Raquel del Valle

Coronary artery disease is a highly prevalent disease that constitutes the leading cause of mortality worldwide. Acute coronary syndromes are the most devastating form of presentation of coronary disease, involving the acute formation of a thrombus within the coronary vessel lumen, further leading to flow limitation and diminished myocardial perfusion. Vulnerable plaques, which are characterized by thin-cap fibroatheroma, a large lipid pool, and macrophage infiltration and spotty calcification of the cap, pose a higher risk of coronary events despite not being flow-limiting. Iterations in intravascular imaging and coronary computed tomography have largely increased the ability to detect and define vulnerable plaques, and its clinical impact in early- and mid-term outcomes has been confirmed in several studies. In this review, we aimed to revise the current concept of vulnerable coronary plaque and its repercussion, to summarize the main pharmacological approaches for its management, and to provide an updated overview of the available evidence on preventive percutaneous interventional strategies in this clinical setting.

Background: Patients with aortic stenosis may continue to have an increased risk of heart failure, arrhythmias, and death after successful transcatheter aortic valve implantation. Renin‐angiotensin system inhibitors may be beneficial in this setting. We aimed to explore whether ramipril improves the outcomes of patients with aortic stenosis after transcatheter aortic valve implantation. Methods and Results: PROBE (Prospective Randomized Open, Blinded Endpoint) was a multicenter trial comparing ramipril with standard care (control) following successful transcatheter aortic valve implantation in patients with left ventricular ejection fraction >40%. The primary end point was the composite of cardiac mortality, heart failure readmission, and stroke at 1‐year follow‐up. Secondary end points included left ventricular remodeling and fibrosis. A total of 186 patients with median age 83 years (range 79–86), 58.1% women, and EuroSCORE‐II 3.75% (range 3.08–4.97) were randomized to receive either ramipril (n=94) or standard treatment (n=92). There were no significant baseline, procedural, or in‐hospital differences. The primary end point occurred in 10.6% in the ramipril group versus 12% in the control group ( P =0.776), with no differences in cardiac mortality (ramipril 1.1% versus control group 2.2%, P =0.619) but lower rate of heart failure readmissions in the ramipril group (3.2% versus 10.9%, P =0.040). Cardiac magnetic resonance analysis demonstrated better remodeling in the ramipril compared with the control group, with greater reduction in end‐systolic and end‐diastolic left ventricular volumes, but nonsignificant differences were found in the percentage of myocardial fibrosis. Conclusions: Ramipril administration after transcatheter aortic valve implantation in patients with preserved left ventricular function did not meet the primary end point but was associated with a reduction in heart failure re‐admissions at 1‐year follow‐up. Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT03201185.

Aims To assess the anterograde's drainage clinical and technical success in non-neoplastic obstructed biliary and pancreatic ducts. Methods Data from patients with an obstructed biliary or pancreatic duct between 01/2021-10/2022 were retrospectively analyzed. Clinical and technical success were the primary endpoints. Adverse events, re-stenosis, and re-intervention were also evaluated ([Table 1]). Results Twenty patients included: 15/20 EUS-guided biliary drainage (EUS-BD) and 5/20 EUS-guided pancreatic duct drainage (EUS-PDD). A) EUS-BD: Anterograde drainage was performed in 7/15 using a single pigtail stent, 5/15 double pigtail stents and 3/15 lumen-apposing metal stent (LAMS). Stomach puncture was the preferred approach site in 12/15. A 15/15 (100%) technical success was achieved, but a 8/15 (60%) clinical success based on bilirubin decrease. During follow-up, adverse events were documented in 5/15 cases: upper GI bleeding, cholangitis, and subhepatic fluid collection. Stent migrated in 3/15 cases. There was no re-stenosis, but reintervention was necessary on 8/15. Survival rate 13/15. B) EUS-PDD: In 3/5 cautery-assisted dilation was required. In 1/5, balloon dilation was also necessary. Used stents: single and double pigtail stents, LAMS, and self-expandable metal stents (SEMS). Technical and clinical success was achieved in 5/5 (100%), with no adverse events [1] [2] [3]. Conclusions Anterograde EUS-BD and EUS-PDD for managing non-neoplastic obstructed biliary and pancreatic ducts are valuable alternatives when ERCP is not feasible. Reintervention after EUS-BD and EUS-PDD appears to be related to stent migration and re-stenosis, respectively. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims To evaluate the real-world effectiveness of an AI-assisted colonoscopy (AI-VCC) and compare the results among experts and non-experts endoscopists (Fig. 1). Methods Consecutive patients ≥45 years old who underwent VCC (11/2020-03/2021). First, a standard HD-VCC was performed. Then, an AI-VCC was performed by a second operator blinded to previous findings. Adenoma detection rate (ADR) was a quality indicator of the procedure. The polyp detection rate (PDR), and the adenoma and polyp miss rates (AMR and PMR, respectively) were also calculated. The results were compared between experts and non-experts endoscopists. NCT04915833 [1] [2] [3] [4] [5] [6] (Fig. 2). Results 115 patients were included. 58/115 (50.4%) had a total of 205 polyps/adenoma, with a PDR and ADR of 132/205 (64.3%) and 73/205 (35.6%) with VCC, respectively: 19/205 (9.3%) NICE II, 7/205 (3.4%) >10 mm. With AI-assistance, the ADR and PDR increased from 16.5% to 18.2% and from 50.4% to 60%, respectively. The ADR increased from 10.8% to 16.2% in the junior group with the AI-VCC. No difference in ADR was observed in the senior cohort ([Table 1]). PMR was 43.13%, AMR was 5.19%. Sensitivity among different colon segments ranged from 56.25% (rectum) to 78.26% (ascending colon). Capability of AI for appropriate polyp and adenoma presence discharging (negative predictive value, NPV) ranged from 61.54% (sigmoid) to 89.09% (cecum). Lower rates for specificity (8.42-49.49%) and PPV (9.89-19.78%) were observed due to high false positives. ([Table 2]). Conclusions Junior endoscopists benefit from the AI-assisted polyp detector during screening colonoscopy as it helps them achieve an ADR comparable to that of senior endoscopists. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims To estimate EUS-guided shear wave elastography (EUS-SW) diagnostic accuracy for chonic pancreatitis (CP) and solid pancreas neoplasms (PN). Methods Included cases with recent diagnosis of CP or PN undergoing EUS-SW (12/20-11/22); a control group (CG) with cases requiring EUS evaluation for subepithelial lesion. Fatty pancreas score, strain ratio (SR), histogram (SH), and ten EUS-SW elasticity (SWE) measurements and dispersion (SWD) were assessed. SWE/SWD variation was based on quotient among IQR and median. SWE and SWD association was estimated with a MANOVA in <30% variation. SWE and SWD cut-off values were calculated with Youden’s index [1] [2]. Results 88 enrolled cases (37 CG, 14 CP, 37 PN). Fatty pancreas score II and III was similar in CG (37.8%/56.8%) and CP (57.1%/42.9%); there was a significant difference in PN, with a score II, III, and IV of 24.3%, 40.5%, and 29.7%, respectively (p<.001). Median SR was similar among CG (3.6; IQR 2.9 – 4.3) and CP (3.9; IQR 3.6 – 4.7), but significantly different to PN (7.6; IQR 5.3 – 11.1; p<.001). Median SWE and SWD were 10.5 kPa (7.3 – 16.6) and 1.9 [m/s]/kHz (1.6 – 2.4), with a <30% variation in 30.7% and 64.8%, respectively (table 1). Diabetes was associated to higher SWE and SWD (p<.05). Predicted SWE were significantly different among PN vs CG (-13.1; -24.4 to -1.7; p=.0242) ([Fig. 1]). SWE ≥17.4 diagnosed PN with a 75% sensitivity, 91% specificity, 60% PPV and 95% NPV; while SWD ≥2.31 predicted PN with a diagnostic accuracy of 54%, 70%, 35%, 84%, respectively. Conclusions EUS-SW is a valuable measuring tool for CP and PN diagnostic workups. NCT05095831 ([Fig. 2]). Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Paravalvular leakage (PVL) is yet a potential and serious complication after transcatheter aortic valve replacement. Percutaneous PVL closure may be the treatment of choice upon failure of balloon postdilation in patients with excessive surgical risk. If the retrograde approach fails, an antegrade strategy might provide the solution.

Aims A new DSOC system called Eye-Max^TM (Micro-Tech, Nanjing, China) has been developed with a 9Fr and 11Fr scopes and full HD+image (150000 pixels). We aimed to report diagnostic accuracy, biliary stone clearance, and procedure-related adverse events with this new device. Methods Prospective data was collected in consecutive patients aged≥18 years referred for DSOC between July-November 2021. Suspected malignancy/indeterminate stricture diagnosis were allocated into the diagnostic group; failed lithotripsy or>20mm biliary stones were allocated into the therapeutic group. Patients withTM DSOC has excellent diagnostic efficacy for distinguishing neoplastic biliary lesions, as well as therapeutic profitability. Publication Date: 14 April 2022 (online) © 2022. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Revista Española de Cardiología: Interventional Cardiology