Precise appreciation of the 3-dimensional relationship between the edge-to-edge clips and mitral valve apparatus remains clinically challenging. We demonstrate the images of clips observed in situ 4 years after implantation. Detailed observation from this case helps improve our understanding of 3-dimensional clinical cardiac anatomy related to transcatheter edge-to-edge mitral valve repair. (Level of Difficulty: Intermediate.).

Objectives

This study was performed to determine predictors of subacute stent thrombosis (SST) in the era of intravascular ultrasound (IVUS)-guided coronary stenting without anticoagulation.

Background

The incidence of stent thrombosis has declined with the application of high pressure stent deployment with only antiplatelet therapy. However, no data are available on predictors of stent thrombosis in this era.

Methods

Between March 30, 1993 and July 31, 1995, 1,042 consecutive patients underwent coronary stenting without anticoagulation. For this analysis, we excluded patients who underwent coronary artery bypass surgery, died or had acute stent thrombosis within the 1st 24 h after stenting (41 patients). A total of 1,001 patients (1,334 lesions) were included; 982 patients (1,315 lesions) without SST and 19 patients (19 lesions) with SST.

Results

The rate of SST was 1.9% (per patient). There was no difference between the SST and No SST groups in rescue stenting (12% vs. 13.5%, p = 1.0) or mean +/- SD reference diameter (3.11 +/- 0.58 vs. 3.19 +/- 0.53 mm, p = 0.54). A preexisting thrombus was present in 12% of the SST group and in 4.5% of the No SST group (p = 0.19). Predictors of SST by univariate analysis were low ejection fraction (p = 0.004), more stents per lesion (p = 0.049), use of combination of different stents (p = 0.012), smaller balloon size (p = 0.012) and suboptimal result in terms of smaller lumen dimensions by angiography (p = 0.016) and IVUS (p = 0.004), residual dissections (p = 0.027) and slow flow (p = 0.0001). In stepwise logistic regression analysis, ejection fraction (p = 0.019), use of a combination of different stents (p = 0.013) and postprocedure dissections (p = 0.014) and slow flow (p = 0.0001) were predictive of SST.

Conclusions

In the present era of stent implantation, factors that may predispose to SST are low ejection fraction, intraprocedural complications leading to utilization of more stents, particularly with different stent designs, and suboptimal final result in terms of smaller lumen dimensions and persistent slow flow and dissections.

Background

Treatment of calcified (in contrast to simple) lesions with PTCA has been associated with a lower success rate and more procedural complications. Rotablation can improve acute results, but the high restenosis rate remains a problem. The purpose of this study was to evaluate the clinical and angiographic outcome of patients with complex and calcified lesions treated with a combination of rotablation and stenting.

Methods and results

Seventy-five consecutive patients with 106 lesions had rotablation prior to coronary stenting. Intravascular ultrasound-guided stenting was used without subsequent anticoagulation in 93% of patients. Procedural success was achieved in 93.4% of lesions. Acute stent thrombosis occurred in two lesions (1.9%), and subacute stent thrombosis in one lesion (0.9%). Angiographic follow-up was performed in 82.5% of lesions at 4.6 +/- 1.9 months with an angiographic restenosis rate of 22.5%. Clinical follow-up was performed in all patients at 6.4 +/- 3 months; target lesion revascularization was needed in 18% of lesions; Q-wave myocardial infarction occurred in 1.3%, coronary bypass surgery in 4.0%, and death in 1.3%.

Conclusions

Optimal coronary stenting after rotablation in calcified and complex lesions can be performed with a high success rate, an acceptable rate of procedural complications, and a low rate of stent thrombosis. This approach was associated with a low incidence of angiographic restenosis compared with results usually obtained with other interventional strategies in calcified and complex lesion subsets.