bluuebunny/crossref_metadata_2025 huggingface dataset:
Post-occlusive reactive hyperaemia can objectify the occurrence of vasospasm induced ischemia during acetylcholine provocation testing
Authors: Feenstra R G T , Woudstra J , Bijloo I , Eringa E C , De Winter R J , Van De Hoef T P , Appelman Y , Beijk M A M , Piek J J
Published: October 2022

Introduction

Acetylcholine (ACh) spasm provocation testing together with the diagnostic criteria published by the Coronary Vasomotor Disorders International Study Group (COVADIS) are considered the gold standard for the diagnosis of coronary vasospasm in contemporary clinical practice. In 20–29% of patients undergoing vasospasm provocation an equivocal test result occurs when these criteria are only partially met and poses a diagnostic dilemma. Post-occlusive reactive hyperaemia is a marker of acute myocardial ischemia and could serve as an added objective diagnostic criterium for the diagnosis of acetylcholine induced vasospasm.

Purpose

The aim of this study is therefore to evaluate the occurrence of post-occlusive reactive hyperaemia in the equivocal, positive and negative test result that follows acetylcholine vasospasm provocation.

Methods

66 patients with angina and non-obstructive coronary artery disease on angiography (ANOCA) who underwent the entire ACh spasm provocation testing protocol were included in this analysis. After each ACh dose angiography was performed and when vasospasm occurred 200 μg nitro-glycerine was administered intracoronary. Definitions and diagnostic criteria for CAS were in line with those used by the COVADIS working group to diagnose epicardial and microvascular vasospasm. An equivocal test result was defined as the induction of recognisable angina without ischemic ECG changes, in reaction to ACh. Doppler flow was continuously measured during the procedure. Changes in flow due to ACh mediated vasodilation quickly return to baseline values due to its short-half life. Therefore, the occurrence of post-ischemic reactive hyperaemia was assessed by the extended time to return to baseline flow, the so called “flow recovery time”.

Results

We analysed the flow recovery time in 21 patients with epicardial vasospasm, in 16 with microvascular spasm, in 14 with an equivocal test result and in 15 with a negative test result. Mean age of the entire study population was 56±11 years and 86% were female. In reaction to dose 1 to 3 flow recovery time was similar between all diagnostic endotypes. In reaction to the fourth dose flow recovery time was extended in the epicardial, microvascular and equivocal test result compared to the negative test result indicative of post-ischemic reactive hyperaemia.

Conclusion

Post-occlusive reactive hyperaemia occurs in patients with an equivocal test result similar to patients with microvascular vasospasm and epicardial vasospasm. These findings indicate the occurrence of acetylcholine induced vasospasm in the equivocal test result and these patients may benefit from medical treatment.

Funding Acknowledgement

Type of funding sources: None.
Validation and diagnostic performance of a fast on-site deep learning-based CT-FFR algorithm
Authors: Giannopoulos A , Keller L K , Sepulcri D S , Boehm R B , Garefa C G , Tsinaridis A T , Sager D S , Venugopal P V , Mitra J M , Ghose S G , Pack J D P , Davis C L D , Edic P M E , Kaufmann P A K , Buechel R R B
Published: October 2022

Background/Introduction

CT-based fractional flow reserve (CT-FFR) has been extensively studied and established as a valuable tool for clinical decision making over the past decade. Nevertheless, clinical implementation has not been systematically adopted due to economic and technical reasons. Among the latter, the turn-around time for the computation and analysis' results potentially plays an important role.

Purpose

To evaluate the feasibility and diagnostic accuracy of CT-FFR computed on-site with a novel, deep learning-based algorithm using invasive hemodynamic indices as the reference standard.

Methods

Sixty-one patients who underwent clinically indicated coronary computed tomography angiography and invasive FFR (iFFR) and/or instantaneous wave-free ratio (iFR) measurements were retrospectively included. CT-FFR analysis was performed in 77 arteries using an on-site prototype software based on deep learning algorithms for coronary anatomy segmentation and prediction of the pressure drop under rest and hyperemia. The diagnostic performance of CT-FFR to detect hemodynamic significant lesions was assessed using iFFR (≤0.8) and/or iFR (≤0.89) as the standard of reference (60 patients with iFFR, 11 patients with iFR, and 3 patients with both) and the receiver operating characteristic area under the curve (AUC) was calculated. Furthermore, correlation analysis and Bland-Altman (BA) analysis was performed. Time for analysis including processing and manual edits to the lumen segmentation was recorded.

Results

CT-FFR analysis was successful in 59 (97%) patients and 74 (96%) arteries. In 74 arteries, 31 of 74 coronary lesions were invasively found to be hemodynamically significant. Total mean time for per patient CT-FFR analysis was 7 minutes and 55 seconds. Compared with invasive indices, per-lesion sensitivity and specificity of CT-FFR were 90%, and 98%, respectively. The AUC of CT-FFR vs. invasive indices for hemodynamic significance was 0.94, (95% confidence interval: 0.86–0.98). Compared to iFFR, CT-FFR correlated well (r=0.77) with only a very small bias (0.02) and narrow BA limits of agreement (−0.14 to 0.17). The per-lesion accuracy, sensitivity and specificity vs. iFFR were 96%, 93%, and 100%, respectively.

Conclusion

A novel deep learning-based CT-FFR algorithm yields excellent diagnostic accuracy compared to invasive hemodynamic indices to detect lesion-specific ischemia and offers the potential to be readily implemented into clinical practice given that it can be performed fast and on-site.

Funding Acknowledgement

Type of funding sources: None.
Bleeding in patients undergoing percutaneous coronary intervention: factors associated with procedural outcomes and major bleeding complications
Authors: Bimal T , Bhuiyan M , Fishbein J , Gandotra P , Selim S , Ong L , Gruberg L
Published: October 2022

Background

Bleeding complications are infrequent in patients undergoing percutaneous coronary interventions (PCI), however they are associated with a poor outcome and increased mortality and morbidity rates.

Purpose

To assess bleeding complications in patients undergoing PCI adjusting for other factors such as estimated glomerular filtration rate (eGFR), sex, left ventricular ejection fraction (EF), ST-segment elevation myocardial infarction (STEMI), intra-aortic balloon pump (IABP) and/or Impella, age, and prior coronary artery bypass graft (CABG).

Methods

Data was collected for quality control on all patients that underwent PCI between 2010 and 2018 at 6 tertiary care hospitals in our system. Outcomes were classified and reported in accordance with the Bleeding Academic Research Consortium (BARC) criteria. BARC Type 4 (CABG-related) and BARC Type 5 (fatal) bleeds were excluded. Major bleeding was defined as BARC Type ≥3. Major adverse cardiac and cerebrovascular events (MACCE) was the combined endpoint of hospital death; post procedural myocardial infarction; cerebrovascular events (ischemic and hemorrhagic) and major bleeding complications. Due to the clustering of patients within hospitals, hierarchical generalized linear mixed models were used. Due to the high intraclass correlation of procedures within patients, only the first procedure within the study period was selected from each patient for analysis.

Results

A total of 25,647 patients underwent PCI during the time period. Baseline and procedural characteristics are shown in the Table. Patients with major bleeding (BARC ≥3) differed significantly from patients with BARC <3 bleeding complications. By multivariate analysis, age (OR: 1.15, CI: 1.1–1.2), femoral site (OR: 1.5, CI: 1.2–1.8), CKD (OR: 1.7, CI: 1.4–2.0), STEMI (OR: 3.3, CI: 2.8–4.0), prior cardiogenic shock (OR: 5.8, CI: 4.1–8.3), and use of IABP/Impella (OR: 5.5, CI: 4.4–6.9) were associated withBARC ≥3 (Figure).

Conclusion

In large contemporary dataset of patients undergoing PCI: 1) patients with BARC ≥3 bleeding complications were significantly different from those having BARC<3 bleeding complications; 2) femoral access, chronic kidney disease, STEMI on presentation and the use of mechanical circulatory devices were associated with major bleeding complications; and 3) male patients had significantly lower odds of major bleeding complications.

Funding Acknowledgement

Type of funding sources: None.
Drug-eluting balloons and drug-eluting stents in the treatment of small vessel coronary artery disease: a systematic review and metanalysis of long-term clinical and angiographic outcomes
Authors: Murphy G , Durand R , McCaughey C , Naughton A , Heron E , Pearson I
Published: October 2022

Introduction

Coronary artery disease is a leading cause of mortality and morbidity worldwide. For those undergoing PCI, there are 20–30% with disease of the small coronary arteries on presentation [1]. Small coronary artery disease asserts a significant risk factor for adverse events. It is often diffuse and multi-vessel on presentation and confers higher rates of major adverse cardiac events, (MACE) and target lesion failure after intervention [2,3]. Best practice guidelines on the management of SvCAD interventions remain limited.

Drug-eluting balloons are a novel therapy, which has shown promise in treating in-stent restenosis (ISR), however their use in small coronary arteries when compared to drug-eluting stents remains unclear.

Purpose

This systematic review and meta-analysis compare long-term outcomes (>1 year), of drug-eluting balloons (DEB), vs. drug-eluting stents (DES), in the treatment of small coronary artery disease (<3mm).

Methods

A systematic review was completed within PRISMA guidelines. The primary outcome was non-inferiority of DEB Vs. DES in major adverse cardiac events (MACE). Secondary outcomes include all-cause mortality, MI, vessel thrombosis, major bleeding and target vessel revascularization at one, two and three years follow-up. Two independent reviewers extracted data. All outcomes used the Mantel-Haenszel and Random effect model. Odds ratios (OR), were presented with a 95% confidence interval (CI).

Result

Of 4661 articles, four RCTs were included (1414 patients). DEB demonstrated reduced rates of non-fatal MI at one year, OR 0.44 (95% CI 0.2, 0.94) and Basket-2 small reported a significant reduction in two-year bleeding rates OR 0.3 (95% CI 0.1, 0.91). DEBs were non-inferior to DES for all other outcomes.

Conclusion

Long duration follow-up of DEB and DES use in small coronary arteries demonstrates DEB to be non-inferior to DES in all outcomes across all years of follow-up. There was a significant reduction in rates of non-fatal MI at one year in the DEB arm and a reduction in major bleeding episodes at two years in the Basket Small 2 trial. These data highlight the potential utility and long-term safety of novel DEBs in small coronary artery disease revascularization.

Funding Acknowledgement

Type of funding sources: None.
Deferred stent implantation in patients with ST segment elevation myocardial infarction with high thrombus burden
Authors: Mohamady M A S
Published: October 2022

Background

Recent guidelines recommend against deferred stenting as a routine strategy in STEMI patients.

Objectives

Current study aimed to assess whether deferred stenting strategy in primary PCI might reduce angiographic or in-hospital major adverse cardiac events in comparison to immediate stenting.

Methods

one hundred patients of STEMI with high thrombus burden divided equally into; 50 patients (group 1) treated with immediate stenting and 50 patients (group 2) treated with deferred stenting. Procedural angiographic events were the primary endpoints, while in hospital MACE were designed as secondary endpoints.

Results

patients of deferred stenting group had statistically significant reduction of distal embolization, slow flow and no reflow (P value = 0.016). In contrast, deferred strategy didn't improve the short term clinical outcomes. Composite of MACEs was statistically significant in the deferred stenting group (20%) versus only (6%) in the immediate stenting group (P value = 0.037).

Conclusion

Deferred stenting in patients with STEMI those with high thrombotic burden improves only the angiographic outcomes but could not improve the short term clinical outcomes in comparison to immediate stenting. Deferred stenting shouldn't be used as a routine strategy in STEMI patients.

Funding Acknowledgement

Type of funding sources: None.
Impact of age at the time of the first ST-elevation myocardial infarction on 10-year outcomes. A sub-analysis from the EXAMINATION EXTEND trial
Authors: Arevalos Rivas V , Spione F , Gabani R , Ortega-Paz L , Gomez-Lara J , Jimenez-Diaz V A , Jimenez M , Jimenez-Quevedo P , Diletti R , Pineda J , Campo G , Silvestro A , Maristany J , Sabate M , Brugaletta S
Published: October 2022

Background

The aim of this post-hoc sub analysis of the EXAMINATION-EXTEND study was to analyze 10-year outcomes according to the age of the patient at the time of the first STEMI.

Methods

Out of 1498 STEMI patients included in the EXAMINATION-EXTEND study, those with a previous history of atherosclerotic cardiovascular disease (coronary ischemic event, ischemic stroke, or previous coronary revascularization) were excluded for this analysis. The remaining 1375 patients were divided into three age groups: <55, 55–65 and >65 years. The primary endpoint was 10-year patient oriented composite endpoint (POCE) of all-cause death, any myocardial infarction (MI), or any revascularization. Secondary endpoints included the individual components of the primary endpoint, cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularization (TLR), and stent thrombosis. The association between age and endpoints was adjusted for baseline confounders.

Results

At 10-year follow-up, patients <55 years (Adjusted hazard ratio [HR]: 0.42, 95% CI: 0.33–0.53, p=0.001), and 55–65 years (Adjusted HR: 0.44, 95% IC: 0.35–0.56, p=0.001) showed lower risk of POCE compared with those >65 years, led by a lower incidence of all-cause death (<55: 5.8% vs. 55–65: 11.3% vs. >65 years: 40.67%, p=0.001). Cardiac death was more prevalent in the older group (<55: 3.5% vs. 55–65: 5.5% vs. >65 years: 21.3%, p=0.001). There were not significant differences in the incidence of TVMI, TLR and stent thrombosis among the different age groups. In the landmark analyses, between 5 and 10-year follow-up, young patients exhibited higher incidence of any revascularization (<55: 7.4% vs. 55–65: 4.9% vs. >65 years: 1.7%, p=0.001) and a trend towards a higher incidence of any MI (<55: 5.2% vs. 55–65: 3.6% vs. >65 years: 1.5%, p=0.064). No differences were found in any other endpoints.

Conclusions

In patients with a first STEMI, advanced age was associated with high rates of POCE at 10-year follow-up, in particular, due to all-cause and cardiac death. Conversely, patients who presented at younger age exhibited a high risk of revascularization at long-term follow-up.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott Vascular
Ten years survival benefit of CABG or PCI based on individual prediction
Authors: Serruys P W , Gao C , Ninomiya K , Hara H , Garg S , Onuma Y , Kappetein A P , Mohr F W , Mack M
Published: October 2022

Background

To compare the observed and individual predicted mortalities according to the SYNTAX score II 2020 (SSII-2020) in the all-comers SYNTAX population, and retrospectively assess the appropriateness of revascularization with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three vessel disease (3VD) and/or left main disease (LMCAD).

Methods

Internal and external validation of the SSII-2020 to predict 10-year all-cause death was performed in the respective randomized and registry SYNTAX populations. Differences in individual predicted mortalities following CABG or PCI were ranked and displayed with the observed mortalities. The proportions of screened patients deriving a survival benefit from CABG or PCI were determined retrospectively.

Results

A total of 2602 participants (as-treated population) were included in the randomized and registry cohorts. In the randomized cohort, all-cause mortality at 10 years, as an average treatment effect, was 23.8% (199/865) with CABG and 28.6% (249/901) with PCI, with a differential survival benefit of 4.6% (95% CI: 0.58% to 8.7%, log-rank p value=0.023). In the CABG and PCI registries, mortalities were 27.8% (167/644) and 55.4% (99/192), respectively. Calibration and discrimination of the SSII-2020 was helpful in CABG and PCI patients in the randomized and registry cohorts. In the PCI registry, the SSII-2020 underestimated mortality since specific comorbidities that entail high mortality are not included in the formula (C-index: 0.72, intercept: 0.38, slope: 0.66), whilst in the CABG registry, it predicted mortality with a helpful calibration and discrimination (C-index: 0.70, intercept: 0.00, slope: 0.76). The proportions of patients with a predicted survival benefit following CABG and PCI were respectively 78.3% (1383/1766) and 21.7% (383/1766) in the randomized cohort, and 82.4% (2143/2602) and 17.7% (459/2602) in the whole SYNTAX trial population.

Conclusion

In the randomized and registry cohort of this all-comers population with 3VD and/or LMCAD, there was reasonable agreement between the individual predicted and observed mortalities after CABG or PCI, such that the predicted 10-year survival benefit might be helpful in determining the appropriateness of each modality of revascularization.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The SYNTAX Extended Survival study was supported by the German Foundation of Heart Research (Frankfurt am Main, Germany). The SYNTAX trial, during 0-5 years follow-up, was funded by Boston Scientific Corporation (Marlborough, MA, USA). Both sponsors had no role in the study design, data collection, data analyses, and interpretation of the study data, nor were involved in the decision to publish the final manuscript. The principal investigators and authors had complete scientific freedom.
Prevention of radial artery spasm during coronary angiography with transdermal glyceryl trinitrate patches: the NURSE-TTS trial
Authors: Doundoulakis I , Kalamakidou I , Koliastasis L , Samara M , Papazisis G , Tsiachris D , Tsioufis K , Economou F
Published: October 2022

Background/Introduction

One of the most common complications encountered during transradial procedures is radial artery (RA) spasm, whereas its management remains a challenge.

Purpose

We hypothesized that in patients undergoing cardiac catheterization via the RA, the use of transdermal nitroglycerin (NTG) patches applied to skin over the RA puncture site may prevent the occurrence of radial artery spasm.

Methods

NURSE-TTS (Nitrate Use to Obtain Radial Spasm Embarrassment) is a parallel-group, randomized, double-blind, placebo-controlled trial evaluating the impact of transdermal NTG application to RA spasm prevention. 146 patients were consecutively enrolled from February 2021 to December 2021 from an experienced center in Greece and underwent diagnostic coronary angiography. The primary endpoint was the exerting force of the RA measured by the dynamometer in Newton.

Results

The primary endpoint of the dynamometer measurements was found to be significantly different between the two groups. The treatment group's mean force was 5.95±2.60 and 7.21±2.82 for the placebo group respectively (p=0.007). The multivariate analysis confirmed that NTG patches affected radial spasm (treatment group p=0,010, 95% CI: −2,038, −0,282; age p=0,010, 95% CI: −0,099, −0,014; male gender p=0,011, 95% CI: −2,612, −0,349; CKD p=0,044, 95% CI: 0,064,0,951).

Conclusions

This is the first prospective randomized study demonstrating that the application of transdermal NTG 10mg on skin for 30 minutes before coronary angiography resulted in lower exerting force of the cannulated radial artery thus lower arterial spasm.

Funding Acknowledgement

Type of funding sources: None.
Low burr-to-artery ratio predict stent underexpansion in patients with high OCT based calcium score underwent rotablator atherectomy
Authors: Wongpraparut N , Chongthaveepol S
Published: October 2022

Background

Stent under-expansion is the potent predictor for stent thrombosis.

Purpose

We aim to determine the incidence of stent under-expansion and its predictors in patient who undergoing rotational atherectomy (RA) assisted percutaneous coronary intervention (PCI) assessed by optical coherence tomography (OCT).

Method

The study included 83 consecutive patients who undergoing OCT guidance RA assisted PCI during January 2016 through September 2020. Baseline clinical characteristics and intracoronary imaging data were recorded. Stent under-expansion was defined as the minimal stent area divided by average of proximal and distal reference lumen area <80%.

Results

Majority of patients (83%) had OCT based calcium score 3–4. The incidence of stent under-expansion was 9.6%. Comparing between the patient with optimized stent expansion and stent under-expansion, patients with stent under-expansion has older age (79.1±6 vs 69.8±10.4, p=0.015), higher calcium thickness (1.01±0.83 vs 0.65±0.22, p<0.001), longer calcium length (18.68±1.88 vs 12.69±5.33, p<0.001). and lower burr to artery ratio (0.53±0.09 vs 0.65±0.09, p<0.001). The optimal cut-off values of burr to artery ratio <0.54 predict stent under-expansion.

Conclusion

In the patients with high OCT based calcium score underwent RA assisted PCI, burr to artery ratio<0.54 is a predictor for stent underexpansion.

Funding Acknowledgement

Type of funding sources: None.
Coronary perforation incidence and temporal trends (COPIT): systematic review and meta-analysis
Authors: Mikhail P , Howden N , Monjur M , Said C , Jeyaprakash P , Bland A , Collison D , McCartney P , Adamson C , Morrow A , Carrick D , McEntegart M , Ford T
Published: October 2022

Background

Despite advancements in Percutaneous Coronary Intervention (PCI) technology and techniques, iatrogenic coronary artery perforation (CAP) remains a dreaded potential complication within the cardiac catheterisation laboratory. Data detailing the incidence of coronary perforation during PCI has previously been obtained from relatively small datasets. A swell of large data published in recent times provides invaluable information regarding PCI related CAP.

Purpose

COPIT is a systematic review and meta-analysis targeted at detailing the incidence, outcomes, etiology and treatment modalities of PCI related CAP including evaluation of temporal trends since the inception of PCI to contemporary practice. Additionally, COPIT provides hypothesis generating data regarding predictors of CAP during PCI.

Methods

A prospective systematic review and meta-analysis using MEDLINE and EMBASE via the OVID interface (PROSPERO ID: CRD42020207881) was performed according to the PRISMA guidelines. Identified relevant studies were used in a pre-specified sensitivity analysis to detail incidence, outcomes, etiology, treatment modalities and risk factors of PCI complicated by CAP. Studies limited to PCI in high risk populations only such as CTO-PCI or rotational atherectomy only were excluded.

Results

67 studies met eligibility criteria detailing 5,568,191 PCIs over a 38-year period (1982–2020). The pooled incidence of CAP was 0.39% (95% CI: 0.34–0.45%) with no change in incidence over that time. Approximately 1 in 5 perforations led to cardiac tamponade (21.1%). Ellis 3 perforations are increasing in frequency and account for 43% of all perforations. Mortality due to perforation occurs in 7.5% of all CAP (95% CI 6.7% - 8.4%) but has declined over the studied period. Meta-regression suggested that female gender, hypertension, chronic kidney disease and previous coronary bypass grafting were all associated with higher incidence of CAP. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%.

Conclusion

Coronary perforations occurs in approximately 1 in 250 all-comer PCI procedures. A tendency towards increase in coronary perforations is likely reflective of contemporary trends towards high pressure post-dilatation with 1:1 vessel sizing as well as an ageing population with increasingly complex, calcific coronary disease. However, reduction in CAP related mortality suggests earlier recognition and effective treatment with transcatheter techniques.

Funding Acknowledgement

Type of funding sources: None.
Prevalence and prognostic implications of the no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention in a university center in a middle-income country
Authors: Godinez Cordova L B , Gonzalez-Pacheco H , Gopar-Nieto R , Eid-Lidt G , Briseno-De La Cruz J L , Araiza-Garaygordobil D , Mendoza-Garcia S , Altamirano-Castillo A , Ontiveros-Mercado H , Arias-Mendoza A
Published: October 2022

Background

No-reflow (TIMI flow ≤2) during primary PCI for STEMI occurs in 7–25% of cases, indicates poor myocardial tissue perfusion, and is associated with a poor outcome. (1–3) The incidence in our hospital is unknow.

Purpose

To analyse the prevalence of no-reflow and the 30-day mortality in our hospital.

Methods

We analysed the database of a teaching hospital and identified 2463 patients who underwent primary PCI from January 2006 to December 2021. No-reflow was defined as post-PCI TIMI flow ≤2, in the absence of post-procedural significant (≥25%) residual stenosis, abrupt vessel closure, dissection, perforation, thrombus of the original target lesion, or epicardial spasm. The outcome measure was 30-day mortality.

Results

Of total of 2050 patients, no-reflow phenomenon was found in 413 (16.8%) patients, and it was associated with significantly higher 30-day mortality (16.7% vs. 4.29%; p = <0.001). Patients with no-reflow were older (60 [53–69.5] vs. 59 [51–66]; p=0.001), with a higher delay in onset of symptom to emergency department arrival (270 min vs. 247 min; p=0.001) but had similar door to balloon time (75 min vs. 80 min; p=0.434). No-reflow patients also had had fewer previous myocardial infarction (11.6 vs. 18.4; p=0.001), lower systolic blood pressure (128 mm Hg vs. 132 mm Hg; p = <0.001) and a Killip class >1 (37% vs. 26.4%; p = <0.001). No-reflow patients were more likely to have an anterior myocardial infarction (55.4% vs. 47.8; p=0.005), initial TIMI flow 0 (76% vs. 68%; p = <0.001) and TMP 0 (14.1% vs. 4.5%; p = <0.001).

Conclusion

No-reflow occurred in 16.8% of STEMI patients undergoing primary PCI and was more likely with older age, delayed presentation, anterior myocardial infarction and Killip class >1. No-reflow was associated with a higher mortality at 30-day follow-up.

Funding Acknowledgement

Type of funding sources: None.
Clinical and angiographic outcomes following percutaneous treatment of non-occlusive vs. chronically total occluded coronary lesions
Authors: Aytekin A , Cassese S , Kufner S , Ndrepepa G , Voll F , Rheude T , Seguchi M , Coughlan J J , Pinieck S , Joner M , Fusaro M , Kastrati A , Xhepa E
Published: October 2022

Background

Recent advancements in recanalization techniques, introduction of dedicated equipment and elaboration of systematic algorithmic approaches have significantly improved procedural success of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures. However, despite their undisputable merits in terms of procedural success, direct comparisons of mid-term clinical and angiographic outcomes following CTO and non-CTO-PCI are missing.

Purpose

The aim of this study was to assess the clinical and angiographic outcomes of patients undergoing successful CTO-PCI as compared to a propensity matched cohort of patients undergoing PCI of non-occlusive coronary lesions.

Methods

All consecutive patients undergoing successful CTO recanalization procedures at our center between 2015 and 2018 were included (N=453; 472 lesions). For matching purposes, all patients undergoing non-CTO-PCI present in our database were included (N=14733; 23458 lesions). A 1-to-1 nearest neighbour matching using baseline clinical and angiographic variables was performed to identify one patient undergoing non-CTO-PCI (N=453; 472 vessels) for each patient undergoing CTO-PCI (N=453; 472 vessels). Surveillance angiography was scheduled at 6–9 months and clinical follow-up was performed up to 12 months. The primary clinical endpoint of interest was the incidence of major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR). The secondary angiographic endpoint was in-segment binary restenosis.

Results

Patients undergoing CTO-PCI displayed a tendency towards higher degrees of binary restenosis at surveillance angiography as compared to those undergoing non-CTO-PCI (CTO vs. non-CTO: 30.5% vs. 24.0%; P=0.058), despite not meeting statistical significance. Of note, the incidence of occlusive restenosis was low and comparable between groups (2.2% vs. 1.4%; P=0.603). At 12 months follow-up, MACE occurred in 83 patients (19.7%) in the CTO-PCI and 59 patients (14.1%) in the non-CTO-PCI group (hazard ratio [HR] = 1.44; 95% confidence interval [CI]: 1.03–2.01; P=0.033). TLR rates were significantly higher following CTO- as compared to non-CTO-PCI (17.2% vs. 10.3%; HR=1.72 [1.18–2.51], P=0.005). The incidence of all-cause death (2.6% vs. 3.3%; P=0.548) and MI (0.5% vs. 1.4%; P=0.177) was not significantly different between the groups.

Conclusion

In this large, propensity-matched comparison of clinical and angiographic outcomes following CTO- vs. non-CTO-PCI, we found CTO-PCI to be associated with a higher MACE rate at 12 months, primarily driven by significantly higher TLR rates. The incidence of occlusive restenosis was low and comparable between groups.

Funding Acknowledgement

Type of funding sources: None.
Radiofrequency thermal balloon angioplasty of vulnerable atherosclerotic plaque accompanied by delta-aminolevulinic acid photodynamic therapy and catheter-based samarium-153 brachytherapy
Authors: Mehrad H , Mokhtari Soureh A
Published: October 2022

Background

The balloon angioplasty methods that are currently in use, cause to inflammation and subsequent neoatherosclerosis.

Purpose

The aim of this study was to evaluate the effect of combined photodynamic therapy and brachytherapy on inflammation and intimal hyperplasia reduction after radiofrequency thermal balloon angioplasty of carotid artery in an animal model of thin fibrous cap atheromatous plaque, wherein a high resolution diagnostic ultrasound is adjuncted with angioplasty and combination therapy system, with a goal of increased safety.

Methods

Briefly, New Zealand white rabbits were submitted to carotid artery vulnerable atherosclerotic plaque by primary intravascular balloon injury followed by a 1.5% cholesterol-rich diet for eight weeks. Histopathology results showed the formation of advanced atherosclerosis with a foam cell-rich atheromatous plaque, resulted in severe stenosis (>70%) in all of the rabbits' arteries. Then treatment group underwent B-mode ultrasound-guided radiofrequency thermal balloon angioplasty followed by catheter-based samarium-153 brachytherapy (153Sm, 18 Gy, β particles) and photosensitizer delta-aminolevulinic acid (delta-ALA)-mediated fiber optic catheter-based polarized light-emitting diodes (LEDs) violet light (λ±Δλ = 405±5 nm, E/A = 120 J/cm2) photodynamic therapy.

Results

Results from ultrasonography and histopathology showed a significant reduction in the mean value for macrophages, lymphocytes, mast cells, foam cells and hyperplastic vascular smooth muscle cells density after angioplasty in the treatment group compared with the other groups (p<0.05).

Conclusion

Apoptotic effect of brachytherapy in combination with cytotoxic and anti-inflammatory effect of delta-ALA photodynamic therapy on immune cells and hyperplastic vascular smooth muscle cells, can cause to reduce the neoatherosclerosis in the intimal layer. These findings provide the basis for developing of combined brachytherapy and photodynamic therapy for a successful clinical application in the inhibition of neoatherosclerosis after radiofrequency thermal balloon angioplasty.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Mehrad Research Lab
Coronary angioplasty or medical treatment in patients with aortic stenosis and coronary artery disease undergoing transcatheter aortic valve implantation: a real world analysis
Authors: Belo Nunes R , Da Costa L M A , Cantarelli M J , Castello Junior H , Oliveira G B F , Avezum Junior A
Published: October 2022

Backgroud

Patients undergoing transcatheter aortic valve implantation (TAVI) due to severe aortic stenosis have a high prevalence of coronary artery disease (CAD). As many of them have high surgical risk, CAD treatment in this group usually has been carried out with optimal medical treatment alone or associated with percutaneous coronary intervention (PCI). However, the best approach in this scenario is not well established.

Purpose

We aimed to compare the incidences of major adverse cardiovascular outcomes in patients with aortic stenosis and chronic CAD treated with medical treatment alone or medical treatment plus PCI before or during TAVI, using data from a large multinational electronic health record network (TriNetX).

Methods

Patients aged ≥18 years with severe aortic stenosis and CAD who underwent TAVI in the last 10 years before the analysis were considered eligible. Patients who underwent PCI before or during TAVI were named the PCI-TAVI group and no coronary intervention patients were named isolated TAVI group. Patients with a past history of acute coronary syndrome, stroke or coronary artery bypass graft before TAVI were excluded from the analysis. The primary outcome was major adverse cardiovascular events (MACE) including the composite of death, unstable angina or myocardial infarction and ischemic stroke. We used propensity score matching to balance the cohorts. The 5-year cumulative incidences for MACE, Kaplan Meier curves and hazard ratios were calculated.

Results

We identified 13,171 patients undergoing isolated TAVI and 1,884 patients undergoing TAVI and PCI. Using propensity score matching, 1,884 patients in each group were compared. The 5-year incidence of MACE was 23.1% in the isolated TAVI group vs 24.7% in the PCI-TAVI group. The probability of survival without MACE was not significantly different between the isolated TAVI group vs PCI-TAVI group (47.4% vs 50.3%, Log-rank test p=0.718) (Figure 1). The hazard ratio (HR) between the 2 groups was also not significant (HR 1.027, CI 95% 0.89–1.18).

Conclusions

In a real-world cohort of patients with severe aortic stenosis and chronic coronary artery disease, the 5-year probability of major adverse cardiovascular events was not different between patients undergoing isolated TAVI versus patients undergoing PCI before or during TAVI.

Funding Acknowledgement

Type of funding sources: None.
High- vs. low-intensity statin therapy and changes in coronary artery calcification density after one year
Authors: Vogel L , Dykun I , Raggi P , Schmermund A , Rassaf T , Mahabadi A
Published: October 2022

Introduction

High-dose statin therapy (HIST) halts coronary plaque progression and reduces the risk of cardiovascular events by increasing atheroma calcification. The Agatston score is well established in the clinical routine for assessment of coronary artery calcification using non-contrast computed tomography. However, randomized controlled trials failed to detect an influence of HIST vs. low-to-intermediate statin therapy (LIST) on the Agatston and CAC volume score after one year. Coronary plaques with lower density including spotty calcifications may represent dynamic and early stages of atherosclerosis. We evaluated whether CAC density differentiates in HIST- vs. LIST-treated patients after one year.

Methods

The meta-analysis contains data from two prospective, randomized, double-blind studies (BELLES, EBEAT) that were designed to detect CAC changes after one year comparing HIST vs. LIST. In both studies, patient's coronary calcification burden was measured at baseline and one-year follow-up using electron beam computed tomography (EBCT). Patients data were pooled and stratified by intensity of statin therapy. Furthermore, the cohort was divided into several subgroup analyses, accounting for LDL-Cholesterol reduction, initial Agatston score and a consistent number of lesions.

Results

Data from 852 patients, 66% female were included. The amount of CAC overall increased after 1 year [Agatston score: 169.3 (80.0, 377.1) vs. 214.9 (95.4, 450.0); p<0.0001NP; volume score: 292.1±445.4 vs. 355.5±482.4; p<0.0001; number of lesions: 6 (3,10) vs. 7 (4,12); p<0.0001NP, at baseline and follow-up, respectively]. Likewise, the average CAC density was higher at follow-up [CAC density: 228.8±35.4 vs. 232.6±37.0; p<0.0001]. HIST vs. LIST more effectively reduced LDL-cholesterol (annualized change: −58.6±50.9 vs. −44.4±43.7 mg/dL, p=0.005). Comparing patients on HIST vs. LIST, CAC density at follow-up (231.9±36.1 HU vs. 233.3±37.7, p=0.59) and its change from baseline (4.0±19.1 HU vs. 3.6±19.6 HU, p=0.73) did not differ. Subgroup analyses, stratifying by LDL-reduction (

Conclusion

HIST vs. LIST leads to a higher reduction in cholesterol levels, which does not translate into relevant differences in the change of CAC density at one-year follow-up.

Funding Acknowledgement

Type of funding sources: None.
Comparison of the safety and efficacy of antithrombotic regimens following TAVR in patients without having an indication for chronic oral anticoagulation
Authors: Guedeney P , Roule V , Mesnier J , Chapelle C , Portal J J , Laporte S , Ollier E , Zeitouni M , Kerneis M , Barthelemy O , Sorrentino S , Silvain J , Vicaut E , Montalescot G , Collet J P
Published: October 2022

Aims

To compare the safety and efficacy of antithrombotic regimens following transcatheter aortic valve replacement (TAVR) in patients without having an indication for chronic oral anticoagulation

Methods and results

We conducted a Prospero-registered systematic review and network meta-analysis of randomized controlled trials evaluating post-TAVR antithrombotic regimens up to March 2021. We estimated the relative risk and 95% confidence intervals using a fixed effect model in a frequentist pairwise and network metanalytic approach. We included 6 studies comprising of 3,777 patients with a mean weighted follow-up of 13.3 months. Single antiplatelet therapy (SAPT) was associated with a significant reduction of life-threatening, disabling, or major bleeding compared to dual antiplatelet therapy (DAPT) (Risk Ratio [RR] 0.44, 95% confidence interval [CI]: 0.28–0.69), apixaban (RR: 0.47, 95% CI 0.26–0.84) and low-dose rivaroxaban + 3-month SAPT (RR: 0.30, 95% CI: 0.16–0.57). Risk of all-cause death was significantly reduced with DAPT compared to low-dose rivaroxaban + 3-month SAPT (RR: 0.60, 95% CI: 0.41–0.88) and a consistent reduction was observed with SAPT and DAPT compared to apixaban (RR: 0.60, 95% CI: 0.31–1.16 and RR: 0.58, 95% CI: 0.32–1.04, respectively). There were no differences between the various regimens with respect to myocardial infarction and stroke. Apixaban significantly reduced the risk of pulmonary embolism, valve thrombosis and grade 3 or 4 reduced leaflet motion.

Conclusion

Following TAVR in patients without an indication for chronic oral anticoagulant, SAPT was associated with the lowest risk of bleeding compared to DAPT and direct oral anticoagulant-based regimens without significant ischemic offset.

Funding Acknowledgement

Type of funding sources: None.
Prognostic impact of left ventricular ejection fraction recovery in patients undergoing pecutaneous aortic valve replacement
Authors: Lopez Otero D , Bastos Fernandez M , Sanmartin Pena X C , Gonzalez Salvado V , Agra R , Cid Alvarez B , Trillo Nouche R , Iglesias Alvarez D , Pena Gil C , Gonzalez Juantey J R
Published: October 2022

Background

A lot of studies have shown a positive effect of transcatheter aortic valve implantation (TAVI) on left ventricular ejection fraction (LVEF). However, the association between long-term outcomes and LVEF recovery after TAVI has not yet been well investigated.

Purpose

To detect differences in long-term all cause mortality between patients who recover LVEF at six mounths after TAVI and those who do not.

Methods

This is a retrospective, single-center study of 1092 patients undergoing TAVI. LVEF was determined before the intervention and at 6 months. The primary outcome was long-term all-cause mortality. Left ventricular dysfunction was defined as LVEF <50% and recovered LVEF as LVEF >50%.

Results

Of the 1.092 patients included, 250 (22.8%) had LVD. Of these, adequate follow-up was only achieved in 188, which were the ones included in the analysis. At 6 months, 86 patients (45.7%) had RLVEF. Table 1 shows the baseline characteristics of patients with RLVEF versus those who did not. No significant differences were found between the two groups in terms of comorbidity, procedural complications, or discharge therapy. There were no differences in baseline LVEF or severity of aortic valve disease, although the transaortic peak gradient (63.9±15.6 vs 73.6±19.7; p=0.019) and transaortic mean peak gradient (38.7±11.2 vs 45±12.7; P=0.026) were significantly higher in the RLVEF group. On the other hand, the group where the LVEF did not recover presented a higher percentage of moderate-severe mitral regurgitation (MR) (25.4 vs 8.1; p=0.005). These data could explain a more advanced state of cardiomyopathy and be an explanation for the different evolution of LVEF. In the multivariate analysis, only moderate-severe MR was associated as a predictor of non-recovery of LVEF after TAVI (HR 1.12; (1.09–1.45); p=0.023). During follow-up RLVEF was associated with a reduction in long-term all-cause mortality (p<0.001) (Figure 1)

Conclusions

Up to 25% of patients undergoing TAVI have baseline LVD. Of these, almost half recover it within six months. Patients who recover LVEF have a significant reduction in mortality in the medium term. The presence of a moderate-severe MR was associated with the non-recovery of LVEF after TAVI, probably because it was a more advanced cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.
Effect of TAVR generation on conduction abnormalities – is newer always better?
Authors: Masoudian B A , Azzu M , Mihkli E , Vincent A , Shaukat J , Speight M , Fearon W , Liang D
Published: October 2022

Objective

Transcatheter aortic valve replacement has become an established approach to treat severe symptomatic aortic stenosis in patients of all risk levels. Development of conduction abnormality and the need for a permanent pacemaker are known complications of TAVR. The introduction of third generation valves with cuffs has resulted in a significant decrease in post-deployment perivalvular regurgitation. However, there is concern for an increase in development of a new onset left bundle branch (LBBB) and the need for permanent pacemaker (PPM) implantation. This study aimed to identify whether newer valve generations along with the move away from transesophageal echocardiography (TEE) guidance for valve deployment is associated with changes in frequency of conduction block.

Methods

601 consecutive patients who underwent transfemoral TAVR implantation with a balloon expandable valve in a native aortic valve at a single institution from July 2009 to March 2019 were included in the study. 40 patients with LBBB and 91 patients with pacemakers prior to TAVR were excluded from the LBBB analysis. Multivariate logistic regression was used to test for significance.

Results

New LBBB occurred significantly more frequently with the newer generation valves, 1st Gen 2/104 (1.9%), 2nd Gen 9/88 (10.2%), 3rd Gen 33/278 (11.9%) (p<0.01). There was no statistically significant increase in pacemakers across valve generations, 1st Gen 7/113 (6.2%), 2nd Gen 7/92 (7.6%), 3rd Gen 30/305 (9.8%). Use of TEE guidance had no effect on either LBBB or pacemaker. There was a strong trend (p=0.057) toward need for pacemaker as larger valves where used, with OR of pacemaker relative to 29 mm valve for 23 mm valve of 0.26 and for 26 mm valve of 0.63.

Conclusion

Newer TAVR valves, although beneficial in reducing perivalvular regurgitation, increases the risk of LBBB, without increasing risk need for pacemaker, suggesting possibly different mechanisms for the two complications. Understanding the mechanism for avoiding these complications may be important to avoiding them, as we move to a lower risk population where complication free results are even more important.

Funding Acknowledgement

Type of funding sources: None.
Prognostic value of right ventricular dysfunction in patients undergoing transcatheter aortic valve replacement
Authors: Jimeno Sanchez J , Perez Guerrero A , Fuertes Ferre G , Gambo Ruberte E , Peiro Aventin B , Ferrer Gracia M C , Sanchez-Rubio Lezcano J , Galache Osuna G , Cortes Villar C , Simon Paracuellos T , Gomez Martin D , Ortas Nadal M R , Diarte De Miguel J A
Published: October 2022

Introduction

Right ventricular dysfunction (RVD) in patients with severe aortic stenosis seems to increase the risk of worse long-term outcomes after transcatheter aortic valve replacement (TAVR). The purpose of this study was to investigate the association between RVD at baseline and the prognosis after TAVR (readmission for heart failure and death).

Methods

A cohort study was conducted. Consecutive patients undergoing TAVR from January 2012 to December 2020 were included and analysed depending on the right ventricular function prior to the procedure. RVD was assessed using tricuspid annular plane systolic excursion (≤17 mm). Clinical and follow-up characteristics were recorded. The median follow-up was 26±22 months.

Results

Of 292 patients who underwent TAVR, 64 (21.9%) met the criteria for RVD at baseline. Patients with RVD undergoing TAVR were significantly more often male (65% vs 46%) and smokers or former smokers (42% vs 23%). They had significantly a higher EuroScore risk score (9.1±7.2 vs 5.3±4) with greater prevalence of atrial fibrillation (55% vs 32%), previous heart valve surgery (20% vs 4%) or pacemaker implant (25% vs 14%), less left ventricular ejection fraction (48±15% vs 58±11%), lower aortic valve mean gradient (41±13 vs 50±13 mmHg) and higher estimated pulmonary artery pressure (50±18 vs 42±13 mmHg) compared with patients with preserved RV function. Procedural characteristics and complications were similar in both groups. Normalization of right ventricular function after TAVR was found in 50.8% of patients with RVD at baseline. Readmission for heart failure during the follow-up was more common in patients with RVD at baseline (29.7% vs 13.3%, p 0.04), also observing a higher trend in terms of mortality (29.7% vs 19.1%, p 0.08).

Conclusions

Patients with RVD undergoing TAVR had an increased risk of readmission for heart failure and a higher trend in mortality.

Funding Acknowledgement

Type of funding sources: None.