SummaryBackgroundRemote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months.MethodsWe did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed.FindingsBetween Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91–1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed.InterpretationRemote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI.FundingBritish Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden.

Background Use of drug coated balloons (DCBs) in coronary intervention is escalating. There is a plethora of data on Paclitaxcel‐DCB. However, when it comes of stents, Limus‐drugs are preferred over Paclitaxel. There is very limited data on Sirolimus coated balloons (SCB). MagicTouch‐SCB (Concept Medical, FL) elutes Sirolimus via nano‐technology and have been used in our centers since March 2018. We report a mid‐term follow‐up with this relatively novel‐technology. Methods and results We retrospectively analyzed all patients treated with MagicTouch‐SCB between March‐2018 and February‐2019. Results are reported as cardiac‐death, target‐vessel myocardial‐infarction (TVMI), target lesion revascularization (TLR) and Major Adverse Cardiac Events (MACE). During the study period, 288‐patients (373‐lesions) with a mean age of 65.8 were treated with MagicTouch‐SCB. 84% (n = 241) were male, 155 (54%) were in the setting of acute coronary syndrome, 38% (n = 110) had diabetes and 62% (n = 233) were in de‐novo lesions. Most lesions treated were in the LAD/diagonal‐system (n = 170; 46%). Pre‐dilatation was performed in 92% (n = 345) of cases. Bailout stenting was required in 9% lesions (n = 35). The mean diameter and length of SCBs were 2.64 ± 0.56 mm and 24 ± 8.9 mm respectively. During a median follow‐up of 363 days (IQR: 278–435), cardiac death and TVMI occurred in 5‐patients (1.7%) and 10‐patients (3.4%) respectively, TLR per‐lesion was 12%. The MACE rate was 10%. There were no documented cases of acute vessel closure. Conclusions The results from mid‐term follow‐up with this relatively new technology SCB is encouraging with a low rates of hard endpoints and acceptable MACE rates despite complex group of patients and lesion subsets.

A 64-year-old man underwent successful salvage angioplasty on an occluded right coronary artery after a failed thrombolysis for an acute inferior myocardial infarction. A second successful stenting procedure was performed 1 week later with Taxus drug-eluting stents (Boston Scientific) on further significant disease in the left mainstem and proximal left anterior descending artery. Both procedures were performed via the right radial approach with a 6F Cook sheath (William Cook Europe). The patient presented 5 weeks later complaining of dilated superficial veins over the right forearm (Figure 1), with an easily palpable thrill at the right radial puncture site. Subsequent Doppler ultrasound imaging demonstrated a radial arteriovenous fistula (Figure 2). Arteriovenous fistula is a well-recognized complication after cardiac catheterization via the femoral or brachial approach, but it has not been reported in previously published series of radial catheter-based procedures. This patient was referred for surgical ligation of the fistula, which was delayed until he completed a 6-month course of clopidogrel. Figure 1. Dilated superficial veins on the volar surface of the right forearm. A prominent thrill was detected over the radial artery puncture site.Figure 2. Doppler ultrasound confirmed the presence of an arteriovenous fistula over the radial artery puncture site.

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images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 354;21 www.nejm.org may 25, 2006 2262A 71-year-old man who had had rheumatic fever as a child presented with prosthetic-valve endocarditis. A mitral valvotomy had been performed 37 years before, and 21 years later, his mitral valve was replaced with a Starr-Edwards prosthesis. Lateral chest radiography showed complete calcification of the left atrial wall (Panel A, arrows). A transesophageal echocardiogram showed calcification of the interatrial septum (Panel B, arrow). This rare condition was first described in 1898, in association with chronic rheumatic mitral disease, and is more common in women, most of whom have symptoms for more than 20 years. The condition is assumed to be the end result of extensive rheumatic pancarditis. The calcification may be confined to the left atrial appendage or, rarely, to the posterior left atrial wall -owing to a regurgitant mitral jet -in which case the calcified patch is called the MacCallum's patch. Massive calcification usually spares the interatrial septum, but when the septum is affected (as in Panel B, arrow), any further surgery near the mitral valve is hazardous. Radiography of the left lateral side of the chest is recommended to assess long-standing rheumatic mitral-valve disease. Complete calcification has been described as a "coconut atrium" or "porcelain atrium."