Carlo di Mario, MD,cc Kefei Dou, MD,dd Mohaned Egred, MD,ee Basem Elbarouni, MD,ff Ahmed M. ElGuindy, MD,gg Javier Escaned, MD,hh Sergey Furkalo, MD,ii Andrea Gagnor, MD,jj Alfredo R. Galassi, MD,kk Roberto Garbo, MD,ll Gabriele Gasparini, MD,mm Junbo Ge, MD,nn Lei Ge, MD,nn Pravin Kumar Goel, MD,oo Omer Goktekin, MD,pp Nieves Gonzalo, MD,qq Luca Grancini, MD,rr Allison Hall, MD,ss Franklin Leonardo Hanna Quesada, MD,tt Colm Hanratty, MD,uu Stefan Harb, MD,vv Scott A. Harding, MD,ww Raja Hatem, MD,XX Jose P.S. Henriques, MD,yy David Hildick-Smith, MD,zz Jonathan M. Hill, MD,aaa Angela Hoye, MD,bbb Wissam Jaber, MD,ccc Farouc A. Jaffer, MD, PHD,ddd Yangsoo Jang, MD,eee Risto Jussila, MD,fff Artis Kalnins, MD,ggg Arun Kalyanasundaram, MD, MPH,hhh David E. Kandzari, MD,iii Hsien-Li Kao, MD,jjj Dimitri Karmpaliotis, MD, PHD,kkk Hussien Heshmat Kassem, MD, PHD,lll Jaikirshan Khatri, MD,mmm Paul Knaapen, MD,nnn Ran Kornowski, MD,ooo Oleg Krestyaninov, MD,ppp A.V. Ganesh Kumar, MD,qqq Pablo Manuel Lamelas, MD, MSC,rrr Seung-Whan Lee, MD,sss Thierry Lefevre, MD,ttt Raymond Leung, MD,uuu Yu Li, MD,vvv Yue Li, MD,www Soo-Teik Lim, MD,XXX Sidney Lo, MD,yyy William Lombardi, MD,zzz Anbukarasi Maran, MD,aaaa Margaret McEntegart, MD, PHD,bbbb Jeffrey Moses, MD,cccc Muhammad Munawar, MD,dddd Andres Navarro, MD,eeee Hung M. Ngo, MD, PHD,ffff William Nicholson, MD,gggg

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Introduction and objective: Assessment of coronary lesions by the instantaneous wave free ratio (iFR) has generated significant debate. We aimed to assess the diagnostic performance of iFR and its impact on the decision to use fractional flow reserve (FFR) and on procedural characteristics. Methods: In this single-center registry of patients undergoing functional assessment of coronary lesions, FFR was used as a reference for assessing the diagnostic performance of iFR. An iFR value <0.86 was considered positive and a value >0.93 was considered negative. Results: Functional testing was undertaken of 402 lesions, of which 154 were assessed with both techniques, 222 with FFR only, and 26 with iFR only. Using a cut-off of <= 0.80 for iFR, the area under the curve was 0.73 (95% CI 0.65-0.81), with an optimal value of <= 0.91. FFR was undertaken in 93 out of 94 lesions with an inconclusive iFR and was performed in 69.1% of the remaining iFR-tested lesions. Concordance between iFR and FFR was 87% (chi-square=22.43; p<0.001). Notwithstanding, there were four out of 13 cases (30.7%) of positive iFR with negative FFR and three out of 42 (7.1%) cases of negative iFR and positive FFR. This difference was significant (p=0.026). iFR had no impact on procedure time, fluoroscopy time or radiation dose. Conclusion: iFR had a reasonable diagnostic performance. Operators often chose to perform FFR despite conclusive iFR results. iFR and FFR were highly concordant, but a non-negligible proportion of lesions classified as ischemic by iFR were classified as non-ischemic by FFR. iFR had no impact on procedural characteristics. Copyright (C) 2018 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier Espana, S.L.U. All rights reserved.

Resumo: Introdução e objetivos: A avaliação de lesões coronárias pelo instantaneous wave free ratio (iFR) tem gerado debate. Pretendeu‐se analisar o desempenho diagnóstico do iFR e o seu impacto na decisão de usar o fractional flow reserve (FFR) e nas características do procedimento. Métodos: Registo unicêntrico de doentes submetidos a avaliação funcional de lesões coronárias. O desempenho do iFR foi aferido com o FFR como referência. Valores de iFR < 0,86 e > 0,93 foram considerados positivos e negativos, respetivamente. Resultados: Avaliaram‐se 402 lesões, em 154 casos com ambas as técnicas, em 222 apenas com FFR e 26 apenas com iFR. Com um limiar de FFR ≤ 0,80, a área sob a curva foi de 0,73 (95% IC 0,65‐0,81) – valor ótimo de iFR ≤ 0,91. Efetuou‐se FFR em 93 de 94 lesões inconclusivas por iFR e em 69,1% dos restantes casos aferidos com iFR. O iFR e o FFR foram concordantes em 87% dos casos (X2 =22,43; p < 0,001). Não obstante, verificaram‐se quatro em 13 casos (30,7%) de iFR positivo e FFR negativo e três em 42 casos (7,1%) de iFR negativo e FFR positivo. Essa diferença foi estatisticamente significativa (p = 0,026). O iFR não teve impacto na duração, dose/tempo de radiação do procedimento. Conclusões: O desempenho diagnóstico do iFR foi razoável. Os operadores habitualmente efetuaram FFR apesar de valores conclusivos de iFR. Verificou‐se elevada concordância, mas com uma proporção não negligenciável de lesões classificadas como isquémicas por iFR e não isquémicas por FFR. O iFR não teve impacto nas características do procedimento. Abstract: Introduction and Objective: Assessment of coronary lesions by the instantaneous wave free ratio (iFR) has generated significant debate. We aimed to assess the diagnostic performance of iFR and its impact on the decision to use fractional flow reserve (FFR) and on procedural characteristics. Methods: In this single‐center registry of patients undergoing functional assessment of coronary lesions, FFR was used as a reference for assessing the diagnostic performance of iFR. An iFR value <0.86 was considered positive and a value >0.93 was considered negative. Results: Functional testing was undertaken of 402 lesions, of which 154 were assessed with both techniques, 222 with FFR only, and 26 with iFR only. Using a cut‐off of ≤0.80 for iFR, the area under the curve was 0.73 (95% CI 0.65‐0.81), with an optimal value of ≤0.91. FFR was undertaken in 93 out of 94 lesions with an inconclusive iFR and was performed in 69.1% of the remaining iFR‐tested lesions. Concordance between iFR and FFR was 87% (chi‐square=22.43; p<0.001). Notwithstanding, there were four out of 13 cases (30.7%) of positive iFR with negative FFR and three out of 42 (7.1%) cases of negative iFR and positive FFR. This difference was significant (p=0.026). iFR had no impact on procedure time, fluoroscopy time or radiation dose. Conclusion: iFR had a reasonable diagnostic performance. Operators often chose to perform FFR despite conclusive iFR results. iFR and FFR were highly concordant, but a non‐negligible proportion of lesions classified as ischemic by iFR were classified as non‐ischemic by FFR. iFR had no impact on procedural characteristics. Palavras‐chave: Instantaneous wave‐free ratio, Fractional flow reserve, Avaliação funcional invasiva de lesões coronárias, Keywords: Instantaneous wave‐free ratio, Fractional flow reserve, Invasive functional assessment of coronary lesions

Although radiation dermatitis is a widely known complication of radiotherapy, its association with fluoroscopy-guided interventional procedures is yet under recognized. We present a case of a 66-year-old man with a left scapular cutaneous lesion, initially diagnosed as a fixed drug eruption. The subsequent knowledge of a previous percutaneous aortic paravalvular leak closure procedure allowed a correct clinicopathological correlation and the final diagnosis of subacute radiodermatitis associated with fluoroscopy. Many of the patients with skin injury associated with fluoroscopic procedures do not associate both and seek physicians other than the one who performed the procedure. Besides interventional physicians, dermatologists and other physicians should be aware of this form of radiation injury and its manifestations. Suspicion and active search for a history of previous fluoroscopic procedures in patients with figurate cutaneous lesions in allusive locations may allow the diagnosis of this potentially serious complication that should have long follow-up due to the possibility of long-term side effects.

Improvements in echocardiographic technology have made technically difficult studies a rare entity. However, physical barriers such as bandages, inability for patients to turn because of intubation, arterial lines, and organ and life support machines make echocardiographic imaging challenging.We performed echocardiographic imaging from left and right posterior thoracic approach using acoustic properties of pleural fluid to assist in obtaining good imaging windows in patients who had pleural effusion (PE). In this study we describe one author’s (T. Z. N.) experience with the mid to lower posterior thoracic window in 18 patients who had PE and in whom conventional transthoracic windows either provided suboptimal images or incomplete clinical information.The posterior approach allowed excellent differentiation of pericardial effusion versus PE, detection of pericardial disease and pericardial infiltration, and excellent endocardial border definition of left and right ventricle in those with poor anterior transthoracic windows. Native and prosthetic aortic valve gradients could be assessed adequately as a result of perfectly parallel Doppler alignment beam to left ventricular outflow tract and aortic valve. In addition, right posterior thoracic window provided views comparable with subcostal view and allowed visualization of inferior vena cava, right atrium, and liver.In patients with PE, imaging from low to midposterior thorax can provide additional diagnostic echocardiographic images and should be used in patients in whom conventional images are technically difficult or require additional information.

La homeostasis de los distintos ejes hipotálamo-hipofisarios se mantiene gracias a la interacción de los circuitos de retroalimentación positiva y negativa en los que participan las hormonas hipofisarias, señales distales, incluidas las hormonas esteroideas, y aferencias nerviosas de otras regiones cerebrales sobre las neuronas hipofisotróficas. Existen múltiples mecanismos que pueden ocasionar una enfermedad del eje hipotálamo-hipofisario; entre ellas se encuentran mutaciones genéticas, alteraciones epigenéticas, procesos inflamatorios, infecciosos y tumorales, trastornos vasculares, traumatismos y diversas situaciones psicógenas. El síndrome hipotalámico puede presentarse con manifestaciones tanto endocrinas como no endocrinas. Una característica clínica habitual es la «obesidad hipotalámica». El diagnóstico clínico es complicado, por lo que el diagnóstico de confirmación debe complementarse con distintas pruebas orientadas según la sospecha clínica; generalmente con un estudio hormonal y radiológico. Es recomendable realizar un abordaje multidisciplinar para tratar los síntomas y deficiencias hormonales y mejorar la calidad de vida de los pacientes.Maintaining homeostasis in hypothalamic-pituitary axis is accomplished through interlinked positive and negative feedback loops involving both pituitary hormones, distal signals (including steroid hormones), and nerve inputs from other brain regions on hypophysiotropic neurons. Pituitary-hypothalamic axis disorders may be caused by several ways: genetic mutations, epigenetic alterations, inflammatory and tumoral conditions, vascular disorders, traumatisms and different psychogenic situations. Hypothalamic syndrome can present with both endocrine and non-endocrine manifestations. Hypothalamic obesity is a common clinical feature. Clinical diagnosis is complicated. In accordance with clinical suspicion, complementary tests (generally hormonal and radiological study) must be carried out to confirm the diagnosis. In order to treat the symptoms, restore hormone levels and improve the quality of life of patients, multidisciplinary approach is recommended.