The interest in rotational atherectomy (RA) has increased over the past decade as a consequence of more complex and calcified coronary stenoses being attempted with percutaneous coronary interventions. Yet adoption of RA is hampered by several factors: amongst others, by the lack of a standardised protocol. This European expert consensus document stems from the awareness of the large heterogeneity in the protocols adopted to perform rotational atherectomy. The objective of the present document is to provide some points of consensus among highly experienced operators on the most controversial steps of RA in an attempt to build the basis of a standardised and universally accepted protocol.

The aim of this study was to investigate the immediate and long-term outcome of patients who were treated with rotational atherectomy (RA) to facilitate the delivery of drug eluting stents (DES) in heavily calcified lesions. We analyzed 150 consecutive patients who underwent RA and subsequently DES implantation in our institution. The patients had heavily calcified coronary artery lesions requiring plaque modification prior to conventional angioplasty and stent implantation. Rotational atherectomy was performed using the standard Boston Scientific Rotablator system. A 2-burr stepped approach was selected in most of the cases. Following successful modification of the plaque, the angioplasty was performed with a balloon at low pressure to avoid dissection and a DES was implanted. The mean follow up period was 3 years (max. 78 months). Follow-up data included all cause death, stroke, myocardial infarction (MI), recurrent angina, re-hospitalization, target lesion revascularization (TLR), target vessel revascularization (TVR), and long-term duration of dual antiplatelet therapy. The rate of recurrent angina and MI during follow up was low (3.3%) and the overall major adverse cardiac events (MACE) rate was 11.3%. No MACE occurred during hospitalization. There was no relationship between discontinuation of clopidogrel and occurrence of death or MI. The combined approach of RA-DES has a favorable effect when dealing with heavily calcified lesions in both the angiographic and clinical outcomes. No safety concerns are observed up to 6 years.

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Objective-To use transthoracic Doppler echocardiography to assess coronary blood flow non-invasively in patients with hypertrophic cardiomyopathy. Design-High frequency transthoracic Doppler echocardiography was used to assess resting phasic coronary velocity patterns in patients with hypertrophic cardiomyopathy and to define the relation between coronary flow patterns and clinical, echocardiographic, and haemodynamic manifestations of this condition. Patients with hypertrophic cardiomyopathy commonly have evidence of myocardial ischaemia despite angiographically normal coronary arteries. Alterations of the coronary circulation have been described in left ventricular hypertrophy and proposed as a mechanism for the development of angina pectoris in these patients. Invasive studies have described a reduced cardiac reserve in patients with left ventricular hypertrophy secondary to many conditions, including aortic stenosis, systemic hypertension, and hypertrophic cardiomyopathy.' 5 There are few data available on coronary blood flow in unsedated patients with hypertrophic cardiomyopathy. Transthoracic echocardiography allows non-invasive evaluation of coronary flow patterns in the distal segment of the left anterior descending coronary artery (LAD).6 In the present study transthoracic echocardiography was used to assess phasic coronary velocity patterns in patients with hypertrophic cardiomyopathy and to define the relation between coronary flow patterns and clinical and haemodynamic manifestations of this condition. Methods PATIENTSFifteen patients (10 men and five women, mean (SD) age 49 (10 3) years) admitted to hospital for assessment of hypertrophic cardiomyopathy were studied. The patients were selected from a group of 21 because of the ease of imaging the LAD. Hypertrophic cardiomyopathy was diagnosed on the basis of an echocardiographic demonstration of a hypertrophied and non-dilated left ventricle in the absence of a secondary cause of left ventricular hypertrophy. Thirteen patients had a thickness ratio > 1 5 between the interventricular septum and the posterior wall. Of the remaining two patients, one had evidence of an intraventricular gradient by echocardiography and cardiac catheterisation, and the other had severe hypertrophy without coronary artery disease or hypertension. Eight patients had symptoms of chest pain, palpitation, or dyspnoea. Coronary angiography was performed in 11 patients, all of whom had normal coronary arteries. A control group of 16 normal participants (nine men and seven women, mean age 61 2 (10-7) years) was also studied. ECHOCARDIOGRAPHY OF THE LAD

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