bluuebunny/crossref_metadata_2025 huggingface dataset:
Patient characteristics and clinical outcomes of type 2 myocardial infarction in patients with acute ischemic stroke in the united states
Authors: Ariss R W , Nazir S , Minhas A M , Moukarbel G V , Jneid H
Published: October 2021

Background

Type 2 myocardial infarction (MI) due to supply-demand mismatch may occur as a sequala of acute ischemic stroke (AIS). However, scarce data exits on the patient profiles and the prognostic impact of type 2 MI on outcomes of AIS.

Purpose

To determine the risk profiles and examine the association of type 2 MI with outcomes and resource utilization in primary AIS hospitalizations.

Methods

We utilized the Nationwide Readmission Database from October 1st, 2017 to December 31st, 2018 to identify primary AIS hospitalizations with and without type 2 MI in the United States. The International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes I63.x were utilized to identify patients with AIS. Complex samples multivariable logistic and linear regression models were used to determine the predictors of type 2 MI and the association with outcomes (in-hospital mortality, poor functional outcomes [defined as a composite of mortality or discharge to hospice or to a long-term facility], index length of stay, hospital costs, discharge to nursing facility, and 30-day all-cause readmissions).

Results

Of 587,550 AIS hospitalizations included in this study, 4,182 (0.71%) had type 2 MI. Compared to AIS hospitalization without type 2 MI, those with type 2 MI were older (73 years vs. 70 years; P<0.001), more likely to be females (52% vs. 49.7%; P<0.001), and had a higher prevalence of heart failure (32% vs. 15.5%; P<0.001), atrial fibrillation (38.5% vs. 24.2%; P<0.001), prior myocardial infarction (8.8% vs. 7.7%; P<0.001), valvular heart disease (17% vs. 9.8%; P<0.001), peripheral vascular disease (12.2% vs. 9.2%; P<0.001), chronic kidney disease (24.4% vs. 16.7%; P<0.001), neurological disorders (49.3% vs. 34.6%; P<0.001), drug abuse (4.9% vs. 4.1%; P=0.04), chronic liver disease (2.6% vs. 1.7%; P<0.001), chronic lung disease (18.1% vs. 15.8%; P<0.001), anemia (4.3% vs. 2.8%; P<0.001), and weight loss (9.7% vs. 4.4%; P<0.001). Compared with their counterparts without type 2 MI, AIS with type 2 MI had significantly higher in-hospital mortality, poor functional outcomes, hospital costs, rate of discharge to nursing facility, length of stay, and rate of 30-day all-cause readmissions (Table 1). Heart failure, weight loss, neurological disorders, drug abuse, valvular heart disease, atrial fibrillation, chronic kidney disease, and age (per year) were identified as independent predictors of type 2 MI among AIS hospitalizations (Figure 1).

Conclusion

Patients with AIS complicated by type 2 MI have a high prevalence of underlying cardiovascular disease. In addition, type 2 MI in patients hospitalized with AIS is associated with poor prognosis and higher resource utilization.

Funding Acknowledgement

Type of funding sources: None.
Secondary prevention of cerebrovascular events in patients with “asymptomatic” atherosclerotic stenosis of the vertebral arteries
Authors: Shugushev Z , Karasev S , Maximkin D , Volkov S , Korobkov A , Chepurnoy A , Bagin S
Published: October 2021

Aim

To determine the feasibility of performing endovascular interventions in patients with “asymptomatic” atherosclerotic stenosis of the vertebral arteries, as a method of secondary prevention of cerebrovascular events.

Material and methods

The patients were randomized into 2 groups: in group I (n=78), secondary prevention of cerebrovascular events were carried out in a combined strategy - stenting of the vertebral arteries in combination with medication therapy, and in group II (n=78) - only medication therapy. Group I were randomized in 2 subgroups – Ia and Ib. In subgroup Ia (n=39) – endovascular intervention were performed with embolism protection devices, and in subgroup Ib (n=35) - embolism protection devices were not used. Long-term follow-up was planned after 12, 24 and 36 months. Inclusion criteria: “asymptomatic” stenosis of vertebral arteries 50–95%; the diameter of the vertebral arteries is not less than 3.0 and not more than 5 mm; the presence of not gross cerebral and focal symptoms corresponding to the initial (asymptomatic) stage of encephalopathy (according to E.V. Schmidt). Primary endpoint: total frequency of cerebrovascular events.

Results

The total incidence of spasm and dissection during endovascular intervention was 20.5% in subgroup Ia and 2.5% in subgroup Ib (p=0.0367). Also in subgroup Ia, 2 (4.5%) patients had transient ischemic attack. In subgroup Ib, perioperative cerebrovascular events was not observed. The total frequency of major cerebral complications over 36 months of follow-up was 4.5% in group 1 and 37.5% in group II (χ2=15.101; p<0.0001). The frequency of cardiac events was 9.1 and 19.6%, respectively, to groups I and II (χ2=14.784; p<0.0001). These indicators were obtained against the background of high patient adherence to treatment and high rates of achieving tough target lipid values. Restenosis of the stents was observed in general, in 18% of patients from group I, who underwent stenting of the vertebral arteries by various generations of stents. Moreover, restenosis alone did not affect the incidence of major cerebral complications in the long-term period (χ2=0.1643; p=0.735).

Conclusion

In spite of the development of restenosis, it is endovascular intervention in combination with drug therapy that helps to avoid the development of large cerebrovascular events arising from the instability of atherosclerotic plaque in patients with “asymptomatic” vertebral artery stenosis and is a reliable method of secondary prevention of of cerebrovascular events.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Russian academic excellence project 5-100
Detection and prevalence of intra-cardiac thrombus in patients with embolic stroke of undetermined source
Authors: Nardi Agmon I , Barnea R , Shafir G , Auriel E , Peretz S , Kornowski R , Hamdan A
Published: October 2021

Background

Embolic Stroke of Undetermined Source (ESUS) is defined as non-lacunar brain infarct without proximal arterial stenosis or known cardioembolic source (including atrial arrythmias). Little is known about the prevalence of intra-cardiac thrombus as a potential source of embolism in patients presenting with ESUS.

Objectives

To examine the use of contrast-enhanced electrocardiogram-gated computed tomography (CT) to elucidate the prevalence of intra-cardiac thrombus in patients suspected of ESUS.

Methods

We retrospectively investigated 101 consecutive patients who presented to our hospital with ESUS between January 2019 and March 2021 and underwent 2D echocardiography and CT as part of stroke etiology evaluation.

Results

In our study population (73.2±9.98 years, 41% female), CT detected intra-cardiac thrombus in 19 (18.8%) patients. Left ventricular thrombus (LVT) was found in 10 (9.9%) patients and left atrial/left atrial appendage in 8 patients. All of cases of LVT were detected by cardiac CT, while 2D echocardiography was able to detect only four of these cases. All cases of LVT were associated with significant coronary obstructive disease, while in 2 out of 10 patients, a previous history of ischemic heart disease was unknown. Using CT 2 patients after transcatheter aortic valve implantation were diagnosed with hypoattenuated leaflet thickening, and 3 patients with concomitant pulmonary embolism. In total, the finding of CT resulted in change of management, indication for anticoagulation instead of antiplatelets drugs, in 23 (22.7%) patients.

Conclusion

CT may help to improve the detection of intra-cardiac thrombus in patients presenting with ESUS and therefore provide relevant information for anticoagulation therapy and need of further coronary evaluation and intervention. The high prevalence of intra-cardiac thrombus in ESUS patients make the use of complementary 3D imaging important.

Funding Acknowledgement

Type of funding sources: None.
Differences in left atrial stain, endothelial glycocalyx and arterial elasticity between ESUS, lacunar and atherosclerotic type of stroke
Authors: Ikonomidis I , Katogiannis K , Frogoudaki A , Vrettou A R , Thymis J , Kostelli G , Kountouri A , Korakas E , Michalopoulou E , Vythoulkas D , Koliou G , Simou A , Benas D , Lambadiari V , Tsivgoulis G
Published: October 2021

Background and purpose

Patients with stroke are at high risk to develop cardiovascular complications. We assessed endothelial glycocalyx, aortic elastic properties, left atrial and ventricular function in patients with lacunar, atherosclerotic and stroke of undetermined source (ESUS).

Methods

In 68 patients (age 56,1±10.9) with acute cerebral stroke (22 lacunar, 19 atherosclerotic and 27 ESUS) and 20 controls with similar risk factors, we measured: (1) perfused boundary region (PBR) of the sublingual arterial microvessels (range 5–25 μm), a marker inversely related with glycocalyx thickness, (2) pulse wave velocity (PWV), central systolic blood pressure (cSBP), and augmentation index (AIx), (3) LA volume and strain using speckle-tracking imaging, and (4) left ventricular global longitudinal strain.

Results

Compared with controls, patients with stroke had higher PWV (11,38±3,62 vs 9,51±1,57 m/sec, p=0,045), PBR (2,10±0,27 vs 1,94±,020, p=0,039) and central SBP (139,64±26,31 vs 116,36±37,23 mmHg, p=0,039), while ventricular (−17,902±3,77 vs −19,87±1,17%, p=0,025) and atrial deformation (24,8±9,99 vs 39,050±2,08%, p<0.001) were impaired in patients with stroke (p<0.05).

LA reservoir strain was more reduced in ESUS patients compared to other 2 stroke types (ESUS 21,7±6,6%, Lacunar 25,6±13,2%, atherosclerotic 22,3±7,8%, P<0.05).

Regarding endothelial glycocalyx, PBR5–9 (the smallest vessels with diameter 5–9 μm) was higher in patients with ESUS than in the other two types of stroke (ESUS 1,22±0,12 μm, LACUNAR 1,19±0,12 μm, ATHEROSCLEROTIC 1,15±0,09 μm, p<0.05), despite the fact that PBR5–25 was similar between all stroke types (ESUS 2,09±0.23 μm, LACUNAR 2,13±0,33 μm, ATHEROSCLEROTIC 2,09±0,24 μm, p=0.8).

PWV was significantly higher in patients with atherosclerotic stroke (15,57±5,50 m/sec, p=0,007), while in patients with lacunar it was mildly elevated (10,53±3,22 m/sec) and in ESUS patients it was moderately increased (11,7±3 m/sec).

Conclusion

Patients with stroke have impaired atrial strain, endothelial glycocalyx and arterial elasticity, compared with controls. Arterial stiffness is more affected in atherosclerotic stroke, while LA deformation and glycocalyx of small size micro vessels are more affected in ESUS patients.

Funding Acknowledgement

Type of funding sources: None.
Residual quantitative flow ratio to estimate post-intervention fractional flow reserve
Authors: Van Diemen P A , De Winter R W , Schumacher S P , Bom M J , Driessen R S , Everaars H , Jukema R , Van Rossum A C , Nap A , Verouden N J , Opolski M , Danad I , Knaapen P
Published: October 2021

Objective

To assess the performance of residual quantitative flow ratio (QFR) to estimate post percutaneous coronary intervention (PCI) fractional flow reserve (FFR).

Background

QFR computes FFR based on invasive coronary angiography (ICA) images. Residual QFR is a novel tool that assesses the functional outcome of an intervention by estimating post-PCI FFR.

Methods

Residual QFR analyses, using pre-PCI ICA images, were attempted in 159 vessels with post-PCI FFR measurements. QFR lesion location was matched with the treated segment to allow virtual removal of the lesion similar to the performed PCI and computation of residual QFR (Picture 1: case example of residual QFR analysis). A post-PCI FFR <0.90 was used to define a suboptimal PCI result.

Results

Residual QFR computation was successful in 128 (81%) vessels. Median residual QFR was higher than post-PCI FFR (0.96 interquartile range (IQR): 0.91–0.99 vs. 0.91 IQR: 0.86–0.96, p<0.001). A moderate correlation and agreement was observed between residual QFR and post-PCI FFR (Spearman correlation coefficient=0.56 and Intraclass correlation coefficient=0.47, p<0.001 for both). Following PCI, an FFR <0.90 was observed in 54 (42%) vessels. Specificity, positive predictive value, sensitivity, and negative predictive value of residual QFR for determining a suboptimal PCI result were 96% (95% confidence interval (CI): 87–99%), 89% (95% CI: 72–96%), 44% (95% CI: 31–59%), and 70% (95% CI: 65–75%), respectively. Overall, residual QFR had an accuracy of 74% (95% CI: 66–82%) and an area under the receiver operating characteristic curve of 0.79 for assessing a post PCI FFR <0.90.

Conclusion

A moderate correlation and agreement between residual QFR and post-PCI FFR was observed. Residual QFR ≥0.90 does not necessarily commensurate with an optimal PCI result. However, residual QFR <0.90 is a good indicator of a post-PCI FFR <0.90 and might therefore be utilized to determine PCI location in order to obtain a satisfactory PCI result (Picture 2: central illustration).

Funding Acknowledgement

Type of funding sources: None. Case example of residual QFR analysisCentral illustration
Clinical profile and in hospital mortality of invasively managed patients with suspicion of acute coronary syndrome during the COVID-19 pandemic
Authors: Michalski B , Peruga J Z , Plewka M , Kupczynska K , Szymczyk E , Kasprzak J D
Published: October 2021

Background

The pandemic of COVID-19 significantly changed the treatment of patients with suspicion of ACS and COVID-19 infection. Access to cardiology department and possibility of invasive diagnosis and treatment of ACS are still significantly impaired.

Aim

Our aim was to evaluate the characteristic and prognosis of patients with suspicion of ACS and COVID-19 infection.

Materials and methods

Our department of cardiology was transformed for Covid unit and was dedicated for diagnosis and treatment of patients with suspicion of ACS. COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test. From 14th of October 2020 to 14th of March we performed 39 coronary angiographies. We included 39 patients (27 men) with mean age 69±8.5. In that group 11 patients had NSTEMI, 10 patients had STEMI, 2 patients Tako-Tsubo and 16 unstable angina. All patients underwent coronary angiography, and in 27 patients we performed PCI.

Results

In hospital mortality rate was 35% (14 patients). Cardiac arrest was present in 3 (8%) patients and cardiogenic shock in 4 (10%) patients. The rate of NSTEMI was higher in patients who died 7 vs 4 (p=NS) and STEMI were comparable in both groups 4 vs 6, (p=ns). The IL 6 levels in patients who died were 389±278pg/mL, in compare to 101±93pg/mL (p=0.3) who survived. Independent predictors of death were: sex with the OR=1,1 (95% CI: 0.6–2.4), p=0,03 and IL-6 level on admission OR=1,4 (95% CI: 0.6–2.4), p=0,04. There were no statistically significant differences regarding age, left ventricle ejection fraction, CRP levels and oxygen saturation od admission.

Conclusion

This study confirms the higher risk of death in patients with ACS and SARS-CoV-2. In the multivariable analysis only sex and Il-6 level on admission were the independent risk factors of the in hospital death. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are needed.

Funding Acknowledgement

Type of funding sources: None.
Reference values for intracoronary doppler flow velocity-derived hyperaemic microvascular resistance index
Authors: Feenstra R G T , Seitz A , Boerhout C K M , De Winter R J , Ong P , Beijk M A M , Piek J J , Sechtem U , Van De Hoef T P
Published: October 2021

Background

Invasive assessments of microvascular function are rapidly becoming an integral part of physiological assessment in chronic coronary syndromes.

Objective

We aimed to establish a reference range for Doppler flow velocity-derived hyperaemic microvascular resistance index in a cohort of ANOCA patients with no structural pathophysiological alterations in the coronary circulation.

Methods

The reference population consisted of ANOCA patients undergoing invasive coronary vasomotor function assessment who had a coronary flow reserve (CFR) >2.5, and had either (1) tested negatively for spasm provocation (n=12) or (2) tested positively with only angina at rest (n=29). A reference range for HMR was established using a non-parametric method and correlations with clinical characteristics were determined using a spearman rank correlation analysis.

Results

In 41 patients median HMR amounted to 1.6 mmHg/cm/s [Q1, Q3: 1.3, 2.2 mmHg/cm/s]. The reference range for HMR that is applicable to 95% of the population was 0.8 mmHg/cm/s (90% CI: 0.8–1.0 mmHg/cm/s) to 2.7 mmHg/cm/s (90% CI: 2.6–2.7 mmHg/cm/s). No significant correlations were found between HMR and clinical characteristics.

Conclusion

In this reference population undergoing invasive coronary vasomotor function testing, the 90% confidence interval of the HMR upper limit of normal ranges from 2.6 to 2.7 mmHg/cm/s. A >2.5 mmHg/cm/s HMR threshold can be used to identify abnormal microvascular resistance in daily clinical practice.

Funding Acknowledgement

Type of funding sources: None. Example of HMR measurement
The relationship between adverse outcomes and a full spectrum of ejection fraction in patients without acute myocardial infarction undergoing percutaneous coronary intervention
Authors: Liu Y L , Song J S , Wang W W , Tang Y T
Published: October 2021

Background

There is insufficient study evaluating how the risk of adverse cardiovascular outcomes varies across the full range of LVEF in patients undergoing percutaneous coronary intervention (PCI). A more comprehensive evaluation could provide further understanding of prognosis and support the management of these patients.

Purpose

The present study aimed to assess the association between left ventricular ejection fraction (LVEF) and major adverse cardiovascular events (MACE) in patients with coronary artery diseases undergoing PCI.

Methods

A consecutive series of 9475 patients without acute myocardial infarction (AMI) undergoing PCI were enrolled into the study and followed up for a median 2.4 years. Patients were stratified into 8 groups by 5% intervals: under 40%, 40–45%, 45–50%, 50–55%, 55–60%, 60–65%, 65–70%, and over 70%. MACE, consisting of cardiac death, myocardial infarction, stent thrombosis, and revascularization, was evaluated as the outcome.

Results

MACE occurred in 594 (6.3%) patients. The MACE rates decreased before LVEF under 65% while increased after LVEF over 70%, showing a U-shaped pattern. The 65–70% group showed the lowest rate of MACE (4.5%). Consistently, in the Cox regression, the association between LVEF and MACE presented as a U-shaped pattern regardless of different age and sex groups, and after adjusted for clinical and procedural covariables. The LVEF categories lower than 65% or higher than 70% were independent predictors of MACE, compared with 65–70% group (Hazard ratios 1.311 to 2.657, all P value >0.05). Similar trend was also observed in restricted mean survival time analysis.

Conclusions

LVEF and MACE displayed a U-shaped association and patients with LVEF of 65–70% showed the lowest risk of MACE. The present study provided an insight into how the MACE risk changed in a wide spectrum of LVEF in patients without AMI undergoing PCI, which might improve preprocedural evaluation.

Funding Acknowledgement

Type of funding sources: None.
In-hospital clinical outcomes of percutaneous coronary intervention for patients deemed ineligible for surgical revascularization
Authors: Farag M , Ibrahem A , Al-Atta A , Abdalwahab A , Egred M
Published: October 2021

Background

Ineligibility for surgical revascularization remains subjective with limited data. Coronary artery bypass graft surgery (CABG)-ineligible patients usually have a high prevalence of risk factors and complex coronary disease, which lead to worse clinical outcomes.

Aim

We aimed to evaluate CABG surgical ineligibility reasons and in-hospital percutaneous coronary intervention (PCI) outcomes at a large tertiary centre.

Methods

Anonymized, prospectively collected data from the institutional electronic records between April 2013 and November 2020 were analysed retrospectively. All patients who were formally turned down for CABG and had PCI were included.

Results

There were 473 patients in total. Perceived frailty of the patient with associated comorbidities and/or the quality of distal coronary arteries were the main documented reasons for surgical ineligibility in 52.4% of patients. Mean age was 72±11 years, mean body mass index was 29±6 kg/m2 and 69.8% were male. Stable angina constituted 216 patients (45.7%) and 257 patients (54.3%) had acute coronary syndromes. Mean hospital stay was 4±5 days. Procedural success was documented in 457 out of 473 patients (96.6%). PCI adjunctive tools included coronary imaging in 97 patients (20.5%), rotational atherectomy in 96 patients (20.3%), laser atherectomy in 12 patients (2.5%), lithotripsy in 3 patients (0.6%) and physiological assessments in 34 patients (7.2%). In-hospital major adverse cardiac events were experienced in 32 patients (6.8%), death in 12 patients (2.5%), myocardial infarction in 21 patients (4.4%), ischaemic stroke in 1 patient (0.2%), coronary perforation in 7 patients (1.5%), repeat target vessel revascularization in 6 patients (1.3%), major access-site bleeding in 2 patients (0.4%), aortic dissection in 1 patient (0.2%) and new acute kidney injury requiring dialysis in 1 patient (0.2%).

Conclusions

PCI in surgically ineligible patients is generally safe and effective. The process of determining suitability for surgical revascularization remains complex in the real-world.

Funding Acknowledgement

Type of funding sources: None.
Unprotected left main coronary artery stenting: true vs. non true bifurcation lesions; a single-centre experience
Authors: Santucci A , Scavelli F , Jacoangeli F , Mattei C , Sclafani R , Notaristefano S , Bordoni E , Aimi A , Cavallini C
Published: October 2021

Aims

We investigated the impact of bifurcation lesions involving a side branch lesion combined with a main branch stenosis on clinical outcomes after percutaneous coronary intervention (PCI) on unprotected left main coronary artery (ULM).

Methods and results

We defined “true” bifurcation lesions as significant (>50%) side branch stenosis associated with a significant main branch lesion, either proximal or distal, according to the Medina classification (1.1.1, 1.0.1 or 0.1.1 lesions). “Non true” lesions were defined by absence of significant side lesions, or significant side lesions without concomitant main branch stenosis. We compared patients with “non-true” bifurcation lesions (N=132; 56%) with those with “true” bifurcation lesions (N=105; 44%) in their 12-month incidence of target vessel failure (TVF) (composite of (i) cardiac death related to target vessel; (ii) myocardial infarction related to target vessel, or (iii) ischemia-driven target vessel revascularization), death from any cause, target lesion revascularization (TLR) and stent thrombosis (ST). TVF occurred in 56 patients (24%) (figure 1). Patients with “true” bifurcation lesions had a significantly higher risk of TVF than those with “non-true” bifurcation lesions (HR 2.39; 95% CI 1.39–4.11, P=0.002). “True” bifurcation lesions were also associated with a higher risk of all cause of death (HR, 2.54; 95% CI, 1.09–5.94; P=0.031) and TLR (HR, 2.33; 95% CI, 1.1–4.94, P=0.027). 'True' bifurcation lesions, diabetes mellitus, as well as cardiogenic shock, were independently associated with an increased risk of TVF (figure 2). Of note, the SYNTAX score I was not identified as an independent predictor of TVF. The stenting strategy (1 vs 2 stents) did not show any significant association with the outcome.

Conclusions

Patients with ULM and “true” bifurcation lesions who undergo PCI have a worse clinical outcome than those with “non-true” bifurcation lesions.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier curves for TVFFigure 2. Independent predictors of TVF
Prognostic impact of coronary artery disease severity and revascularization in TAVI patients
Authors: Silva G , Espada Guerreiro C , Goncalves Teixeira P , Queiros P , Ribeiro Da Silva M , Ferreira D , Brandao M , Sampaio F , Rodrigues A , Braga P , Fontes-Carvalho R
Published: October 2021

Background

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis. In patients who undergo surgical aortic valve replacement, the presence of CAD and the need for CABG adversely influences short- and long-term outcomes. However, the impact of concomitant CAD and its revascularization in patients undergoing transcatheter aortic valve implantation (TAVI) is still a matter of debate.

Purpose

The aim of this study was to evaluate the prognostic impact of CAD severity in 1-year all-cause mortality of patients undergoing TAVI and whether prior complete or incomplete reasonable revascularization can improve prognosis after TAVI.

Methods and results

Retrospective analysis of a total of 575 patients (51,3% female, mean age 79,7±7,7 years) who underwent TAVI from August 2007 to November 2018. 50,3% of patients had significant CAD (at least one stenosis >50%) which 54,2% of these had history of prior revascularization (64,8% complete or incomplete reasonable revascularization and 35,2% incomplete revascularization).

Pre-TAVI CAD severity was defined by the SYNTAX Score (SS) and reasonable revascularization by the residual SYNTAX Score (rSS). Patients without history of revascularization were stratified into 3 groups: no CAD (SS=0); nonsevere CAD (SS between 1 and 22); and severe CAD (SS ≥23); Patients who had undergone revascularization prior to TAVI were separated into 2 categories based on their residual SS: complete or incomplete reasonable revascularization (rSS<8) and incomplete revascularization (rSS≥8). The primary end point was an all-cause mortality. 1 year, patients with severe CAD had significantly higher rates of mortality (no CAD: 9,8%, nonsevere CAD: 12,6%, severe CAD: 38,9%; P=0.001) without significant differences between patients with no CAD and nonsevere CAD (p=1,00). Patients with high rSS had significantly higher rates of mortality comparing to no CAD or rSS<8 (no CAD: 9,8%, rSS<8: 8,6%; rSS≥8: 28,0%, p=0.001).

Conclusions

In our study, only the presence of severe CAD (SS≥23) prior to TAVI was associated with increased 1-year all-cause mortality. In patients with previous history of revascularization, a complete/reasonable revascularization (lower rSS) was associated with lower long-term mortality, which may attenuate the association of severe CAD and mortality and therefore improve the prognosis of these patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho Figure 1. Prognostic Impact of CAD severityFigure 2. Prognostic Impact of Revascularization
Anticoagulant profile of supplementary-dose enoxaparin in patients undergoing prolonged percutaneous coronary intervention
Authors: Liu Z , Chen Q , Li J , Zhu X , Xu L , Wu W
Published: October 2021

Background

Enoxaparin 0.75 mg/kg, with either a staged-dose regimen (0.5+0.25 mg/dl) or a single-dose regimen (0.75 mg/dl) achieves target anticoagulation for 90 min in patients undergoing percutaneous coronary intervention (PCI). In patients with prolonged procedures (>90 min), a supplementary-dose enoxaparin (0.375 mg/kg) needs to be given at 90 min to maintain target anticoagulation for additional 90 min. However, the actual anticoagulant profile of this supplementary-dose regimen remains unknown because it is recommended only based on pharmacokinetic simulations.

Purpose

This study directly assessed the anticoagulant profile of supplementary-dose enoxaparin (0.375 mg/kg) in troponin-negative patients undergoing prolonged elective trans-radial PCI who received a total dose of enoxaparin 0.75 mg/kg during the first 90 min of their procedures.

Methods

In 33 patients with prolonged procedures, 15 patients received enoxaparin 0.5 mg/kg at the beginning of coronary angiography and additional enoxaparin 0.25 mg/kg before PCI (Staged-dose regimen); while, 18 patients received enoxaparin 0.75 mg/kg at the beginning of coronary angiography without additional dose before PCI (Single-dose regimen). A supplementary-dose enoxaparin (0.375 mg/kg) was administered at 90 min after the first dose was given, and every 90 min thereafter until the end of PCI. Anti-Xa levels were assessed at 0 min (immediately before), 10 min and 90 min after each supplementary dose was given (S_0min, S_10min, and S_90min, respectively). Target anticoagulation was defined as anti-Xa level of 0.5–1.8 IU/ml.

Results

In patients who received only one supplementary dose (n=28), the anti-Xa levels were S1_0min: 0.87±0.19 IU/ml, S1_10min: 1.44±0.21 IU/ml, and S1_90min: 1.10±0.21 IU/ml. In patients who received two supplementary doses (n=5), the anti-Xa levels were S1_0min: 0.86±0.07 IU/ml, S1_10min: 1.27±0.27 IU/ml, and S1_90min: 1.03±0.23 IU/ml, as well as S2_0min: 1.03±0.23 IU/ml, S2_10min: 1.56±0.28 IU/ml, and S2_90min: 1.28±0.18 IU/ml, respectively. No patient received more than two doses of supplementary enoxaparin. All anti-Xa levels were within the range of target anticoagulation except for two patients receiving one supplementary dose (S1_10min: 1.96 IU/ml and 1.81 IU/ml, respectively) and another one receiving two supplementary doses (S2_10min: 1.87 IU/ml).

Conclusions

In patients undergoing prolonged PCI who received a total dose of enoxaparin 0.75 mg/kg during the first 90 min of their procedures, a supplementary-dose enoxaparin (0.375 mg/kg), which was administered at 90 min and every 90 min thereafter, maintained target anticoagulation for additional 90 min each time it was given.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Peking Union Medical College Hospital (PUMCH) Science Fund for Junior Faculty
Correlation of Seattle Angina Questionnaire score and post-procedural outcomes in patients undergoing multi-vessel coronary intervention
Authors: Johal G , Kyaw H , Farhan S , Gedela M , Hooda A , Goel S , Iruvanti S , Sartori S , Mehran R , Kini A , Sharma S
Published: October 2021

Introduction

The Seattle Angina Questionnaire (SAQ) score has been used to assess angina severity in patients undergoing coronary intervention. However, assessment of clinical outcomes using the SAQ score in those with multi-vessel disease (MVD) requiring multiple interventions has not been determined.

Purpose

To analyse patient-reported outcomes over time among individuals undergoing multiple staged interventions using serial SAQ scores.

Methods

We performed a retrospective analysis of 531 consecutive elective patients who underwent multi-vessel coronary intervention from January 1, 2015, to December 31, 2018, at a single academic centre. We used a short-form version of the SAQ score calculator that is built into our hospital electronic medical record. Trained clinical staff administered the SAQ at the point of care before each procedure. We divided the baseline SAQ scores into three groups [Group 1: <50, Group 2: 50–66, Group 3: ≥67] and analysed the correlation between the scores and patient-reported angina symptoms before the final staged intervention. Post index procedural outcomes, including myocardial infarction, congestive heart failure, post-procedural bleeding, and blood transfusion were reported.

Results

In all, 531 patients met inclusion and exclusion criteria. Patients' mean age was 65.66±10.30 years, and 78.3% of patients were males. Group 1 had an increased prevalence of diabetes (59.3% vs. 49.4% and 44%), prior coronary artery bypass surgery (CABG) (24.7% vs. 17.2% and 11.4%), a lower haemoglobin value (12.88±1.56 vs. 13.06±1.7 and 13.33±1.56) compared with group 2 and group 3. The rate of in-stent restenosis (ISR) was 18.7%, 11.5% and 8.6% in group 1, 2, and 3, respectively. Summary SAQ-7 values between interventions had improved significantly in group 1 (22.30±21.35) and group 2 (10.45±17.77), while group 3 failed to show any meaningful change (−1.09±14.79) (P<0.0001). [Table 1] The post-index-procedural outcomes were not statistically different among the three groups. In group 1, women (adjusted odds ratio [aOR]: 3.96; 95% confidence interval [CI]: 2.44 to 6.45; p<0.0001) and prior CABG patients (aOR: 2.03; 95% CI: 1.27 to 3.24; p=0.0031) had higher odds of SAQ-7 improvement between index and staged intervention.

Conclusion

The lowest baseline SAQ group had a significant improvement of SAQ score between the index and a staged intervention. The study demonstrated that serial SAQ scores could be used as a surrogate to measure patient-reported outcomes in those with MVD undergoing multiple interventions.

Funding Acknowledgement

Type of funding sources: None.
The use of floating wire technique and intravascular ultrasound for precise aorto-ostial stenting
Authors: Daibes J A , Reddy P K , Fujisaki T , Skaf M , Abed R , Ochoa R , Patel A , Kwan T W
Published: October 2021

Background

Aorto-ostial interventions often lead to imprecise ostial demarcation, suboptimal stent implantation, and worse clinical outcomes when compared to non-ostial interventions. The floating wire technique (bumper or sepal wire technique) employs a second guidewire placed in the aortic root to both mark the ostium and prevent prolapse of the guide catheter past the target ostial lesion. Its use has been described in the literature and is used often in daily practice however, procedural and long-term clinical endpoints have not been assessed using the gold standard of post-implant IVUS to determine technical success. The aim of the study is therefore to objectively assess the rate of geographic miss using the floating wire technique as well as long-term clinical outcomes.

Methods

A single center retrospective study was conducted. Patients who underwent ostial lesion percutaneous coronary intervention (PCI) with the floating wire technique between January 2019 and September 2020 were identified. Procedural and clinical outcomes at 6 months follow up were investigated. The co-primary endpoints include 1) Geographic miss defined as inadequate ostial coverage by IVUS or excess stent protrusion on angiography and 2) Target lesion failure (TLF) at 6 months after PCI, defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and target lesion revascularization.

Results

In total, 48 patients were identified. The average age was 71.7 years old, and 85.4% were male. Indication for PCI was acute coronary syndrome in about a third of patients. Twenty-six patients had left main ostial lesion, and 22 patients had right coronary artery ostial lesions. The average syntax score was 24.2. IVUS assessment was performed in 45 patients. Four (8.3%) patients had more than 2mm of excess stent proximal protrusion. Ostial miss occurred in 1 (2.2%) patient. Seven patients had loss to follow up. TLF, stroke, or major bleeding were not observed in any patients. One non-cardiovascular death, three type 2 MIs, and 1 type 4 MI were observed, which occurred in non-target vessels.

Conclusions

The floating wire technique was safe and efficient with low rates of geographic miss or adverse clinical outcomes. This is the first study to confirm precise aorto-ostial stent implantation using the floating wire technique with IVUS assessment.

Funding Acknowledgement

Type of funding sources: None. Floating Wire Technique for LM Stenting
Drug-coated balloon versus drug-eluting stent following orbital atherectomy for calcified coronary artery: one-year outcomes of a retrospective cohort study
Authors: Mitsui K , Lee T , Miyazaki R , Hara N , Nagamine S , Nakamura T , Terui M , Okata S , Nagase M , Nitta G , Watanabe K , Kaneko M , Nagata Y , Nozato T , Ashikaga T
Published: October 2021

Background

Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug-eluting stent (DES) era. The effectiveness of drug-coated balloons (DCBs) and orbital atherectomy system (OAS) is unknown.

Methods

In this retrospective, single-center study, we compared the use of DCBs with second- and third-generation DESs following orbital atherectomy (OA) for calcified de novo coronary lesions. All patients underwent PCI with intravascular imaging. The primary endpoint was major cardiac event, that was a composite of cardiac death, death for unknown cause, non-fatal myocardial infarction, or target lesion revascularization at 1 year.

Results

Between June 2018 and December 2019, 107 patients with coronary lesions were enrolled in this study and divided into two groups: 23 patients in DCB group and 84 patients in DES group. The post-procedure segment percentage diameter stenosis was 23.1% (interquartile range [IQR], 17.7 to 32.5) with DCB versus 14.4% (IQR, 10.0 to 21.2) with DES (P<0.001). Overall adverse event rate for PCI procedure was low: one dissection with DES group, no persistent slow/no-flow, and no perforation with both group. The primary endpoint was not significantly different between 2 groups [DES: 6.0% (5/84), DCB: 0.0% (0/23), log-rank P=0.24].

Conclusions

In calcified coronary artery disease, using DCB following OA is as safe and effective as using DES following OA with respect to 1-year clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.
Use of sirolimus-coated balloon in de novo small vessel coronary lesions; Long-term follow-up from a single centre registry
Authors: Loku Waduge B H , Kalkat H , Saif A , Fawzy A M , Athukorala S , Bhatia G , Kumar N , Freestone B , Ment J , Lee K , Pitt M , Pulikal G , Basavarajaiah S
Published: October 2021

Background

Drug coated balloons (DCBs) in Europe are mainly used in restenotic lesions as endorsed by the European Society of Cardiology, with a class IA recommendation. However, some of the recent data suggest, it can also be considered in a subset of denovo lesions, especially in small vessels. Most DCBs used, are coated with Paclitaxcel. There is no data on the efficacy of Sirolimus in DCBs, the drug of choice in drug eluting stents. In this study, we report outcomes from the use of a Sirolimus coated balloon (SCB) in de novo small-vessel coronary lesions, from a single high yield centre.

Methods

A retrospective analysis was conducted on all patients treated with an SCB between March 2018 and October 2020. Follow-up was achieved with clinic visits, telephone calls and admission records. The outcomes measured include cardiac death, target-vessel myocardial-infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, target-vessel MI and TLR).

Results

During the study period, 279-patients (with 332-lesions) with de novo lesions were treated with an SCB. The mean age of patients was 65±12 years, 219 (79%) were male, 36% (n=100) had diabetes, 16% (n=45) had chronic kidney disease and 61% were in the setting of acute coronary syndrome (n=169). Predilatation was performed in 96% (320-lesions). Bailout stenting (with DES) was required in 5% of lesions (n=18) of which 16 were due to dissections and 2 were due to recoil >30% following DCB use. The mean diameter and length of DCBs were 2.35 mm and 26 mm respectively.

During a median follow-up of 584-days (19-months) cardiac death was reported in 8 patients (3%). Target vessel MI was in 3% (n=9), TLR per lesion was 8% (n=26) and the MACE rate was 11% (n=31). There were no documented cases of acute vessel closure.

Conclusion

The long-term outcome from the first ever study on sirolimus eluting balloons in de novo small vessel lesions appears promising with low rates of hard endpoints, and acceptable repeat rates of TLR despite a complex group of patients (50% ACS, 36% diabetics and 19% CKD) and lesion subsets (small vessel and diffuse disease). Implanting stents in these subsets renders them vulnerable to restenosis, making treatment challenging and resulting in high rates of recurrence.

Funding Acknowledgement

Type of funding sources: None.
Long term clinical outcomes from use of Sirolimus coated balloon in coronary intervention; data from a real-world population
Authors: Loku Waduge B H , Kalkat H , Saif A , Fawzy A M , Athukorala S , Bhatia G , Kumar N , Freestone B , Ment J , Lee K , Pitt M , Pulikal G , Basavarajaiah S
Published: October 2021

Background

The use of drug coated balloons (DCBs) in coronary intervention is escalating. There are two drugs of choice for coating either DCBs or drug eluting stents: Paclitaxel or Sirolimus. Most available DCBs are coated with Paclitaxcel, due to pre-existing, extensive data that support good clinical outcomes. With drug eluting stents both the literature and hence clinical practice favour Sirolimus over Paclitaxcel. This is due the cytostatic properties and wide therapeutic window of Sirolimus. However, there is very limited data on Sirolimus coated balloons (SCBs). We report a long-term follow-up with this relatively new technology from our centre.

Methods

A retrospective analysis was conducted on all patients treated with an SCB between March 2018 and October 2020. Follow-up was achieved with clinic visits, telephone calls and admission records. The outcomes measured include cardiac death, target-vessel myocardial-infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, target-vessel MI and TLR).

Results

533 patients (690-lesions) with a mean age of 65.4 (range; 37–90) were treated with an SCB. 79% (n=419) were male, 314 (59%) were in the setting of acute coronary syndrome, 40% (n=211) had diabetes and 60% (n=414) had DCB in de-novo lesions. Small vessels accounted for 59% of cases (n=406). Pre-dilatation was performed in 97% (n=670) of cases. Bailout stenting (with a drug eluting stent) was required in 6.5% lesions (n=45), of which 11 were due to dissections and 34 were due to >50% recoil following DCB use. The mean diameter and length of DCBs were 2.8 mm and 26.3 mm respectively.

During a median follow-up of 572 days (IQR: 381 - 868); cardiac death occurred in 15 patients (3%). Target vessel MI was in 4%; n=21, TLR per lesion and per patient were 10% (n=72 and n=55 respectively). The overall MACE rate was 12%. There were no documented cases of acute vessel closure.

Conclusions

The results from long term follow-up with this relatively new technology DCB are encouraging with low rates of hard endpoints and acceptable rates of TLR and MACE despite complex group of patients (59% ACS and 40% diabetics) and lesion subsets (40% restenotic lesions and 59% small vessels). However, in order to further inform clinical practice, more longer-term data on SCBs compared with Paclitaxel coated balloons is needed.

Funding Acknowledgement

Type of funding sources: None.
Coronary perforations and its clinical impact during CTO recanalization: a 2054 patients pooled analysis from the Latin American (LATAM) CTO registry
Authors: Harada Ribeiro M , Quadros A , Padilla L T , Belli K C , Piccaro P , Dallan L A , Silveira C E , Quesada F H , Morales N , Santiago R , Mashayekhi K C , Azzalini L A , Galassi A R , Campos C M
Published: October 2021

Introduction

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) are the most challenging procedures and still associated with the highest complications rates. Coronary perforation is a life-threatening acute PCI complication, but data are limited regarding its impact on mid-term outcome. We aimed to assess 30-days and 1-year outcomes in CTO PCI patients with coronary perforations.

Purpose

Analyze the clinical impact of Cto perforations during CTO PCI at short and mid-term in a muticenter continental registry in Latin America (LATAM).

Methods

We analyzed data from the continental multicenter Latin America CTO Registry including patients who underwent CTO PCI in 57 centers from 9 countries. Coronary perforation during the index procedure were categorized according to Ellis classification. We assessed 30-days adverse events and 1-year major adverse cardiac and cerebrovascular (MACCE) defined as the composite of all-cause death, myocardial infarction (MI), target vessel revascularization and stroke. MI was defined according both the LATAM CTO protocol and SCAI definitions.

Results

From January 2015 to October 2018, 2054 patients underwent CTO PCI. The median J-CTO score was 2.0 (1.0–3.0) and the median Progress score was 1.0 (0.0–2.0). The overall perforation rate was 3.7% (n=76) in which 55% were Ellis class 1, 24% Ellis class 2 and 21% Ellis class 3. No differences were found in any baseline clinical characteristics. Patients with perforation had more frequently retrograde instrumentation (P<0.01) and antegrade knuckle wire (P<0.01) and lower success rate (P<0.01). At 30-days, perforations were associated with more heart failure (6.6% vs 1.5%, p<0.01), bleeding (15.2% vs 3.7%, p<0.01), transfusion (7.9% vs 1.1%, p<0.01) and cardiac tamponade (13.2% vs 0.4%, p<0.01). After 1-year follow-up, patients with perforations had higher MACCE rates according to both LATAM CTO protocol (18.2 vs. 9.4%; P=0.02) and SCAI definitions (22.7% vs. 11.3%; P<0.01).

Conclusions

In this multicenter continental real-world analysis, coronary perforation in CTO PCI was infrequent and was related with higher anatomical and procedural complexity characteristics. Despite the similarity in clinical characteristics, patients that had coronary perforation were exposed to an increased risk of both hemorrhagic and ischemic events.

Funding Acknowledgement

Type of funding sources: None.
Long-term follow-up of early leaflet thrombosis after transcatheter aortic valve replacement
Authors: Hein M H , Schoechlin S S , Schulz U S , Minners J M , Breitbart P B , Neumann F J N , Ruile P R
Published: October 2021

Background

The long term impact of early leaflet thrombosis (LT) after transcatheter aortic valve implantation (TAVI) on clinical endpoints is unclear.

Purpose

Define the long term risk of leaflet thrombosis post TAVI.

Methods

We analysed data of our prospective observational in-house registry including all 821 patients with available post-TAVI computed tomography angiography (CTA) (between May 2012 and December 2017). Endpoints were mortality, cardiovascular mortality, transient ischemic attack (TIA) or stroke and symptomatic hemodynamic valve deterioration.

Results

In 131 (15.9%) of 821 patients early LT was diagnosed in post-TAVI-CTAs after a median of 5 [IQR 4; 6] days. Median FU was 1188 days (interquartile range (IQR) [784; 1840]). LT was observed more frequently in female [85 (64.9%) vs. 46 (35.1), P=0.013] and in patients in sinus rhythm [285 (41.3%) vs. 38 (29.0%), P=0.008]. The primary endpoint all-cause and secondary endpoint cardiovascular mortality did not differ significantly between patients without LT and with LT (Kaplan-Meier 3 years estimates for survival 74.1% vs. 71.1%, P=0.619; for cardiovascular mortality 88.7% vs. 88.2% P=0.662). The tertiary combined endpoint stroke and transient ischemic attack (TIA) was comparable between both groups (3-year stroke- and TIA-free survival 95.6% vs. 96.3; P=0.662). Patients with LT exhibited more often symptomatic hemodynamic valve deterioration (11/131 (8.3%) vs. 14/690 (2.0%), log-rank P=0.003). Predictors for all-cause mortality in multivariate Cox regression analysis were atrial fibrillation and paravalvular leakages, whereas LT was not predictive (P<0.001; P=0.035 and P=0.619).

Conclusion

During a median follow-up of more than 3 years, LT was not associated with mortality, TIA or stroke. LT was, however, associated with an increased risk of symptomatic hemodynamic valve deterioration.

Funding Acknowledgement

Type of funding sources: None.