Circulation: Cardiovascular Interventions最新文献

Background: Lower (<10 mm Hg) discharge echocardiographic mean gradients (MGs) following transcatheter aortic valve replacement with balloon-expandable valves are associated with lower ejection fraction and higher 5-year mortality compared with higher gradients. Using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, we studied the relationship between echocardiographic MG and patient prosthesis mismatch (PPM) following transcatheter aortic valve-in-valve replacement and clinical outcomes.

Methods: Patients who underwent aortic valve-in-valve replacement with a balloon-expandable valve from July 2015 to December 2023 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were included. Adjusted Cox models with regression splines explored the relationship between MG and 5-year mortality. Kaplan-Meier estimates and adjusted hazard ratios compared the occurrence of 5-year mortality between gradient cutoffs and PPM presence.

Results: A total of 13 054 patients were included; spline curves demonstrated a nonlinear relationship between discharge MG and 5-year mortality. Kaplan-Meier curves suggested higher 5-year mortality with MG <10 mm Hg compared with MG ≥10 mm Hg (hazard ratio, 1.15 [95% CI, 1.02-1.29]; P=0.024). MG <10 mm Hg was associated with lower ejection fraction compared with higher MG (50.4±13.9 versus 53.2±12.8; P<0.0001). Severe PPM and MG ≥20 mm Hg were not associated with worse 5-year outcomes compared with none/moderate PPM or MG ≤20 mm Hg, respectively.

Conclusions: Discharge MG <10 mm Hg are associated with lower ejection fraction and increased 5-year mortality following aortic valve-in-valve replacement compared with higher MG in a nonlinear fashion. Incorporating data on ejection fraction with PPM and MG is important before determining the need for valve optimization.

Background: The Alterra Adaptive Prestent provides a landing zone for implantation of the 29 mm SAPIEN 3 transcatheter heart valve (THV) in patients with a dysfunctional right ventricular outflow tract (RVOT) to treat pulmonary regurgitation (PR). Here, we report 3-year outcomes from a pooled analysis of patients who underwent Alterra/SAPIEN 3 THV implantation enrolled in the ALTERRA pivotal trial, Continued Access Protocol, and Pulmonic Delivery System Registry.

Methods: This multicenter, prospective trial enrolled patients with moderate or greater PR and RVOT/pulmonary valve anatomy suitable for implantation. The nonhierarchical composite end point of THV dysfunction was examined at 6 months: RVOT/pulmonary valve reintervention, moderate or greater PR, and mean RVOT/pulmonary valve gradient ≥35 mm Hg. Individual components of the composite, as well as additional clinical and echocardiographic outcomes were examined up to 3 years.

Results: The Alterra/SAPIEN 3 THV system was implanted in 118 patients at 14 sites. At 6 months, THV dysfunction was 3.5% (4/113). At 3 years, 97.3% of patients in the valve implant population had freedom from reintervention, 100% of patients had a mean RVOT/pulmonary valve gradients <35 mm Hg, and 93.3% of patients had mild or lesser total PR. The Kaplan-Meier estimate of all-cause mortality was 3.5% at 3 years. There were no cases of coronary artery compression, hemopericardium, or endocarditis.

Conclusions: This analysis reports the longest follow-up in the largest cohort of patients from the ALTERRA trials. The Alterra Adaptive Prestent with the SAPIEN 3 THV system has shown excellent procedural outcomes and is effective in reducing PR at 3-year follow-up.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03130777.

Background: Isolated coronary artery ectasia (CAE) is a less common form of CAE. The clinical significance of isolated CAE has not been elucidated yet. We aimed to compare the patients with myocardial infarction (MI) due to isolated CAE with the patients without CAE.

Methods: We retrospectively included patients who underwent coronary angiography with a diagnosis of first MI caused by isolated CAE. We excluded patients with >20% stenosis in any vessel other than the lesion responsible for the MI. A second group of patients with MI without CAE was selected as the control group. The primary outcome was the composite of all-cause death and nonfatal recurrent MI occurring after index hospitalization.

Results: A total of 404 patients were included. Overall, 63.9% of MIs were ST-elevation MI. Almost all patients in the isolated CAE group had multivessel diffuse ectasia, with 71.3% classified as Markis I, and 26.7% as Markis II. Death or MI recurrence occurred in 54 (26.7%) patients in the isolated CAE group and 33 (16.3%) patients in the control group (P=0.011). Death occurred in 8 (4.0%) patients in the isolated CAE group versus 6 (3.0%) patients in the control group; recurrent MI in 46 (22.8%) versus 27 (13.4%) patients, respectively. Stent thrombosis was more common in the CAE group compared with the control group (8.9% versus 1.5%; P<0.001). In multiple variable analysis, the presence of CAE was associated with death/recurrent MI (hazard ratio, 1.84 [95% CI, 1.11-3.05]; P=0.017), and recurrent MI (hazard ratio, 2.07 [95% CI, 1.08-3.96]; P=0.029).

Conclusions: The patients with MI due to isolated CAE had a higher risk of recurrent MI and stent thrombosis compared with the patients without CAE. In this study, the rate of recurrent MI from the index infarct artery was also higher in the patients with CAE.

Background: Pulmonary atresia with ventricular septal defect is a rare and complex congenital heart disease. In cases where pulmonary blood flow is supplied exclusively by major aortopulmonary collateral arteries, traditional surgical interventions may be challenging or delayed, especially in resource-limited settings. This study evaluated the feasibility, safety, and outcomes of the right ventricular outflow tract perforation through the retrograde trans-collateral approach in patients with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries dependent pulmonary circulation.

Methods: The study cohort comprised 10 patients with pulmonary atresia and ventricular septal defect who underwent attempted retrograde trans-collateral right ventricular outflow tract perforation via major aortopulmonary collateral arteries from October 2021 to February 2025, including 1 unsuccessful procedure.

Results: The median age at intervention was 4.1 years, and the median weight was 17 kg. Post-procedure, systemic oxygen saturation increased significantly (P<0.01). Follow-up imaging demonstrated substantial growth of the pulmonary arteries following retrograde trans-collateral right ventricular outflow tract recanalization, with significant improvements in both right and left pulmonary artery Z scores (P<0.01) and a significant increase in the Nakata index from a median of 49 to 111.7 mm²/m² (P<0.01).

Conclusions: Retrograde trans-collateral right ventricular outflow tract perforation is a feasible and safe catheter-based strategy for selected patients with pulmonary atresia with ventricular septal defect, promoting central pulmonary artery growth and serving as a bridge to future surgical repair.

Background: Chronic therapy with SGLT2i (sodium-glucose cotransporter 2 inhibitors) is associated with long-term reno-protective benefits. There are limited data on the benefits of these agents against the risk of contrast-associated acute kidney injury (CA-AKI).

Methods: The retrospective study population included all patients with diabetes enrolled in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Percutaneous Coronary Intervention registry, a clinical registry of all PCI cases at nonfederal hospitals in the state of Michigan. Included patients underwent PCI between January 2022 and September 2023. Patients on dialysis and those without post-PCI serum creatinine measurements were excluded. SGLT2i users were compared with nonusers with respect to CA-AKI outcomes, defined as an increase in serum creatinine of ≥0.5 mg/dL following PCI. Outcomes were evaluated in a risk-adjusted, propensity-matched analysis.

Results: Among 13 804 patients with diabetes who underwent PCI, CA-AKI occurred in 3.8% (82/2186) of SGLT2i users versus 5.2% (602/11 618) of nonusers (odds ratio, 0.71; P=0.004). In propensity-matched, risk-adjusted analysis, the pre-PCI use of SGLT2i correlated with a lower incidence of CA-AKI (3.69% versus 4.68%; adjusted odds ratio, 0.72; P=0.027). The protective effect of SGLT2i was preserved among higher-risk subgroups.

Conclusions: Among patients with diabetes who underwent PCI, preprocedural use of SGLT2i correlated with a lower risk of CA-AKI.

Background: Cardiac structural complications (CSCs) have been recently established by the Valve Academic Research Consortium 3 consensus as a combined end point including multiple life-threatening periprocedural events following transcatheter aortic valve replacement. The objective was to assess the incidence, timing, management, and clinical impact of CSCs in the contemporary transcatheter aortic valve replacement era.

Methods: Multicenter study including consecutive patients undergoing transcatheter aortic valve replacement in 18 European and Canadian centers from 2014 to 2024. According to the Valve Academic Research Consortium 3 criteria, CSCs included cardiac structure perforation, injury or compromise, new pericardial effusion, and coronary obstruction. Data was collected in a dedicated database, and patients were followed at 30 days, 1 year, and yearly thereafter.

Results: Among a total of 10 541 patients, CSCs occurred in 221 (2.1%), with 126 (1.2%) patients exhibiting >1 CSC: 146 (1.4%) cardiac structure compromise events (annular rupture: 41.1%, left ventricular perforation: 26.0%; right ventricular perforation: 24.0%, other injuries: 8.9%), 150 (1.4%) new pericardial effusions, and 59 (0.6%) coronary obstructions. Up to 75.6% of CSCs occurred intraprocedurally, and 61 (27.6%) patients had conversion to open heart surgery. The incidence of CSCs remained similar throughout the 10-year study period (from 1.3% to 3.2%, median annual rate of 2.3%). Thirty-day mortality was 35.3% (47.5% among patients requiring conversion to surgery), with annular rupture associated with the highest (41.0%) mortality rate.

Conclusions: About 2% of contemporary transcatheter aortic valve replacement recipients presented CSCs, which did not decrease over time, required conversion to surgery in more than one-fourth of cases, and were associated with very high periprocedural mortality rates. Further research is needed regarding potential preventive strategies and optimal surgical bailout management.

Background: ST-segment-elevation myocardial infarction (STEMI) is uncommon among inpatients already admitted to the hospital for other indications. Prior studies reported significant differences in clinical characteristics and outcomes of patients who develop STEMI while hospitalized versus those who present with out-of-hospital STEMI. However, prior studies were small or not contemporary.

Methods: We compared the characteristics and outcomes of patients presenting with STEMI at the time of hospital admission (preadmission STEMI) versus in-hospital STEMI (occurring during the hospitalization) using data from the National Cardiovascular Data Registry Chest Pain-MI Registry from 2019 to 2022.

Results: A total of 112 590 patients (3.8% in-hospital STEMI, 96.2% preadmission STEMI) from 670 hospitals were included. Patients with in-hospital STEMI were significantly older (median age, 67 versus 63 years), more likely to be diabetic (37.6% versus 29.6%) and have CHF (13.7% versus 6.0%) compared with preadmission STEMI patients (all P<0.001). The median (interquartile range) time from ECG to first device activation (81 minutes [61-110] versus 69 [55-84]; P<0.0001) and time from cath laboratory arrival to first device time (28 minutes [21-39] versus 23 [18-30]; P<0.001) were significantly longer for in-hospital compared with preadmission STEMI patients. The incidence of major bleeding (25.5% versus 7.1%), cardiogenic shock (19.7% versus 7.0%), and cardiac arrest (22.3% versus 7.3%) were all significantly higher in the in-hospital STEMI cohort (all P<0.001), as was mortality (25.9% versus 5.6%; adjusted OR, 5.7 [95% CI, 5.0-6.4]; P<0.001).

Conclusions: Patients who experience in-hospital STEMI represent a high-risk group, with significantly longer times from the diagnostic ECG to primary percutaneous coronary intervention, more complications, and higher mortality.