale (PFO)-related stroke is a possible and not easily manageable occurrence in ≤60-years-old patients due to the presence of different comorbidities and in particular of diastolic dysfunction which is considered as a contraindication to PFO closure.The grade of diastolic dysfunction for which PFO closure is contraindicated and whether there are changes in diastolic dysfunction class after closure have not been investigated in deep yet.Methods We prospectively enrolled patients who were referred to our centre over a 12 months period for PFO transcatheter closure having echocardiographic demonstration of diastolic dysfunction (≤Ⅲ class diastolic dysfunction).Echocardiography was scheduled at 1,6 and 12 months in order to assess changes in haemodynamic parameters of left ventricle function.Results Thirteen out of 80 patients referred to our centre (16.2%,mean age 65 + 6.4 years) over a 24-month period were enrolled in the study (Table 1).Eighteen Amplatzer PFO Occluder 25 mm and one 35 mm,two Amplatzer 25/25 mm Cribriform Occluder and two 25 nun Premere Occlusion System were successfully implanted with no intraoperative complications.As collateral findings on ICE 8/12 patients (66.7 %) had hypertrophy of the interatrial septum (thickness of the rims ＞ 1.2 mm) probably imputable to hypertensive cardiomyopathy.Four patients developed atrial fibrillation during the first month post-implantation,all successfully treated with antiarrhythmic drugs.After a mean follow-up of 40±4.3 months left ventricle performance indices (ejection fraction and end-diastolic volume) and diastolic dysfunction parameters (E/A,deceleration time,diastolic dysfunction class) did not change significantly.Conclusion The present study suggests that PFO transcatheter closure may be safely performed in aged patients with diastolic dysfunction class 1-2.(J Geriatr Cardio12008;5:3-6.)

Patent foramen ovale in the elderly:what to do?

The increase in life expectance makes the diagnosis of PFO a possible and not easily manageable event in patients > 60-years-old due to the presence of different comorbidities and in particular of diastolic dysfunction which is considered as a contraindication to PFO closure. The literature review suggests that aged patients with PFO cannot be excluded"a priori"from PFO closure that should evaluated as therapeutic options in presence of anatomical and functional indications. Moreover in the elderly many other syndromes than paradoxical stroke mediated by PFO required full assessment and, if needed, transcather PFO closure:deoxygenating in obstructive sleeping apnoea, unexplained increased dyspnoea associated with hypoxemia after lung surgery, paralysis of the hemidiaphragm, and platypnea orthodeoxia. Differently from in the young and middle age, the management of PFO in aged patients should obligatory include the careful evaluation of potential comorbidities and eventual contraindications, such as severe diastolic dysfunction due to for example to hypertensive cardiomyopathy and coronary heart disease, the main causes of diastolic dysfunction.(J Geriatr Cardiol 2007;4:254-256.)