bluuebunny/crossref_metadata_2025 huggingface dataset:
Plaque phenotyping using deep learning in optical coherence tomography imaging
Authors: Yamaji K , Kohjitani H , Watanabe H , Taniwaki M , Akashi R , Kubo S , Ohira H , Numasawa Y , Arikawa M , Iwama M , Kitai T , Kobayashi Y , Tomohisa T , Yamaji Y , Ono K
Published: October 2024

Background

Artificial intelligence (AI) techniques have emerged as powerful tools in various computer vision tasks, particularly in classification, detection, and segmentation.

Purpose

This study aimed to develop a deep learning model for categorizing optical coherence tomography (OCT) frames into different plaque phenotypes, including thin-cap fibroatheroma (TCFA) and fibroatheroma.

Methods

A prospective multicenter observational study enrolled 168 patients who underwent percutaneous coronary intervention (PCI) and received OCT imaging for non-target lesions with angiographically estimated diameter stenosis greater than 30% (177 vessels). Among them, 129 patients (135 vessels) underwent follow-up OCT imaging at 1 year. A total of 45,072 OCT frames were randomly divided into training and validation sets in a 4:1 ratio. An EfficientNet-B3 convolutional neural network model was developed to classify OCT frames into TCFA, thick-cap fibroatheroma, non-fibroatheroma, adaptive intimal thickening, and normal vessel categories.

Results

A confusion matrix comparing manually assessed plaque phenotypes with AI-predicted phenotypes was presented in Table. In the validation datasets (9,015 frames), the overall accuracy of the model was 85.1%. For predicting the presence of TCFA, sensitivity was 81.1%, specificity was 98.8%, positive predictive value was 63.9%, and negative predictive value was 99.5%. Regarding the presence of fibroatheroma, sensitivity was 90.3%, specificity was 89.4%, positive predictive value was 93.1%, and negative predictive value was 85.4%.

Conclusions

The deep learning algorithm demonstrated high accuracy in detecting TCFA and fibroatheroma with excellent reproducibility. This automated process enables operators to promptly identify high-risk lesions during PCI, potentially leading to improved clinical outcomes.
Functinal assessment in Angina and Non-Obstructive Coronary Arteries (ANOCA) patients: from Microvascular Resistance Reserve (MRR) to different subtypes of Coronary Microvascular Dysfunction (CMD)
Authors: Galante D , Vicere A , Giuliana C , Viccaro V , Pollio Benvenuto C , Todisco C , Burzotta F , Trani C , Crea F , Leone A M
Published: October 2024

Background

Coronary microvascular dysfunction (CMD) is a heterogeneous condition defined by a reduced coronary flow reserve (CFR) and low/high values of index of microvascular resistance (IMR). A new index, the microvascular resistance reserve (MRR) has been developed, but its clinical significance is unclear.

Purpose

We aimed to investigate the relationships between functional indices in ANOCA (Angina and No Obstructive Coronary Arteries) patients and to assess the hemodynamic and clinical characteristics of different CMD subtypes.

Materials and methods

We prospectively enrolled consecutive ANOCA patients who underwent a comprehensive functional assessment of microvascular domain by thermodilution technique. CFR, IMR and MRR were estimated and correlated each other. Patients were divided in two groups according to the presence of CMD (defined by a CFR<2.5). Subsequently High Hyperaemic Resistance (HHR) and Low Hyperaemic Resistance (LHR) CMD subtypes were defined according to low or high IMR values respectively (cut-off 25). Microvascular flow and resistance were estimated both at rest and during hyperaemia with Tmnrest /IMRrest and Tmnhyp/IMR respectively. All functional indices were compared between groups.

Results

one hundred and eight patients were available for the analysis. 66 patients in the Normal Group (CFR≥2.5), 20 patients in HHR CMD (CFR<2.5 and IMR≥25), 22 patients in LHR CMD (CFR<2.5 and IMR<25). MRR showed a strong correlation (r 0.966, p <0.01) with CFR, while a mild and negatively correlation was found between CFR and IMR (r -0.242, p=0.01) and MMR and IMR (r -0.261, p<0.01). MRR showed a good discriminatory power (AUC 0.97, 95% CI 0.94 – 0.99) and accuracy (85%) in detecting CMD when compared to CFR. LHR CMD patients showed reduced microvascular resistance (IMRrest 34.3±15.1 vs 90.1±54.5 Normal Group vs 75.8±28.9 HHR CMD, p<0.01) and increased flow at rest (Tmnrest 0.37±0.17 vs 0.96±0.62 Normal Group vs 0.81±0.43 HR CMD, p<0.01), while HHR CMD patients had impaired flow during hyperemia (Tmnhyp 0.45±0.24 vs 0.26±0.18 Normal Group vs 0.21±0.07 LR CMD p<0.01). MRR was reduced in CMD patients (Normal 4.70±1.78 vs CMD 2.20±0.59, p<0.01), with no differences between CMD subtypes (HHR 2.17±0.47 vs LHR CMD 2.24±0.70, p=0.66).

Conclusions

In INOCA patients, MRR and CFR are strongly correlated and could be considered as functionally interchangeable tools. LHR CMD subtype is characterized by a pathological low resistance and high flow at rest while HHR CMD presented an impaired flow during hyperaemia.
Microvascular functional assessment using microvascular resistance reserve in patients undergoing elective fractional flow reserve-guided percutaneous coronary intervention
Authors: Hada M , Usui E , Kanaji Y , Nagamine T , Ueno H , Setoguchi M , Tahara T , Mineo T , Yonetsu T , Sasano T , Kakuta T
Published: October 2024

Background

Microvascular resistance reserve (MRR) has been proposed as an index for coronary microvascular function. However, the determinants of MRR and the prevalence of coexistent coronary microvascular dysfunction (CMD) in patients with obstructive coronary disease remains elusive. We sought to assess the prevalence of CMD and determinants for MRR.

Methods

We retrospectively investigated 703 physiologically significant (FFR≤0.80) chronic lesions in our institutional physiological registry. All patients underwent pre-PCI physiological assessment including FFR, CFR and MRR. CMD was defined with MRR<2.1. The characteristics and physiological findings were compared between CMD and non-CMD. The predicting factors for CMD were investigated.

Results

In a total cohort, FFR, CFR and MRR were 0.70(0.6-0.75), 1.82 (1.27-2.80) and 3.20 (2.22-4.30), respectively. CMD was observed in 142 (20.2%) vessels. Older age (71[65-77] vs 69[62-75], p=0.007), female patients (24.6% vs 14.4%, p=0.005) and non-LAD culprit lesions (42.3% vs 32.4%, p=0.014) were significantly more frequent in CMD. Furthermore, CMD group was significantly associated with the history of hemodialysis and heart failure (10.6% vs 3.6%, p=0.001, 38.0% vs 31.0%, p=0.015 respectively). FFR and CFR were lower in CMD than non-CMD (0.67[0.60-0.73] vs 0.70[0.61-0.76], p<0.001, 1.03[0.82-1.21] vs 2.16[1.56-3.00], p<0.001, respectively).

In multiple linear regression analysis, low FFR, non-LAD lesion, older age, female and history of hemodialysis were significant predictors for the presence of CMD.

Conclusion

The prevalence of coexistent CMD in patients undergoing PCI was 20.2%, when defined as MRR≤2.1. Non-LAD lesion location, older age, women, history of hemodialysis, and FFR were significantly associated with the presence of CMD.
Short versus conventional DAPT in patients undergoing PCI with ultra-thin DES by renal function: an analysis from the HOST-IDEA trial
Authors: Han J , Lee S D , Hwang D , Yang S , Park S H , Yun J P , Kang J , Yang H M , Kang H J , Koo B K , Kim H S
Published: October 2024

Background

Patients with impaired renal function are known to have an elevated risk of both ischemic and bleeding events following percutaneous coronary intervention (PCI). However, there is insufficient data available on the optimal duration of dual antiplatelet therapy (DAPT), especially with the latest generation of drug-eluting stent (DES)s.

Objective

We investigated to assess the efficacy and safety of abbreviated duration of DAPT in patients undergoing PCI with 3rd generation DESs based on their renal function.

Methods

In this prespecified subgroup analysis of the HOST-IDEA trial, a total of randomized 1997 patients with available baseline estimated glomerular filtration rate (eGFR) were categorized into three groups: high eGFR (>90 mL/min), intermediate eGFR (60 to 90 mL/min), and low eGFR (<60 mL/min). The primary outcome assessed during the 1-year follow-up period was net adverse clinical events (NACE). Ischemic and bleeding endpoints were also evaluated.

Results

Compared to intermediate or high eGFR groups, the low eGFR group resulted in significantly worse outcomes (P < 0.001). 3-6 month DAPT was associated with similar risk of NACE across all eGFR groups (High eGFR: HR: 0.91; 95% CI: 0.38-2.20; Intermediate eGFR: HR: 0.76; CI: 0.33-1.73; Low eGFR: HR: 0.99; CI: 0.51-1.92). There was also no significant difference in target lesion failure (HR: 0.95; CI: 0.32-2.83, HR: 0.77; CI: 0.29-2.06, and HR: 1.14; CI: 0.47-2.75) and major bleeding (HR: 0.84; CI: 0.19-3.74, HR: 0.59 CI: 0.14-2.48; and HR 0.83 CI: 0.34-2.05) among all stratified eGFR groups. This effect was also consistent in patients of end stage of renal disease (eGFR <15 mL/min).

Conclusions

In patients undergoing PCI with third generation DESs, short DAPT was comparable to conventional DAPT regardless of their baseline renal function.
Clinical outcome based on functional complete revascularization in patients with three-vessel coronary artery disease: The FAME 3 Trial
Authors: Otsuki H , Takahashi K , Kobayashi Y , Zimmermann F , Minten L , Takahashi T , Woo J , Yeung A , Pijls N , De Bruyne B , Fearon W
Published: October 2024

Background

Anatomic complete revascularization after angiography-guided percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. The impact of functional complete revascularization (PCI of all fractional flow reserve (FFR) positive lesions) in patients with 3-vessel coronary artery disease (3VD) amenable to PCI or coronary artery bypass grafting (CABG) is unknown.

Purpose

To investigate the clinical impact of functional complete revascularization after FFR-guided PCI in the FAME 3 trial

Methods

The FAME 3 trial is a multicenter, international, randomized study comparing FFR-guided PCI with CABG in patients with angiographic 3VD. This pre-specified sub-study evaluated the impact of functional complete revascularization after PCI on the primary endpoint of death, myocardial infarction (MI), or stroke at 3 years. The degree of functional complete revascularization was quantified by calculating the residual functional SYNTAX score (rFSS), defined as the residual anatomic SYNTAX score based on post-PCI angiography minus any FFR-negative deferred lesions.

Results

Of the 757 patients treated with FFR-guided PCI, the rFSS could be calculated by the core laboratory in 81% (n=601). Among the angiographically significant lesions, PCI was deferred based on FFR in 17% (51 % of patients had deferral of at least one lesion). The patients were divided into two groups according to acceptable functional complete revascularization: rFSS 0-8 (63%) and functional incomplete revascularization: rFSS>8 (37%). The cumulative incidence of death, MI, or stroke at 3 years was significantly lower in patients with rFSS 0-8 (9% vs. 17%, Hazard ratio[HR]:0.5, 95% confidence interval[CI]:0.3-0.8, p=0.006) compared with rFSS>8. In comparison with the CABG arm, the patients with rFSS 0-8 had similar outcome (HR:0.97, 95%CI:0.6-1.5, p=0.87), while in those with rFSS >8 outcome was worse (HR:1.9, 95%CI: 1.3-2.8, p=0.002) (Figure). There was no difference in death, MI or stroke in CABG patients with or without anatomic complete revascularization. In a multivariate-adjusted model, rFSS>8 showed a significant association with death, MI or stroke at three years (adjusted HR: 1.83, 95% CI: 1.09-3.09, p=0.02).

Conclusions

Acceptable functional complete revascularization with FFR-guided PCI in patients with 3VD is an independent predictor of death, MI or stroke at three years and can be achieved in 63% of patients resulting in similar outcomes compared with CABG.
Impact of moderate to severe anemia on clinical outcomes in patients with atrial fibrillation and coronary artery disease requiring percutaneous coronary intervention
Authors: Abe K , Kitahara H , Tanabe Y , Yamazaki T , Hiraga T , Kobayashi Y
Published: October 2024

Background

In patients with coronary artery disease undergoing percutaneous coronary intervention (PCI), anemia is one of the important risk factors for thrombotic events as well as bleeding events. In patients with atrial fibrillation (AF), on the other hand, a similar relationship between anemia and the increased risks of mortality, cardiovascular events, or bleeding events has been reported.

Purpose

The purpose of this study was to evaluate the impact of anemia on clinical outcomes in patients with AF undergoing PCI, who required intensive antithrombotic therapy with a combination of anticoagulants and antiplatelet agents, using a multicenter registry database.

Methods

Patients with AF undergoing PCI at 15 institutions between January 2015 and March 2021 were included in this analysis. Based on the baseline hemoglobin levels, moderate to severe anemia was defined as hemoglobin levels <11 g/dL, and mild anemia was defined as hemoglobin levels 11-12.9 g/dL for men and 11-11.9 g/dL for women. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE: all-cause death, myocardial infarction, stent thrombosis, and stroke) and major bleeding events (BARC 3 or 5), were compared among patients with moderate/severe anemia, mild anemia, and no anemia.

Results

In a total of 746 enrolled patients, 119 (16.0%) and 168 (22.5%) patients presented with moderate/severe and mild anemia. The incidence of MACE (22.5%, 11.0%, and 9.1%, log-rank p<0.001) as well as major bleeding events (10.7%, 6.5%, and 2.7%, log-rank p<0.001) was the highest in the moderate/severe anemia group compared with the mild and no anemia groups (Figure 1). In multivariable Cox regression analyses, moderate/severe anemia (p=0.008), severe chronic kidney disease (p=0.019), and acute coronary syndrome (p=0.049) were independently associated with MACE. For major bleeding events, moderate/severe anemia (p=0.031) and platelet count (p=0.021) were independent predictors.

Conclusions

Moderate/severe anemia was significantly associated with the higher incidence of MACE as well as major bleeding events compared with mild and no anemia in AF patients undergoing PCI.Figure 1
The effect of kaolin on postprocedural radial artery compression - randomized comparison
Authors: Bernat I , Jirous S , Horak D , Buchnerova A , Lerchner T , Rokytova R , Rokyta R
Published: October 2024

Background

Mechanical compression is a standard method of postprocedural radial artery hemostasis. We investigated the use of this method and its combination with kaolin impragnated gauze patch as a new method of hemostasis.

Methods

We randomized 712 consecutive patients (pts) from our same day discharge program (age 66±8 years, 76% males) after coronary angiography (69%) and intervention (31%) from the proximal (PRA) and distal radial (DRA) approaches. Compression was performed by mechanical inflatable device with or without kaolin gauze : 241 versus (vs) 241 patients in proximal groups and 115 vs 115 pts in distal groups were compared. Postprocedural proximal radial artery patency was evaluated by reverse Barbeau test with finger oximetry testing. Time to hemostasis and access site complications were analyzed.

Results

Baseline characteristics were similar in all four groups - proximal with kaolin (PK+) and without kaolin (PK-), distal with kaolin (DK+) and without kaolin (DK-). Mean compression time was 57±20 min in PK+ vs 83±19 min in PK- groups (p<0.001) and 48±12 min in DK+ vs 63±12 min in DK- groups (p<0.001). In parallel, compression times were shorter in the distal groups compared to the corresponding proximal groups: (DK+ vs PK+; DK- vs PK-; both p<0.001). Postprocedural EASY grade II (<10cm) and III (> 10cm) hematomas occured more often in PRA (4,7% and 0,8%) in comparison with DRA (1,7% and 0%; p=0,03). There were no other local complications including the absence of proximal radial artery occlusion.

Conclusions

The use of kaolin in combination with mechanical radial artery compression was associated with shorter compression time in both PRA and DRA compared to mechanical compression alone. DRA was associated with an overall lower incidence of hematomas and also shorter compression time compared to the same PRA groups. No proximal radial artery occlusion was detected in our analysis.
Ultrasonographic and functional evaluation of forearm circulation with occluded radial artery
Authors: Lewandowski P , Zuk A , Slomski T , Pluta M , Ramotowski B , Maciejewski P , Budaj A
Published: October 2024

Introduction

The transradial approach (TRA) has gained popularity in cardiology procedures. This study aims to evaluate forearm and hand arterial circulation in radial artery (RA) occlusion (RAO) patients after coronary angiography (CAG) and percutaneous coronary interventions (PCI). The ulnar (UA) and anterior interosseous artery (AIA) can compensate for RAO.

Methods

A prospective, observational study was conducted on 40 RAO patients after CAG/PCI. Ultrasonographic and functional evaluation (Barbeau test) of collateral circulation through AIA or UA were performed. Statistical analyses were applied to evaluate various Doppler ultrasound parameters and the anatomical characteristics of the RAO.

Results

The RAO group mean age was 71.22 ± 9.99 years, and 45% were male. RA, UA, and AIA showed significant differences in peak systolic velocity, end-diastolic velocity, arterial diameter, total flow volume, and stroke volume (p < 0.01). Pulse quality over RA and UA also differed significantly (p < 0.0001). Blood flow direction in the distal RA segment divided patients into an antegrade flow group (50%) from AIA and a retrograde flow group (50%) from UA. The Barbeau test results varied among RAO patients, with type D being the most common. Anatomical locations of RAO included the anatomical snuffbox (10%), wrist (60%), and forearm (30%). The logistic regression model revealed that the Barbeau test results on Finger 2 (p=0.0006, OR=0.1398) and Finger 4 (p=0.004, OR 0.2843) were significant predictors for the occurrence of antegrade or retrograde blood flow in the distal RA when RAO occurred. Furthermore, when the RA was occluded, the study revealed that a palpable pulse over the RA was still possible in 15% of cases.

Conclusion

Ultrasonographic evaluation and the Barbeau test can assess collateral circulation and predict blood flow patterns in RAO patients. Further research is needed to validate these findings, explore additional factors influencing collateral circulation and access route selection, and investigate the clinical implications of different RAO anatomical locations in cardiology procedures.Radial Artery OcclusionThe pulse quality over RA/UA with RAO
Prognostic impact of intravascular imaging in percutaneous coronary intervention according to atherothrombotic risk
Authors: Ha J , Hong D , Lee J M , Park T K , Choi K H , Hahn J Y , Song Y B , Lee S H , Lee J Y , Shin D S , Lee S Y , Gwon H C , Choi S H , Yang J H , Kim S M
Published: October 2024

Background

Recent randomized controlled trials support intravascular imaging-guided PCI to improve patient prognosis, however, future risk of clinical events in patient with coronary artery disease is not solely determined by lesion characteristics or how these lesions are treated.

Objectives

Current study investigated whether the effects of intravascular imaging in complex percutaneous coronary invention (PCI) would differ according to atherothrombotic risks.

Methods

This study was post-hoc analysis of the RENOVATE-COMPLEX-PCI trial that compared intravascular imaging-guided PCI with angiography-guided PCI in patients with complex coronary artery lesions. Study population was stratified according to atherothrombotic risk assessed by Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) (a sum of age≥75 years, diabetes mellitus, hypertension, smoking, peripheral arterial disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction) into low-risk (TRS-2P<3) or high-risk (TRS-2P≥3) groups. The primary endpoint was target vessel failure (TVF), a composite of cardiac death, target vessel related myocardial infarction, or clinically driven target vessel revascularization.

Results

Among the total patients, 1,247 were low-risk and 392 were high-risk. The risk of TVF was significantly higher in the high-risk group than the low-risk group (15.5% vs. 7.2%; hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.51–3.00; P<0.001). The benefits of intravascular imaging-guided PCI over angiography-guided PCI did not differ between the low-risk group (5.6% vs. 10.4%; HR, 0.56; 95% CI, 0.36–0.86) and the high-risk group (14.1% vs. 18.5%; HR, 0.71; 95% CI, 0.41–1.24) without significant interaction (interaction P=0.496).

Conclusions

Although patients with high atherothrombotic risk had significantly worse clinical outcome than those with low atherothrombotic risk, the prognostic impact of intravascular imaging-guided PCI compared with angiography-guided PCI was similarly observed in both low and high future atherothrombotic risk groups.Structured Graphical Abstract
Influence of acute kidney injury and chronic kidney disease on 3-year clinical outcomes in patients with AMI treated by contemporary PCI and optimal medical therapy; insights from J-MINUET study
Authors: Ozaki Y , Nakao K , Kimura K , Ako J , Noguchi T , Suwa S , Shimizu W , Kawashima N , Niwa Y , Miyajima K , Yoshiki Y , Takahashi H , Muramatsu T , Izawa H , Ishihara M
Published: October 2024

Background

The influence of acute kidney injury (AKI) and chronic kidney disease (CKD) on long-term outcomes following AMI in the era of modern primary PCI with optimal-medical-therapy (OMT) is still in debate.

Methods

A total of 3,281 patients with acute myocardial infarction (AMI) were enrolled in the J-MINUET registry with primary PCI of 93.1% in STEMI Consecutive patients hospitalized within 48 h of onset of AMI at 28 Japanese medical institutions were enrolled in the J-MINUET study (UMIN000010037). AKI was defined as an increase in serum-creatinine ≥0.3mg/dL or ≥50% within-48h during-hospitalization. CKD was defined as estimated glomerular filtration-rate [eGFR]<60mL/min/1.73m2. Major adverse cardiac event (MACE) was defined as a composite of all-cause death, cardiac-failure, MI and stroke. Patients were divided into 4 groups based on the presence or absence of CKD and the occurrence or non-occurrence of AKI. The parameters were assessed by the Cox proportional hazards model. Differences were considered statistically significant at P<0.05.

Results

Of the 3,281 patients with AMI, 3220 patients had complete data set. The average age was 69±13 years old and 75.3% of the patients were male. Of the 3220 patients, 1375 patients had CKD (42.7%) and AKI occurred in 365 patients (11.3%) during the initial hospital stay. AKI more frequently occurred in 305 CKD patients (22.2%) than 60 non-CKD patients (3.3%) (p<0.0001). A total of 898 MACE occurred (27.4%) during follow-up period (median of 768days). Kaplan-Meier curves illustrated event-free survival for MACE over 3 years stratified by the 4 groups (Figure).

Conclusions

While both CKD without AKI and non-CKD with AKI showed similar effect on the incidence of MACE, the worst clinical outcome was observed in patients having AKI on pre-existed CKD.
The acute procedural results and subsequent clinical outcomes after CTO-PCI: main-analysis of the japanese CTO-PCI expert registry
Authors: Matsuda H , Tsuchikane E , Tanaka H , Oikawa Y , Kawasaki T , Igarashi Y
Published: October 2024

Background

The prospective and nonrandomized registry by Japanese Board of chronic total occlusion (CTO) experts has been finished. The large-scale clinical data related with acute procedural results and subsequent clinical outcomes after CTO-percutaneous coronary intervention (PCI) has received limited study.

Objectives

The aim of this study was to make clear the procedural results comparing the different primary CTO-PCI approaches and the clinical outcomes after successful CTO-PCI.

Methods

Between January 2014 and December 2022, a total of 11,674 CTO-PCI patients were consecutively enrolled in this registry. We compared the acute procedural results between 2 groups; primary antegrade approach (PAA) versus primary retrograde approach (PRA), following the intention-to-treat principle. The key outcome of interest was a technical success that was defined as successful stent implantation, residual diameter stenosis <30% within the treated segment, and restoration of TIMI grade 3 flow. The clinical outcomes after achieving technical success of CTO-PCI were assessed in terms of major adverse clinical events (MACE) that were composed of all-cause death, myocardial infarction (MI), and target lesion revascularization (TLR). Moreover, the technical failed factors were also investigated with multivariate analyses.

Results

Of overall, the technical success rate was 91.9%, but there were significant differences between PAA and PRA groups in terms of the success rate (93.2% vs 88.3%; p < 0.001). The success rates of switching strategy to final antegrade approach after retrograde failure were very low among both groups (PAA; 55.8%, PRA; 68.1%). Of retrograde success group, the successful channel tracking tended to using septal and graft route (70.8% vs 56.0%; p < 0.001). Severe calcification and tortuosity of CTO lesion were stronger predictors of failed CTO-PCI than the other factors of J-CTO score. Also, The median follow-up duration was 446.7±613.4 days. At 1 year, the clinical incidence of MACE was 9.4%. The individual components of MACE were also shown lower rates (All-cause death; 2.6%, MI; 0.8%, TLR; 6.3%).

Conclusions

In this large cohort of Japanese CTO-PCI registry, CTO-PCI by highly experienced specialists achieved a high technical success rate and clinical impacts. Retrograde approach has been a key to technical success of CTO-PCI in this study.
Concomitant left atrial appendage occlusion and transcatheter aortic valve replacement among patients with atrial fibrillation: an updated systematic review and meta-analysis
Authors: Andrade N , Cumming H S , Katsuyama E S , Fernandes J M , Pinheiro R P S , Pereira V J , Gomes W F
Published: October 2024

Background

Atrial fibrillation (AF) is a prevalent arrhythmia in patients undergoing transcatheter aortic valve replacement (TAVR). Left atrial appendage occlusion (LAAO) has emerged as a viable strategy to prevent stroke in selected patients with AF. While both devices can be implanted simultaneously during a single procedure, the safety and efficacy of this approach remain uncertain.

Purpose

This study aims to evaluate the efficacy and safety of concomitant LAAO in patients with AF and aortic valve disease undergoing TAVR.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials and observational studies that compared concomitant TAVR and LAAO with isolated TAVR. The study's primary outcomes were all-cause mortality, stroke or transient ischemic attack (TIA), and major bleeding. We established a minimum follow-up time of six months.

Results

Three studies met our eligibility criteria, including one randomized controlled trial and two observational studies. The meta-analysis included 570 patients, 249 (44%) who underwent LAAO and TAVR, with a mean follow-up of 16.3 months. In the overall population, there was no significant difference between the groups in all-cause mortality (relative risk [RR] 0.95; 95% confidence interval [CI] 0.67-1.35; p = 0.78; figure 1A), major bleeding (RR 1.15; 95% CI 0.75-1.77; p = 0.51; 1B), and stroke or TIA (RR 0.70; 95% CI 0.33-1.45; p = 0.33; figure 1C).

Conclusion

In conclusion, concomitant LAAO and TAVR did not demonstrate discernible clinical differences compared to isolated TAVR in patients with AF and aortic valve disease. We recommend that this therapeutic approach be individualized until more robust data become available.
Impact of aortic valve calcium score on conductive disturbances after transcatheter aortic valve implantation: a monocentre retrospective study
Authors: Durand E , Barbe T , Fauvel C , Le Pessec G , Levesque T , Tron C , Bouhzam N , Bettinger N , Hemery T , Dacher J N , Eltchaninoff H
Published: October 2024

Introduction

Conductive disorders requiring permanent pacemaker implantation (PPI) remain an important issue after transcatheter aortic valve implantation (TAVI).

Aims

To assess the impact of aortic valve calcium score (AVCS) on conductive disorders requiring PPI after TAVI.

Methods

All patients who underwent TAVI with an available AVCS from the pre-procedural CT-scan report from 2016 to 2022 were included in this retrospective single-centre study. The primary endpoint was the occurrence of a conductive disorder requiring PPI at 30 days. The association between PPI and AVCS was analyzed using multivariable logistic regression and receiver operating characteristics (ROC) curves analyses.

Results

Seven hundred and sixty-one patients were included, of whom 125 (16%) patients required a PPI at 30 days. AVCS score was significantly higher in patients requiring PPI (3788 (2487-5218) vs. 3050 (2043-4367) AU, p<0.001). Using multivariable analysis, pre-procedural right bundle branch block (OR=6.61, 95%CI=3.82-11.5, p<0.001), first atrioventricular block (OR=1.71, 95%CI=1.03-2.83, p=0.037), the use of a self-expanding valve (OR=3.25, 95%CI=1.17-9.09, p=0.025), and AVCS >4510 AU (OR=1.83, 95%CI=1.04-3.20, p=0.035) were independently associated with PPI. The area under the curve for ACVS to predict PPI was 60.3% (95%CI=54.7%-65.9%), indicating moderate discrimination. Of note, AVCS had an incremental discriminative value (C-index 0.79 vs 0.77, LR test p=0.036) over and above traditional PPI risk factors.

Conclusion

The results of our study suggest that a high AVCS is associated with an increased risk of PPI after TAVI.Central illustration
Objective functional improvement and vital prognosis after TAVR in patients with low-gradient aortic stenosis. Development of a predictive score
Authors: Veiga Fernandez G , Sainz Laso F , Lee D H , Ruisanchez Villar C , Garcia Camarero T , Cuesta Cosgaya J M , Fradejas Sastre V , Gil Ongay A , Garilleti C , Hernandez R , De La Torre Hernandez J M
Published: October 2024

Introduction

Patients with low-gradient aortic stenosis (mean gradient < 40 mmHg) (LGAS) supose a clinical challenge because in these patients the degree of functional recovery after TAVR could be lower and their prognostic evolution more adverse. This is relevant for the optimal indication of TAVR, especially with the growing number of patients with a borderline indication due to comorbidities or advanced age with certain degree of frailty.

Purpose

To develop a clinical model to predict the response to TAVR in LGAS patients based in non invasive physiological parameters at baseline.

Methods

In a cohort of patients undergoing TAVR a prospective evaluation of multiple pathophysiological parameters was performed derived from pre- and post-TAVR assessment with echocardiography, computed tomography, and non-invasive arterial pulse wave analysis with the Sphygmocor XCEL system. Objective functional improvement 6 months after TAVR was assessed by the 6-minute walk test and NT-proBNP levels. Clinical follow-up was performed at 1 year.

Results

Of the 450 patients included, 310 showed high aortic gradient and 140 (31%) low gradient, with an objective functional improvement in 90% and 64% (p<0.001) respectively, and with 1-year mortality of 4% and 12% (p=0.001). In the LGAS group, 1-year mortality was 20% in the subgroup without functional improvement and 8% (p=0.001) in the subgroup showing functional improvement. In the LGAS group, the pathophysiological parameters predictive of functional improvement were the augmentation index75 ≥ 45% (OR 4, CI 95% 1.9–11.3; p=0.006), posterior wall thickness ≤ 12 mm (OR 3.2, CI 95% 1.4–8; p=0.01) and absence of atrial fibrillation (OR 2.7, CI 95% 1.5–8.4; p=0.01). To generate a simple integer-based point score for each predictive variable, each beta coefficient was divided by the absolute value of the smallest coefficient, multiplied by 5, and rounded to the nearest integer. The values were 7, 6 and 5 respectively. Among the low-gradient population, in 55 patients with 0-6 score points the functional improvement was only 29%, while in the remaining 85 patients with 7-18 score points the functional improvement was 86% (p<0.001).

Conclusions

LGAS patients account for a relatively high proportion of patients undergoing TAVR. They show less objective functional recovery, which is associated with a significantly higher mortality at follow-up. We have developed a score based on 3 variables (augmentation index75, posterior wall thickness and atrial fibrillation) that can help predict the functional and prognostic response to TAVR in these patients.
Pacing dependency after TAVI, a lasting hazard in every case?
Authors: Barbosa Sousa R , Lima M R , Felix De Oliveira A , Azevedo S , Da Silva Correia D , Domingues M , Albuquerque F , Carmo J , Brito J , Campante Teles R , Almeida M , Adragao P
Published: October 2024

Introduction

Atrioventricular (AV) conductions abnormalities that require permanent pacemaker (PPM) occur in up to 20% of patients after TAVI. The evolution of conduction abnormalities and the long-time pacing burden have not been fully characterized. We aim to characterize ventricular pacing burden after TAVI assessing also the impact of clinical and periprocedural factors.

Methods

Single centre retrospective registry including all consecutive patients undergoing TAVI between 01/2014 and 08/2021 that had a PPM implanted during index admission. Patients with in-hospital death were excluded. Baseline and pacing follow-up data were collected prospectively and assessed retrospectively using local electronic health records. We examined pacing burden as the percentage of ventricular pacing (VP%) and divided our cohort in 3 groups: i VP% ≤10%, ii 10% > VP% < 90%, iii VP% ≥90%. We assessed the difference between discharge and 1y VP% and the interaction between baseline characteristics.

Results

766 patients underwent TAVI and 109 (14.2%) were included. The median age was 84 years (IQR 80 ; 90) and 44% were male (n = 48). 19 patients (17.4%) had previous 1st degree AV block (AVB) and 37 patients (33.9%) had previous right bundle branch block (RBBB). A self-expandable valve was implanted in 78 patients (71.6%). The median time between TAVI and PPM was 2 days (1;5). Sustained complete AVB (cAVB) occurred in 85 patients (78.0%) and was the most common indication for PPM. Data on VP% at discharge was available for 102 patients (93.5%). The median VP% at discharge was 100% (99 ; 100) with 4 patients (3.7%) having ≤10% VP% and 87 patients (79.8%) having ≥90% VP%. 95 patients (87.2%) completed the 1y follow-up. The VP% decreased significantly between discharge and 1y follow-up - 8.0 (IQR -59 ; 0 / p <0.05 Wilcoxon test) (Figure 1), similarly across valve type. At 1y follow-up, 20 patients (18.3%) had ≤10% VP% and 43 patients (39.4%) had ≥90% VP%. In the 18 patients (19.4%) without periprocedural sustained cAVB, 9 patients (50.0%) had ≤10% VP% and 1 patient (5.6%) had ≥90% VP%. In contrast, among patients with sustained cAVB, 11 patients (14.7%) had ≤10% VP% and 40 patients (53.3%) had ≥90% VP% (p <0.05 Chi-squared) (Figure 2).

Conclusions

In this study cohort the pacing burden significantly decreased in the 1st year after TAVI. It was significantly lower in patients without periprocedural sustained cAVB which suggests that a more conservative management may be considered in a small subgroup of patients.
Temporal trends of aortic valve replacement modalities by age group in the United-States 2015 - 2023
Authors: Barghout M , Khan A , Barry C , Imran H , Ahmad K , Sharaf B , Gordon P , Ehsan A , Abbott J , Elkaryoni A , Saad M
Published: October 2024

Background/Introduction

Transcatheter aortic valve implantation (TAVI) has led to a paradigm shift in treating aortic stenosis (AS) across patients of all surgical-risk categories. To guide the clinical decision, the ACC/AHA guidelines recommended an age group classification; with SAVR being recommended in patients < 65 years, and TAVI being favored over SAVR in patients > 80 years. In patients between 65-80 years, both modalities are to be considered after shared decision making. The impact of those guidelines-derived age group classification on the contemporary AVR practice remains of interest and is dynamically changing.

Purpose

This study aims to examine the temporal trends in the modality of AVR (TAVI vs SAVR) in the U.S. among different age groups using a contemporary nationwide database.

Methods

We conducted a retrospective study using de-identified data from the Vizient Clinical Database, which gathers patient and hospital data from more than 1000 medical Centre. We analysed TAVI and SAVR procedures from October 1, 2015, to November 30, 2023, excluding patients under 18. We examined the national trends of TAVI vs SAVR in 3 age groups (<65, 65-80, >80 years) with AS. Trend analysis was performed using linear regression. This study was deemed exempt from the requirements of 45 CFR 46.104(d) by The Miriam Hospital Institutional Review Board given that it involved de-identified data.

Results

During the study period, 467,832 underwent AVR (TAVI n= 252,834, SAVR n= 214,998). The patient and hospital characteristics by age group are summarized in the Table. We observed a significant rise in TAVI adoption from 33.5% in 2015 to 59.96% in 2023. However, the pattern of temporal trends varied among different age groups. In patients > 80 years, TAVI showed a steep rise from 69.95% in 2015 to 92.96% in 2023 (p<0.002). The 65-80 years age cohort demonstrated the most pronounced growth in TAVI, rising from 26.23% in 2015 to about 60% in 2020 (p.001), after which a plateau in percentage was observed. TAVI in patients <65 years has also been increasingly adopted, rising from 7.18% in 2015 to 19.12% in 2020 (p<0.002), however, followed with a slight downtrend to 16.36% in 2023 (Figure).

Conclusion

In this most contemporary analysis from the U.S., we demonstrate an increase in the adoption of TAVI across all age groups over the study period, with the steepest rise observed in patients between 65-80 years of age. Since the 2020 ACC/AHA guidelines, there has been a gradual downtrend in the utilisation of TAVI in patients <65 years of age indicating a possible change in practice based on scientific societal recommendations. The stabilization in TAVI percentage in the age groups 65-80 years and > 80 years in the last few years may hint towards approaching equilibrium between TAVI and SAVR for these age groups.Proportions of AVR across age groups
Impact of epicardial adipose tissue and atrial functional impairment in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement
Authors: Gronwald J , Lange T , Evertz R , Backhaus S J , Kowallick J T , Hasenfuss G , Schulz A , Schuster A
Published: October 2024

Background

Recent studies outlined the additional prognostic value of atrial function in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). At the same time, increased epicardial adipose tissue (EAT) volumes have proven impact on atrial functional impairment in cardiovascular disease by nurturing adverse atrial remodelling.

Purpose

To explore the impact of increased EAT volumes as a potential pathomechanistic factor of atrial functional impairment in patients with severe AS undergoing TAVR.

Methods

146 patients with severe AS underwent cardiac magnetic resonance (CMR) within 48h prior to TAVR between January 2017 and June 2021. Image analyses included myocardial volume quantification as well as CMR-feature-tracking derived strain. EAT volumes were manually delineated on short axis stacks in end-diastolic cardiac phases and indexed to body surface area. Functional and morphological parameters were compared between patients with high and low EAT volumes. Associations between morphological and functional parameters and EAT were tested using a multivariable linear regression model including patient specific parameters.

Results

After dichotomization at the median of 46.5ml/m2 total EAT volume, patients were assigned to high- and low-EAT groups accordingly. There was comparable age and body mass index and similar rates of co-morbidities such as hypertension, diabetes and atrial fibrillation in both groups. We observed a higher number of male patients in the high-EAT group (36 [53%] vs. 50 [72%], p=0.018). Regarding left and right ventricular dimensions and function, no differences could be shown. Left atrial (LA) end-systolic volumes were significantly higher in the high-EAT group (29.4ml/ml² [19.7-39.4] vs. 40.9ml/ml² [30.2-59.3], p=0.008), while there were no significant differences in end-diastolic volumes. Furthermore, LA reservoir strain was significantly lower in the high-EAT group compared to the low-EAT group (18.0% [11.7-21.0] vs. 11.8% [7.7-16.4], p=0.008) and was independently associated with higher EAT volumes (p=0.018) irrespective of cardiovascular risk factors and left ventricular (LV) systolic function in a multivariable regression model.

Conclusion

In patients with severe AS undergoing TAVR, increased EAT volumes are associated with both, morphological and functional changes of the atria. As impaired atrial function was previously shown to be an important predictor of mortality in TAVR patients, those results potentially render EAT as an additional pathomechanistic link between atrial remodelling and worse outcome in TAVR patients.
One-year outcomes of transcatheter mitral valve replacement in patients with severe mitral regurgitation
Authors: Feng S , Wang S , Pan X
Published: October 2024

Background

Mitral valve regurgitation (MR) is a prevalent valvular heart disease, and a subset of patients face challenges in undergoing surgical treatment. Transcatheter mitral valve replacement (TMVR) has emerged as a viable option for selected patients with severe MR deemed unsuitable for traditional valve surgery.

Purpose

This study aims to evaluate the feasibility, safety, durability, and clinical outcomes of a novel transapical mitral valve system (MitraFix valve) in treating moderate to severe MR patients.

Methods

The early feasibility study of the MitraFix TMVR transapical system is a multicenter, prospective, nonrandomized study. All patients underwent evaluation by a multidisciplinary heart team and were deemed suitable for mitral valve intervention. Clinical events were adjudicated by an independent clinical events committee.

Results

From June 2021 to July 2022, 10 patients (mean age: 71.2 ± 7.4 years, 40% male) were enrolled. The mean Society of Thoracic Surgeons(STS) predicted risk of mortality was 7.5 ± 2.7%. All implants were successful, with a mean operational time of 45.2 ± 25.9 min. One patient was converted to open cardiac surgery after successfully implanting the valve due to persistent apical bleeding. At 1-year follow-up, all-cause mortality was 20%, with a cardiovascular mortality at 10.0%. Among survival patients, 87.5% of surviving patients had MR ≤1+ and 75% patients were in NYHA functional class I or II at 1 year. The overall KCCQ score significantly increased from 55.8 (42.9, 72.9) points at baseline to 77.5 (73.7, 88.6) points at 1-year follow up (P = 0.012). Left ventricular ejection fraction showed no significant change from basline (51.5%) to 1 year (50.0%) (P=0.799). No evidence of mitral stenosis or left ventricular outflow tract (LVOT) obstruction was observed.

Conclusions

The MitraFix TMVR transapical system demonstrated excellent valve function, low mortality, sustained MR elimination and clinical improvement up to one year in this study. Further studies, encompassing a larger cohort of patients and an extended follow-up duration, are needed to confirm these findings.Change in MR and NYHA functional classChange in Quality-of-Life Assessment
Neurologic recurrence after transcatheter PFO closure in patients with cryptogenic stroke
Authors: Goessinger B , Greisenegger S , Kastl S , Rosenhek R , Serles W , Hengstenberg C , Gabriel H , Schrutka L
Published: October 2024

Background

Patent foramen ovale (PFO) is associated with an increased risk of cryptogenic stroke, and interventional closure is recommended for secondary prevention. However, there is limited real-world data on long-term results. Our objective was to evaluate outcomes following successful transcatheter PFO occlusion.

Methods

Data from patients undergoing PFO closure for cryptogenic stroke between 2010 and 2015 were analysed to determine short- and long-term outcomes and to identify potential predictors of neurological recurrence.

Results

330 patients underwent successful PFO closure. The mean age of patients was 49 (standard deviation (SD) ±12) years, and 55.5% were male. Any in-hospital adverse event was observed in eight patients (2.4%). During a median follow-up of 9.85 (SD ±2.5) years, the combined outcome of transient ischemic attack (TIA), stroke, or death from stroke was observed in 3.6% of patients (0.38 events per 100 person-years). After 5, 10, and 12 years the percentage of patients free of the composite outcome was 97.5%, 96.2%, and 96.2% respectively (Figure 1). New onset atrial fibrillation was detected in 10 patients (3.0%). A thorough analysis of the neurologic recurrences revealed a total number of six cryptogenic strokes (1.8%). Our results revealed that the Risk of Paradoxical Embolism (RoPE) score (adjHR: 0.70, 95% confidence interval [CI]: 0.52 to 0.95; p=0.022) and the number of prior neurologic events (adjHR: 9.78, 95% CI: 2.66 to 35.99; p<0.001) were strong independent predictors of future recurrent neurologic events. Kaplan Meier survival analysis stratified by number of previous neurologic events proved to be statistically significant (p<0.001; Figure 2).

Conclusion

In this real-world cohort of patients with cryptogenic stroke we observed excellent safety and good efficacy of percutaneous PFO closure, similar to randomized controlled trials or other long-term cohort studies. The rate of recurrent neurological events was low, especially cryptogenic strokes. The RoPE score confirmed good predictive power; in particular, the number of previous neurological events should be taken more into account when determining the indication for closure.