bluuebunny/crossref_metadata_2025 huggingface dataset:
Role of estimated aortic pulse wave velocity in the prediction of future thoracic aortic aneurysm expansion
Authors: Boczar K , Boodhwani M , Beauchesne L , Dennie C , Chan K.L , Wells G.A , Coutinho T
Published: November 2020

Background

Thoracic aortic aneurysm (TAA) is a deadly disease in critical need of novel strategies for risk assessment and medical management. To address this need, we have previously shown that directly measured carotid-femoral pulse wave velocity (cfPWV), a marker of aortic stiffness and health, independently predicts future TAA expansion. Since aortic pulse wave velocity can be estimated from age and mean arterial pressure (MAP), in the present study we sought to determine whether estimated aortic pulse wave velocity (e-aPWV) also predicts TAA expansion.

Methods

One hundred and five consecutive, unoperated subjects with TAA were recruited. e-aPWV was estimated from validated equations based on age and MAP. cfPWV was measured with arterial tonometry according to guidelines. TAA size was measured at baseline and at the latest follow-up using available imaging modalities according to guidelines. Stepwise multivariable linear regression (P≤0.25 to enter, P≤0.10 to stay in the model) assessed independent associations of e-aPWV and cfPWV with future TAA growth. Variables considered in the models were: age, sex, BSA, MAP, TAA etiology and location, baseline TAA size, follow-up time, imaging modality, history of hypertension, diabetes and smoking.

Results

Seventy eight percent of subjects were men. Mean±SD age, baseline aneurysm size and follow-up time were 62.6±11.4 years, 46.2±3.8 mm and 3.0±1.0 years, respectively. e-aPWV and cfPWV were moderately correlated (Pearson's correlation coefficient = 0.61). Results of the linear regression analyses showed that both measured (cfPWV) and estimated (e-aPWV) independently predicted future TAA expansion (β±SE: 0.032±0.011, P=0.048 and 0.240±0.085, P=0.006, respectively). The base model's R-squared value of 0.39 was increased to 0.44 with addition of either cfPWV or e-aPWV to the model, confirming that each parameter of aortic stiffness enhances prediction of TAA growth.

Conclusion

Aortic stiffness is relevant for assessment of TAA disease activity. Similar to cfPWV, e-aPWV is also independently associated with future TAA expansion. Thus, e-aPWV represents a tool to improve TAA risk stratification that is simple, free of cost, and obviates the need for specialized equipment or dedicating training, which leads to excellent potential for widespread incorporation into clinical practice.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research
IL6 trans-signalling associates with atherothrombotic but not with cardioembolic stroke
Authors: Ziegler L , Wallen H , Aspberg S , De Faire U , Gigante B
Published: November 2020

Background

Pro-inflammatory processes underlie ischemic stroke, albeit it is largely unknown if they selectively associate with the risk of atherothrombotic and cardioembolic ischemic stroke. Here we analyse whether the pro-inflammatory interleukin (IL) 6 trans-signalling, associates with the risk of ischemic stroke and underlying atrial fibrillation (AF).

Method

During a 20-year follow-up, 203 incident ischemic strokes were recorded from national registers in the cohort of 60-year-old men and women from Stockholm (n=4232).

For each study participant, we have estimated the activity of the IL6 trans-signalling through the calculation of the ratio between the circulating pro-inflammatory binary IL6:sIL6R complex and the circulating inactive ternary IL6:sIL6R:sgp130 complex, the so called B/T ratio. An excess of the binary complex, mirrored by a high B/T ratio, is associated with an increased risk of cardiovascular events. The B/T ratio has been dichotomized at the median. The risk of ischemic stroke associated with B/T ratio > median was estimated by Cox regression and expressed as hazard ratio (HR) with a 95% confidence interval (CI) in the presence and absence of AF. Risk estimates were adjusted for cardiovascular risk factors and anticoagulant treatment. In a secondary analysis, the association of IL6 trans-signalling with the risk of incident AF (n=279) was analysed.

Results

B/T ratio >median was associated with the risk of ischemic stroke only in study participants without AF diagnosis (adjusted HR 1.49; 95% CI 1.08–2.06). No association was observed with ischemic stroke in study participants also diagnosed with AF. Moreover, the B/T ratio was not associated with the risk of AF (HR 0.96; 95% CI 0.75–1.24).

Conclusions

IL6 trans-signalling, estimated by the B/T ratio, is associated with atherothrombotic but not cardioembolic stroke. Consistently, the B/T ratio did not associate with the risk of incident AF. Our results support the relevance of IL6 trans-signalling in atherosclerosis related ischemic stroke.

Funding Acknowledgement

Type of funding source: None
Deterioration of peripheral microvascular tissue perfusion after transcatheter aortic valve implantation (TAVI) measured by 2D near-infrared spectroscopy (NIRS)
Authors: Herbrand T , Baasen S , Veulemans V , Kelm M , Busch L
Published: November 2020

Background

The data on the effect of transcatheter aortic valve implantation (TAVI) on peripheral microcirculation is scarce. Therefore, in this study, we investigate the changes of peripheral microvascular tissue perfusion before and after TAVI measured by a 2D near-infrared spectroscopy (NIRS) camera. NIRS allows measurement of hemoglobin oxygen saturation (StO2) in the blood perfusing the volume tissue under scrutiny.

Methods

In this prospective, single center study, patients with symptomatic, severe aortic stenosis either planned for elective TAVI procedure or elective cardiac catheterization were included. 2-D StO2 maps of all distal extremities (i.e. hand/foot) were acquired before and after TAVI by using a NIRS camera; macrovascular function of the tibial and forearm arteries was assessed by Doppler ultrasound with spectral analysis including ankle-brachial index (ABI) and applanation tonometry.

Results

26 subjects (19 male, age 83±6 years) undergoing TAVI procedure and 5 subjects (4 male, age 76±10) undergoing cardiac catheterization were included in this trial. In the group undergoing TAVI procedure, 5 patients had diabetes mellitus (19%), one of whom was insulin-dependent, 3 patients had a history of peripheral artery disease (12%) and 1 patient had a history of smoking (4%). TAVI procedure was successful without major complications in all cases.Mean peripheral StO2 decreased significantly on all extremities after TAVI, i.e. right hand (from 71±14% to 61±16%; p=0.01), left hand (from 70±12 to 62±16%; p=0.03), right foot (from 70±11% to 61±15%; p<0.01) and left foot (from 66±15% to 58±14%; p=0.03). ABI did not change after TAVI (right ABI baseline mean 1.08±0.2; Δ0.06; left ABI baseline 1.05; Δ0.05). Macrovascular function of the forearm and tibial arteries did not deteriorate as measured by Doppler ultrasound. Furthermore, aortic mean pressure (from 108±21 mmHg to 87±13 mmHg; p=0.002) and augmentation index (from 34±8 mmHg to 24±8 mmHg; p<0.001) decreased significantly while subendocardial viability ratio (from 128±22 to 147±7; p<0.001), a marker for coronary microvascular function, improved significantly after TAVI. In the group undergoing cardiac catheterization, there were no statistically significant changes in macro- or microvascular function.

Conclusion

This is, to our knowledge, the first study investigating the effect of peripheral microvascular tissue perfusion measured by NIRS after TAVI. Our results show that peripheral microvascular tissue perfusion was significantly deteriorated after TAVI procedure.

StO2 before and after TAVI procedure

Funding Acknowledgement

Type of funding source: None
Complex antithrombotic therapy and bleeding risk in patients with peripheral arterial disease
Authors: Tseng A , Bhatt S , Girardo M , Liedl D , Wennberg P , Shamoun F
Published: November 2020

Introduction

Antiplatelet therapy is the cornerstone of treatment for many atherosclerotic vascular pathologies including peripheral arterial disease (PAD). Patients with PAD often have comorbid conditions that require complex antithrombotic therapy, i.e. combined antiplatelet and anticoagulation.

Methods

All adult patients undergoing ankle brachial index (ABI) measurements were included in the study. ABI values between 1.00 and 1.40 were considered normal, and values below 1.00 or above 1.40 were considered PAD. Demographic, comorbidity and outcome data were obtained using diagnostic codes from the electronic health record. Three medication classes were analyzed: aspirin, non-aspirin oral antiplatelets (e.g. P2Y12 inhibitors) and oral anticoagulants (warfarin and the direct oral anticoagulants). Medication use was determined for patients who had been on a medication for at least one year. Cox proportional hazard analysis for the time to first bleeding event was analyzed. Bleeding was defined as any bleeding requiring medical evaluation (including clinically-relevant non-major bleeding and major bleeding).

Results

In all, 40,144 patients were included in the analysis (mean age 66±15, 43% female). Patients with PAD were more likely to be on double therapy (one antiplatelet with anticoagulation) (28% vs 19%) and triple therapy (dual antiplatelet with anticoagulation) (10% vs 4%). Unadjusted hazard ratios for bleeding risk showed increased risk of bleeding for patients with PAD (1.18, 95% confidence interval [CI]: 1.08–1.29), though the association is no longer present after adjustment for antithrombotic therapy. Adjusting for age, sex and PAD class, compared to no antithrombotic therapy, there was increased risk of bleeding for monotherapy (1.91, 95% CI: 1.61–2.26), double therapy (3.40, 95% CI: 2.89–4.00) and triple therapy (5.00, 95% CI: 4.21–5.96). Among medications, aspirin and anticoagulant use was independently associated with the greatest increase in risk of bleeding.

Conclusion

Patients in PAD are at increased risk of bleeding secondary to antithrombotic therapy. Complex antithrombotic therapy with double or triple therapy confer additional bleeding risk, particularly regimens containing aspirin and oral anticoagulants.

Funding Acknowledgement

Type of funding source: None
Effects of liraglutide and semaglutide on stroke subtypes in patients with type 2 diabetes: a post hoc analysis of the LEADER, SUSTAIN 6 and PIONEER 6 trials
Authors: Strain W.D , Holst A.G , Rasmussen S , Saevereid H.A , James M.A
Published: November 2020

Introduction

Diabetes is an independent risk factor for stroke, with approximately a two-fold excess risk in people with versus those without diabetes. Accumulating evidence suggests glucagon-like peptide-1 (GLP-1) analogues (including liraglutide and semaglutide) may reduce the risk of stroke in patients with type 2 diabetes (T2D).

Purpose

We examined the effect of liraglutide and semaglutide on stroke and its subtypes based on pooled data from LEADER, SUSTAIN 6 and PIONEER 6.

Methods

LEADER (NCT01179048), SUSTAIN 6 (NCT01720446) and PIONEER 6 (NCT02692716) were global randomised cardiovascular (CV) outcomes trials of liraglutide, subcutaneous semaglutide and oral semaglutide, respectively, in patients with T2D at high CV risk. In this post hoc analysis, we evaluated the effect of these GLP-1 analogue treatments (pooled) on time to first occurrence of all strokes and subtypes of stroke. Ischaemic stroke was subcategorised according to the TOAST classification, based on aetiology by an external blinded reviewer. A Cox proportional hazards model stratified by trial with pooled treatment as a factor was used to examine treatment effects.

Results

Across the three trials, 216/7907 (2.7%) patients in the GLP-1 analogue group and 262/7913 (3.3%) in the placebo group had a stroke. The risk of first occurrence of all strokes was significantly reduced in the GLP-1 analogue versus placebo group (HR 0.82, 95% CI 0.68–0.98; p=0.030). Treatment effects were consistent across stroke subtypes: ischaemic (HR 0.84, 95% CI 0.69–1.02; p=0.08), haemorrhagic (HR 0.72, 95% CI 0.42–1.22; p=0.22) and undetermined (HR 0.71, 95% CI 0.32–1.60; p=0.41; Figure 1). Across TOAST subcategories, there was a trend that GLP-1 analogue treatment had the greatest benefit versus placebo in small vessel occlusion strokes compared with large artery disease or cardioembolic strokes; however, no statistically significant effects were found in any subcategory.

Conclusion

In this post hoc analysis of the LEADER, SUSTAIN 6 and PIONEER 6 trials, GLP-1 analogue treatment reduced the risk of stroke in patients with T2D and high CV risk, with an indication using TOAST criteria of the strongest effect on stroke caused by small vessel occlusion.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novo Nordisk A/S. WDS is supported by the NIHR Exeter Clinical Research Facility. MAJ is supported by the NIHR SW Peninsula Applied Research Collaboration. This abstract does not necessarily reflect the views of the NIHR, the Exeter Clinical Research Facility, the NHS or the UK Department of Health.
Machine learning for predicting fractional flow reserve based on optical coherence tomography in intermediate coronary stenosis
Authors: Cha J.J , Son T.D , Ha J , Kim J.S , Hong S.J , Ahn C.M , Kim B.K , Ko Y.G , Choi D , Hong M.K , Jang Y
Published: November 2020

Background

Machine learning approaches using intravascular optical coherence tomography (OCT) to predict fractional flow reserve (FFR) have not been previously investigated. The objective of the study was to evaluate a machine learning method to estimate FFR based on intravascular OCT images in intermediate coronary lesions.

Methods

Data from both OCT- and wire-based FFR methods were obtained for lesions of the left anterior descending artery in 125 patients. Based on the total number of lesions, training and testing groups were partitioned at a ratio of 5:1. For the training group, 36 features, including 16 clinical and lesion characteristics, and 21 OCT features, were used to model machine learning-FFR. machine learning-FFR values were then derived for the testing group and compared with wire-based FFR values in terms of a diagnosis of ischemia (FFR <0.8).

Results

Clinical and lesion characteristics and OCT features between the training and testing groups were similar. During the machine learning modeling of the training group, six important features of machine learning-FFR were identified: minimal luminal area, percentage of the stenotic area, lesion length, proximal luminal area, pre-procedural platelet count, and hypertension. machine learning-FFR values showed a good correlation (r=0.853, P<0.001) with wire-based FFR values (Figure 1A). The diagnostic power of an FFR value less than 0.8, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of machine learning-FFR values for the testing group were 85.7%, 100%, 100%, 77.8%, and 90.5%, respectively (Figure 1B). Additionally, OCT-based machine learning-FFR values showed a good diagnostic accuracy compared with other image-based FFR values.

Conclusions

The OCT-based machine learning-FFR method can be used to simultaneously acquire information on both image and functional modalities using one invasive procedure, suggesting that it may be used to optimize treatments for intermediate coronary artery stenosis, as well as save time and cost.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Funded by the Korean government (MSIT) (no. 2017R1A2B2003191)
Discrepancy between RFR and FFR based decision on revascularization – is coronary microcirculatory dysfunction responsible?
Authors: Niewiara L , Guzik B , Szolc P , Zmudka K , Legutko J
Published: November 2020

Introduction

Confirmation of significant ischemia is crucial for proper management of coronary artery disease. Non-hypaeremic indices along with fractional flow reserve are endorsed by current guidelines to prove ischemia. However some discrepancies between hyperaemic and non-hyperaemic decision on revascularisation is present in significant percentage of cases.

Aim

Aim of our study was to determine frequency of coronary microcirculatory dysfunction in patients with discrepant RFR and FFR measurements compared to concordant group.

Methods

Resting full cycle ratio (RFR) was measured in 69 left anterior descending arteries, all patients had symptoms of chronic coronary syndromes (CCS II-III). Cut-off values for ischemia detection were ≤0.80 for FFR and ≤0.89 for RFR. Coronary microcirculatory dysfunction (CMD) was defined as CFR <2.0 or IMR ≥25 according to current guideline.

Results

Discrepancy between FFR and RFR decision on revascularisation was present in 18 (26.1%) of cases. Mean age of patients was 65 (SD=8.5), all patients were similar in terms of diabetes, prior MI or hypertension and statin use (p=NS for all comparisons). Group with discordant RFR and FFR results had higher prevalence of CMD compared to patients with concordant result (44.4% vs 21.6% respectively, p=0.004), however median values of CFR and IMR were similar (see table).

Conclusions

• Patients with discrepant results have more frequently coronary microcirculatory dysfunction.

• Coronary microcirculatory dysfunction should be further investigated as it could explain discrepancies between RFR and FFR based decision on revascularisation.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University statutory grant
Correlations between fractional flow reserve and a novel non-hyperemic index: resting full-cycle ratio in patients with an ambiguous coronary artery stenosis
Authors: Szolc P , Niewiara L , Guzik B , Horszczaruk G , Podolec J , Kleczynski P , Zmudka K , Buksinska-Lisik M , Mamcarz A , Legutko J
Published: November 2020

Background

Fractional flow reserve (FFR) measurement has been the gold standard for invasive assessment of coronary ischemia. Resting full cycle ratio (RFR) is a new non-hyperemic index used to define physiologic significance of coronary artery stenosis. However, there are limited data available to establish optimal cut-off value of RFR for decision making on revascularization.

Aim

The aim of our study was to assess optimal cut-off value of RFR at which to predict FFR of 0.8.

Methods

The RFR and FFR values were recorded during invasive coronary angiography in vessels with angiographic stenosis 40–70% according to visual assessment. Maximum hyperemia for FFR measurement was achieved with adenosine iv. infusion at 140 μg/kg/min. Left main disease, acute myocardial infarction and systolic left ventricular dysfunction (EF <40%) were the main exclusion criteria.

Results

We evaluated 332 vessels, including 189 (56.9%) left anterior descending arteries, 77 (23.2%) left circumflex arteries and 66 (19.9%) right coronary arteries. Median diameter stenosis as assed by QCA was 45% (IQR 40; 50). Median RFR and FFR values were 0.90 [IQR 0.85; 0.94] and 0.86 [IQR 0.81; 0.92] respectively, with significant correlation (p<0.001, Figure 1, panel A). Optimal cut-off value for RFR to detect FFR 0.80 was 0.90 with area under the curve of 90.3%, sensitivity of 81.4% and specificity 88.0% (Figure 1, panel B).

Conclusions

Our data confirm RFR cut-off value ≤0.90 as an optimal threshold to detect ischemic lesions with good sensitivity and specificity in comparison to FFR assessment. Further research is necessary to assess outcomes of RFR-guided revascularization strategy.

Figure 1. RFR–FFR correlation and ROC analysis

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Jagiellonian University statutory grant
Transulnar Aproach for PCI after failed ipilateral TRA: 2 sheaths in same arm, is it safe?
Authors: Zafirovska Taleska B , Jovkovski A , Vasilev I , Taravari H , Petkoska D , Kedev S
Published: November 2020

Aims

To assess the feasibility and safety of transulnar access (TUA) after failure to cross through ipsilateral radial access (TRA), with two sheaths placed in same arm (RA and UA).

Methods and results

All consecutive patients, with TUA due to inability to cross from ipsilateral TRA in the period from March 2011 until December 2017 were included in the study.

Pre-procedural wrist artery angiography was performed in all patients through radial and afterwards ipsilateral ulnar artery. We examined clinical and procedure characteristics, access site complications and cause of failure of primary chosen TRA. Patients were followed up with a median of 4 years.

From March 2011 untill December 2017, 104 patients had a transulnar artery approach due to inability to cross from ipsilateral radial approach. Mean age of patients was 64±11 years with 48% females. 15% of patients had a PPCI intervention due to STEMI. Cause for crossover to ipsilateral TUA was due to: inability to cross an RA anomaly in 94 patients, inability to cross high degree RA spasm in 8 and in 2 patients due to dissection of the RA. Most common anomaly of the RA that caused inability to cross was full 360 degree RA loop in 53 (56%) patients.

49 Patients (47%) underwent percutaneous coronary intervention, 5 (4,8%) patients carotid artery stenting and 50 (48%) diagnostic coronary angiography through ipsilateral TUA. Procedure duration was 35±16 minutes, contrast volume 120±35 ml and fluoroscopy time was 8±6 minutes.

Access site bleeding complications were present in 7 (6.7%) patients after procedure with Type 4 EASY Score hemathoma present in 3 patients (2.8%) without further consequences. 5.7% of patients had ipsilateral RAO noted on duplex on follow up. There were no ischemic hand complications after intervention and follow up with median of 4 years.

Conclusion

Transulnar artery access due to failed ipsilateral radial access crossing is safe and feasible for angiography and PCI with low rate of complications on long term follow up.

TUA after failed TRA (2 sheaths)

Funding Acknowledgement

Type of funding source: None
Impact of a stent-less percutaneous coronary intervention strategy using directional coronary atherectomy and a drug coated balloon for left main and ostial lesions
Authors: Nakamura S , Rokutanda T , Kurokawa H , Onoue Y
Published: November 2020

Background

With the advent of drug eluting stents (DESs), the restenosis rate has markedly decreased. However, even with DESs, problems remain unsolved for bifurcated lesions including left main trunk (LMT) and right coronary artery (RCA) ostial lesions. In the era of directional coronary atherectomy (DCA) alone, an optimal DCA provides a significantly lower residual stenosis and lower angiographic restenosis than conventional balloon angioplasty, despite failing to reach a statistical significance for reducing late clinical events as compared to balloon angioplasty (Circulation 1998; 97:322–31.).

Purpose

This study aimed to examine the safety and effectiveness of stent-less percutaneous coronary intervention (PCI) using DCA and drug coated balloons (DCBs).

Methods

From November 2017 to June 2019, a stent-less PCI for LMT and ostial lesions was performed in 32 consecutive cases (male 24/female 8; mean age 70.9±9.8). A stent-less PCI was performed using SeQuent Please™ DCB after an ATHEROCUT™ DCA, and procedural success was obtained in all cases (6 cases with LMT, 18 with left anterior descending ostial, 6 with left circumflex ostial, and 2 with RCA ostial lesions).

Results

The percent plaque area (%PA) decreased from 70.0±7.7% at baseline to 51.6±8.1% after the DCA and to 46.1±9.0% after the DCBs. All patients completed a follow up coronary angiography after 6 months and no restenosis was observed. No major adverse cardiac events occurred in any cases including target lesion revascularizations. In 29 cases that the lumen was confirmed with IVUS at 6 months of follow-up, the lumen area (LA) had expanded significantly from 8.0±2.3 mm2 at baseline (post DCBs) to 8.9±2.7 mm2 at 6 months (P=0.023, Figure 1A). Local paclitaxel may induce late lumen enlargement (LLE) after a DCA/DCB. The group in which the LA increased during the chronic phase was defined as the Increased group and the group in which the LA decreased during the chronic phase was defined as the Decreased group. When comparing the LDL-Cho level pre DCA between the two groups, the LDL-Cho level in the Increased group was significantly low (74.0±25.8 mg/dl vs. 101.0±33.6 mg/dl, P=0.050, Figure 1B).

Conclusions

Stent-less PCI using DCA and DCBs for bifurcated lesions including LMT and RCA ostial lesions was effective, safe, and useful. Furthermore, a chronic LLE effect by DCBs is expected. In addition, intensive lipid-lowering therapy may also contribute to the chronic outcome after DCA/DCBs.

Funding Acknowledgement

Type of funding source: None
Long-term efficacy and safety of newer generation ultrathin strut drug-eluting stents: a systematic review and meta-analysis
Authors: Lattuca B , Odorico X , Occean B.V , Cornillet L , Schmutz L , Ledermann B , Fabbro-Peray P , Leclercq F , Cayla G
Published: November 2020

Background

Recent trials have demonstrated that short-term efficacy and safety of ultrathin strut drug-eluting stents (DES) were non-inferior to contemporary stents but long-term benefit remains uncertain.

Purpose

The main objective of this meta-analysis was to evaluate efficacy and safety of ultrathin strut DES with an extended follow-up in comparison to 2nd and 3rd generations DES.

Methods

A double-blind review of randomized controlled trials (RCT) comparing ultrathin strut DES to contemporary DES was performed from MEDLINE and CENTRAL databases and from cardiological congresses. The primary efficacy endpoint was target vessel failure (TLF) defined as a composite of cardiac death, target vessel myocardial infarction (TV-MI) and target lesion revascularization (TLR) and the primary safety endpoint was occurrence of stent thrombosis (ST). Short (1 year) and long term (≥2 years) effects were estimated separately. This analysis was pre-specified in PROSPERO (CRD42019142206).

Results

The meta-analysis included 13 RCT including 19,490 patients. In short term, we found TLF decrease with ultrathin strut DES (RR 0.85, CI [0.75–0.97], p=0.01), driven by lower TV-MI (RR 0.83, CI [0.66–1.03], p=0.1) and TLR (RR 0.77, CI [0.58–1.01], p=0.1) rates, and a non-significant downward trend in ST (RR 0.85 CI [0.64–1.14]).

In long term, from the 5 trials with extended follow-up, there was no significant difference between ultrathin strut DES and thicker strut stents in rate of TLF at the longest available follow-up (RR 0.90, CI [0.76–1.06], p=0.2), despite a numerically reduction of TV-MI (RR 0.81, CI [0.61–1.08], p=0.05) and TLR (RR 0.85, CI [0.69–1.04], p=0.1) in favor of ultrathin strut stents. However, we observed a persistent numerically reduction in ST (RR 0.79, CI [0.61–1.02], p=0.01).

Conclusion

Ultrathin strut DES was associated with a lower target lesion failure rate at one year but not beyond 2-years follow-up. Nevertheless, the safety of the ultrathin strut stents was sustained over time with a numerically reduction of ST.

Funding Acknowledgement

Type of funding source: None
Long-term outcomes in high-bleeding risk patients undergoing PCI for acute coronary syndromes: results from a large single-center pci registry
Authors: Nicolas J , Cao D , Claessen B , Sartori S , Chandiramani R , Roumeliotis A , Goel R , Camaj A , Beerkens F , Turfah A , Dangas G , Baber U , Sharma S , Kini A , Mehran R
Published: November 2020

Introduction

Current clinical guidelines recommend prolonged dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndromes (ACS). However, an extended DAPT duration in high-bleeding risk (HBR) patients amplifies the risk of post procedural complications. Hence, clinicians often face the dilemma of prolonging DAPT duration to prevent recurrent ischaemic events at the expense of increasing the incidence of bleeding in high-risk patients. The actual incidence of ischaemic and bleeding events in this particular population is not well elucidated.

Purpose

To evaluate one-year ischemic and bleeding outcomes following PCI for ACS in a real-world HBR population as defined by the Academic Research Consortium (ARC) consensus document.

Methods

We included all patients who presented with ACS to a high-volume single PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent implantation. Patients were classified as HBR if they met ≥1 major or ≥2 minor criteria according to the recent ARC-HBR consensus. The outcomes of interest were major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), and target lesion revascularization (TLR), and major bleeding events, including both peri-procedural and post-discharge bleeding. All outcomes were assessed at 1-year follow-up. The Kaplan-Meier method was used for time-to-event analyses.

Results

Out of 6,097 ACS patients included in this analysis, 2,717 (44.6%) fulfilled the ARC-HBR definition. Compared to non-HBR group, HBR patients were more frequently female, older, more likely to have cardiovascular risk factors (e.g., diabetes, hypertension, and hyperlipidemia) and complex coronary artery disease (e.g., multi-vessel disease, bifurcation lesions, and calcification). The 1-year incidence of MACE was significantly higher in HBR patients (16.3% vs. 8.1%, HR 2.16, 95% CI [1.81–2.59], p<0.001) (Figure 1A). This finding was driven by higher rates of all-cause death and MI (Figure 1B). The 1-year incidence of major bleeding was also significantly higher in HBR patients compared to non-HBR (11.1% vs. 3.1%, HR: 3.92, 95% CI 3.10–4.95; p<0.001).

Conclusions

HBR patients undergoing PCI for ACS are not only subject to bleeding complications but are also at an increased risk for ischemic events and all-cause mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None
Uninterrupted oral anticoagulant therapy in patients undergoing unplanned percutaneous coronary intervention
Authors: Venetsanos D , Skibniewski M , Janzon M , Lawesson S , Henareh L , Bohm F , Andell P , Karlson L , Simonsson M , Erlinge D , Omerovic E , Alfredsson J
Published: November 2020

Background

To investigate the optimal periprocedural antithrombotic strategy in patients on oral anticoagulants (OAC) who undergoing unplanned percutaneous coronary intervention (PCI).

Methods

Using data from the SWEDEHEART registry, we identified all patients on OAC who underwent an unplanned PCI, from 2005 to 2017. We compared uninterrupted OAC (U-OAC) vs interrupted OAC (I-OAC) therapy, defined as any discontinuation of OAC at least 24 hours prior to PCI. Outcomes were major adverse cardiac and cerebrovascular events (MACCE), including death, MI or stroke and net adverse cardiac and cerebrovascular events (NACCE), including MACCE or major bleeds, up to 120 days after the index procedure.

Results

We included 6485 patients, 3163 in U-OAC and 3322 in I-OAC group. The U-OAC strategy increased over time, by 13% per year. Almost 80% of patients in both groups had an acute coronary syndrome. We found no major differences in terms of medical history, clinical characteristics and the CRUSADE bleeding score on admission. The proportion of patients on warfarin was higher in the I-OAC group (85 vs 81%). Patients in the I-OAC were more likely to receive low-molecular weight heparin (29 vs 12%) and glycoprotein IIb/IIIa inhibitors (6 vs 3%) during the index hospitalisation. In the I-OAC group, dual antiplatelet therapy without OAC was more often prescribed (22 vs 8%) and OAC plus single antiplatelet therapy was less often prescribed (8 vs 22%) at discharge.

At 120 days, the cumulative rate of MACCE was 8.2 vs 8.2% and the rate of NACCE was 12.6 vs 12.9% in I-OAC vs U-OAC, respectively. We found no significant difference in the risk for MACCE and NACCE between the two groups (table). The risk for major or minor in-hospital bleeds was similar. I-OAC was associated with significantly longer time-delay to PCI and length of hospitalisation (table).

Conclusion

Uninterrupted OAC was safe and was associated with significantly shorter length of hospitalisation. Our data support U-OAC as the preferable strategy in patients on OAC undergoing PCI.

Funding Acknowledgement

Type of funding source: None
Incremental prognostic value of tricuspid annular dilatation over the STS score
Authors: Deseive S , Steffen J , Beckmann M , Mehilli J , Theiss H , Braun D , Hagl C , Massberg S , Hausleiter J
Published: November 2020

Background

Transcatheter aortic valve replacement (TAVR) is the treatment of choice in most patients with severe aortic stenosis. The Society of Thoracic Surgeons (STS) score is a well established risk score to estimate morbidity, mortality and procedural risk of patients undergoing TAVR. However, tricuspid annular Dilatation (TAD), which is an increasingly recognized pathology associated with increased mortality, is not implemented in the STS Score.

Purpose

The purpose of this analysis was to investigate the incremental prognoctic value of TAD over the STS score.

Methods

Maximal septo-lateral diameter of the tricuspid annulus was measured in 923 patients on 3-dimensional MDCT datasets. A cut-off of 23 mm/m2 body-surface area was revealed by receiver-operating curve statistics and used to define TAD. Incremental prognostic Information was tested with c-index statistics and continuous net reclassification improvement (NRI). Patients were followed for 2 years and all-cause mortality was defined as study endpoint.

Results

Of 923 patients included in this analyis, TAD was found in 370 patients (40%). Patients with TAD had a significantly higher mortality (hazard ratio 2.18 with 95% CI 1.71 and 2.78, p<0.001). The mean STS score in the investigated patient cohort was 5.6±5.0. TAD provided incremental prognostic Information over the STS score when assessed with c-index statistics (rise from 0.63 to 0.66, p<0.01) or continuous NRI (0.209 with 95% CI 0.127 and 0.292, p<0.001). Estimated survival rates at 2 years were 88.2% (95% CI 84.5 and 92.1) in patients with a low STS score (<4) and no TAD and 57.5% (95% CI 51.1 and 64.7) in patients with a high STS score (>4) and TAD. Estimated survival rates in patients with a low STS score and TAD and patients with a high STS score and no TAD were similiar (75.8% with 95% CI 68.9 and 83.5 and 74.8% with 95% CI 69.2 and 80.7, respectively). Kaplan-Meier curves are shown in Figure 1.

Conclusion

TAD is a common entity in patients undergoing TAVR for severe aortic stenosis. It is associated with significantly higher mortality and provides incremental prognostic Information over the STS score.

Funding Acknowledgement

Type of funding source: None
Use of MitraClip system for severe mitral regurgitation in cardiogenic shock: results from a multicentre observational Italian experience (the MITRA-SHOCK study)
Authors: Falasconi G , Pannone L , Melillo F , Adamo M , Ronco F , Carrabba N , Citro R , Stella S , Ingallina G , Capogrosso C , Scandroglio M , Ancona F , Montorfano M , Denti P , Agricola E
Published: November 2020

Background/Introduction

Cardiogenic shock (CS) is a medical emergency and a frequent cause of death. CS can be complicated by mitral regurgitation (MR). The presence of at least moderate MR in the setting of shock was associated with about three-times higher odds of 1-year mortality. In the setting of refractory CS, percutaneous mitral valve repair (PMVR) can be a potential therapeutic option.

Purpose

The aim of the study was to evaluate the efficacy of percutaneous approach of severe MR in patients with CS assessing short-term clinical outcomes.

Methods

In this study we retrospectively included patients with CS and concomitant severe MR treated with Mitraclip system. We enrolled 28 patients from 5 Italian centers between 2012 and 2019. MitraClip implantation was performed according to each hospital standard care. CS was defined utilizing the Diagnostic Criteria of Cardiogenic Shock used in the SHOCK trial. Procedural success was defined as the presence of moderate or less MR after MitraClip implantation.

Results

All patients presented at least severe MR. All treated patients were at high surgical risk (STS mortality score 36.4±11.7%). Procedural success was obtained in 24 patients (86%). A mean of 1.71±0.76 clips per patients were implanted. In-hospital complications occurred in 13 patients (46%): 7 minor bleedings (25% of patients), 7 major bleedings (25%), 8 acute kidney injuries (28%). In-hospital mortality was 25% and the reported causes of death were cardiovascular in all patients. At Cox multivariate analysis procedural success was a strong predictor of in-hospital survival (HR 0.11, CI 95% 0.02–0.67, p=0.017).

Conclusions

PMVR with Mitraclip system in patients with CS and concomitant MR demonstrated high procedural success and acceptable safety. It can be considered a bailout option in this setting of patients with high short-term mortality. Larger prospective studies are needed.

In-hospital mortality predictors

Funding Acknowledgement

Type of funding source: None
Acute changes in mitral valve geometry after MitraClip procedure assessed by 3D transoesophageal echocardiography
Authors: Saffioti S , Travaglio N , Corciu A.I , Gorla R , Lopopolo Rubio A , Testa L , De Marco F , Tusa M , Bedogni F
Published: November 2020

Background

MitraClip procedure is a treatment option in patients with symptomatic mitral regurgitation (MR) and prohibitive surgical risk. Echocardiographic evaluation of mitral valve (MV) is of paramount importance for the correct identification of patient eligibility and procedural success. Our aim is to assess the acute effect of device implantation on mitral annular geometric parameters still little explored with the use of three-dimensional (3D) transoesophageal echocardiography (TEE) and to investigate its relationship with residual MR at discharge.

Methods

67 consecutive patients (mean age78.7±7.2 yrs, 41 males) undergoing percutaneous MV repair with MitraClip in our Centre were enrolled. Patients eligibility was evaluated according to the EVEREST criteria and current guidelines. Four groups were identified on the base of MR aetiology: 22 were degenerative (DMR), 19 ischemic functional (IFMR), 19 non-ischemic functional (NIFMR) and 7 atrial functional (AFMR). 3D TEE was performed before and immediately after clip deployment with MV anatomical quantification by PHILIPS® QLAB MVQ and GE® 4D-AUTO-MVQ software.

Results

Severe MR (4+) was found in 17 pts, and moderate-severe MR (3+) in 50 pts. Thirteen cases were unsuccessful because of unchanged or residual MR>2+. Immediately after device positioning, almost all the evaluated parameters showed a significant modification within each group with a reduction of anterior-posterior (AP-D) and bi-commissural (CC-D) MV diameters, MV annulus area and perimeter and an increase in tenting volume, tenting height and posterior mitral leaflet angle (PML α). Anterior mitral leaflet angle (AML α), sphericity index and aorto-mitral angle remained unchanged. We observed no significant difference in the sub-analysis between degenerative and all functional MR groups, although a different trend of parameters variation could be evidenced. Post-procedural tenting height with cut off of 5.5 mm was a predictor of procedural success (see fig.), while at univariate analysis basal AP-D in DMR group and sphericity index, PMLα and annulus height at baseline in the FMR group were all significantly correlated to the entity of MR reduction at discharge.

Conclusions

Percutaneous edge-to-edge repair with MitraClip acutely changes the MV annular geometry in degenerative and both ventricular and atrial functional MR, with a different trend within each group. Post-procedural tenting height correlates with significant MR reduction at discharge, a promising marker that could be used in clinical practice for identification of MitraClip procedure success.

Funding Acknowledgement

Type of funding source: None
Incidence and delay of atrial tachycardia after patent foramen ovale closure
Authors: Guedeney P , Silvain J , Hauguel-Moreau M , Sabben C , Deltour S , Zeitouni M , Reibel I , Ferrante A , Alamowitch S , Gandjbackch E , Hidden Lucet F , Hammoudi N , Montalescot G
Published: November 2020

Background

In the large randomized trials evaluating patent foramen ovale (PFO) closure vs. medical treatment in secondary prevention of stroke, the incidence of atrial fibrillation has been reported more frequently with PFO closure (2.9–6.6%) than with medical treatment (0.4–1.9%). These episodes were clinically reported and may not reflect the real incidence detected by prolonged ECG recording.

Purpose

To evaluate the incidence and timing of supraventricular tachycardia (SVT) after percutaneous PFO closure.

Methods

Prolonged cardiac monitoring was proposed to patients undergoing PFO closure at the tertiary center of Pitié Salpétrière Hospital, Paris. According to the estimated risk of SVT, two different approaches were used to monitor cardiac rhythm. A 3-year permanent recording using REVEAL™ XT or LINQ was proposed to high risk patients (age >45 years, multiple CV risk factors, prior palpitations or supraventricular ectopic activity during Holter monitoring prior to the intervention). A 4-week, 15-lead ECG continuous recording using the patch-free, wire-free, wearable Cardioskin™ system was proposed to lower risk patients. Endpoints of interest were the occurrence of SVT episodes (>30 seconds) and unplanned medical consultation or hospitalization for this reason

Results

From October 2018 to January 2020, a total of 64 patients underwent prolonged ECG monitoring including 32 (50.0%) and 32 (50.0%) patients with Cardioskin™ and REVEAL™ systems, respectively. A SVT was recorded in 11 (17.4%) patients, including atrial fibrillation (AF) in 6 (9.5%) patients. The median delay of SVT occurrence was 33.0 (14.0–39) days after the procedure (Figure 1) and 18 (10.8–34.8) days for the 6 patients with AF. Unplanned hospitalization or emergency medical visit for symptomatic SVT occurred in 5 (45.5%) patients. Antiarrhythmic medication and oral anticoagulation were initiated in 10 (90.1%) and 7 (63.6%) of the 11 patients, respectively, and SVT recurrences were recorded in 5 (45.5%) patients. No stroke was reported in any of the 11 patients during follow-up. There were no significant differences with respect to baseline and procedural characteristics among patients with or without SVT during follow-up.

Conclusion

Atrial tachycardia is frequent (17.4%) after PFO closure and long-term continuous ECG recording suggests that the incidence is higher than the clinical episodes reported in the randomized trials. This arrhythmic complication of PFO closure seems limited to the first 4 months following the procedure. Larger studies need now to confirm our findings.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): ACTION coeur
Randomized clinical trial of surgical vs. percutaneous vs. hybrid revasculatization in multivessel coronary artery disease: 3 years follow-up (the HREVS Trial)
Authors: Ganyukov V , Kochergin N , Shilov A , Tarasov R , Skupien J , Szot W , Kokov A , Popov V , Kozyrin K , Barbarash O , Barbarash L , Musialek P
Published: November 2020

Aim

Optimal revascularization strategy in multi-vessel (MV) coronary artery disease (CAD) eligible for percutaneous intervention (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR) or MV-PCI.

Materials and methods

Consecutive MV-CAD patients (n=155) were randomized (1:1:1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy.

The primary endpoint was SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization mid-term efficacy and an independent predictor of long-term prognosis). The secondary endpoint was 3-year MACCE.

Results

Baseline characteristics were similar between the study arms. 5 (9.8%) patients in the HCR group required conversion to CABG.

Data are given respectively for the CABG, HCR and MV-PCI arm. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.86). At 12 months, RI was 5 (2,9)% vs. 5 (3,7)% vs. 6 (3,10)% (median; Q1,Q3) with non-inferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). 3-year MACCE rate was similar (34.7% vs. 27.1% vs. 38%; p=0.18).

Conclusion

In patients with MV-CAD amenable to CABG, HCR, and MV-PCI, endpoints of residual myocardial ischemia at 12 months and 3-year MACCE were similar.

ClinicalTrials: gov identifier: NCT01699048

Funding Acknowledgement

Type of funding source: None
Intraoperative transesophageal assessment of coronary artery flow can predict 5 type myocardial infarction
Authors: Zagatina A , Novikov M , Zhuravskaya N , Balakhonov V , Efremov S , Shmatov D
Published: November 2020

Background

Stenosis of a coronary artery results in an increase in flow velocity in the pathologic segment. Effective grafting should decrease the stenotic native coronary velocity according to hemodynamic law. The range of decreased velocity before and after cardiac surgery can hypothetically reflect the effectiveness of a graft. The aim of the study is to determine if measuring coronary flow velocity changes during coronary artery bypass grafting (CABG) can predict intraoperative myocardial infarction.

Methods

One hundred sixty-six (166) consecutive patients (121 men, 64±9 years old) referred for cardiac surgery, were prospectively included in the study. A standard basic perioperative transesophageal echocardiography (TEE) examination was performed with additional scans of the left main, left anterior descending (LAD), and circumflex (LCx) arteries' proximal segments. Measurements of coronary flow velocities were performed before and after grafting in the same sites of the arteries. The maximal value of cardiac troponin I (cTnI) after CABG and the additive criteria were accounted for in the analysis as it is described in the expert consensus document for Type 5 myocardial infarction (MI) definition.

Results

One hundred sixty-three patients (98%) had arterial hypertension, 28 patients (17%) had diabetes mellitus, 35 patients (21%) were currently smokers. The feasibility of coronary flow assessment during cardiac operations was 95%. Before grafting, the mean velocity in the left main artery was 91±49 cm/s, in LAD 101±35 cm/s, and in LCx 117±49 cm/s.

There was a significant correlation between changes in coronary flow velocities during operation and the value of cTnI (R=0.34, p<0.0001). Ten patients met the criteria for Type 5 MI. There were no differences in age, body mass index, number of coronary arteries with stenoses, frequency of prior MI, ejection fraction or coronary flow velocity before surgery in patients with and without Type 5 MI. The group of patients with Type 5 MI had an increase in native artery velocities during surgery in comparison with patients without MI, who had a significant decrease in coronary flow velocity after grafting (30±48 vs. −10±30 cm/s; p<0.0006). Increases in native coronary velocities greater than 3 cm/s predicted Type 5 MI with 81% accuracy (sensitivity 88%, specificity 70%).

Conclusion

Coronary flow velocity assessment during cardiac surgery could predict an elevation of cardiac troponins and Type 5 MI.

Funding Acknowledgement

Type of funding source: None