Circulation: Cardiovascular Interventions最新文献

Background: Geographic stent-ostium mismatch is an important predictor of target lesion failure after percutaneous coronary intervention of an aorto-ostial right coronary artery lesion. Optimal visualization of the aorto-ostial plane is crucial for precise stent implantation at the level of the ostium. This study investigates whether preprocedural 3-dimensional computed tomography (3DCT), with determination of the optimal viewing angle, would allow for more precise stent implantation and reduce procedure time, contrast, and radiation dose.

Methods: In this single-center, prospective, open-label, core-laboratory blinded trial, a total of 30 patients with an aorto-ostial right coronary artery lesion were randomly assigned to either percutaneous coronary intervention with a preprocedural 3DCT or angiography-guided percutaneous coronary intervention. The optimal working view angle was determined by 3DCT in the intervention group and by the operators' discretion in the control group. The primary end point was the percentage of patients without geographic mismatch, as determined by intravascular ultrasound.

Results: 3DCT-determined C-arm angles were heterogenous but, in general, more extreme left anterior oblique projections were used (P<0.0001). While stent implantation was in the optimal position in all patients randomized to the intervention group, geographic mismatch was present in 5 (33%) patients randomized to the control group (P=0.06). The mean amount of procedural contrast (P<0.0001), mean radiation (P=0.03), and median procedure time (P=0.03) were significantly lower in the intervention group. The 3DCT scan was able to predict the calcium arc (P<0.0001) and minimal lumen area by intravascular ultrasound (P=0.003).

Conclusions: Preprocedural 3DCT planning for percutaneous coronary intervention of aorto-ostial right coronary artery lesions allows for optimal stent positioning while reducing procedure time, contrast, and radiation dose.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05172323.

Background: The association, if any, between the transmitral mean pressure gradient (TMPG) after mitral transcatheter edge-to-edge repair and 1-year mortality is controversial in patients undergoing mitral transcatheter edge-to-edge repair with the MitraClip system. We sought to estimate the association between intraoperatively measured residual mitral regurgitation (rMR) and TMPG and 1-year mortality among patients undergoing mitral transcatheter edge-to-edge repair to facilitate decisions on additional devices.

Methods: In patients with severe secondary (functional) MR, we analyzed registry data using generalized estimating equations. Both rMR and TMPG were nonlinearly transformed using fractional polynomials.

Results: We studied 570 patients with secondary MR who underwent mitral transcatheter edge-to-edge repair in 11 centers. Most patients were men (61%) and averaged 72±12 years of age. Most (78%) patients had TMPG <5 mm Hg and 22% had TMPG ≥5 mm Hg. Postprocedural MR severity improved substantially, being ≤2+ in 95% (with ≤1+ in 76%), 3+ in 3%, and 4+ in 2%. 1-year mortality was 20%. After adjustment for confounders, rMR (odds ratio, 2.10 [95% CI, 1.88-2.35]; P<0.001 for rMR^.5) and TMPG remained associated with mortality, with odds ratios of 1.26 (95% CI, 1.19-1.32), 1.84 (1.58-2.10), and 3.13 (2.31-3.98) for TMPG values of 4, 6, and 8, respectively, compared with TMPG=2 mm Hg at rMR=1+.

Conclusions: Both rMR and TMPG were nonlinearly associated with 1-year mortality. At low levels of rMR, changes in TMPG are associated with only small changes in the risk of death. Conversely, at higher levels of rMR, even small changes in TMPG are associated with larger changes in the absolute risk of death.

Background: Transcatheter heart valve (THV) underexpansion after transcatheter aortic valve replacement may be associated with worse outcomes. THV expansion can be assessed fluoroscopically using a pigtail for calibration; however, the accuracy of this technique specific to transcatheter aortic valve replacement is unknown. We assessed the accuracy and reproducibility of a novel fluoroscopic method to assess THV expansion using the THV commissural post for calibration.

Methods: Patients who underwent transcatheter aortic valve replacement with a SAPIEN 3 (S3) THV had documented 3 cusp and cusp overlap views, and post-implant computed tomography was identified. THV expansion was fluoroscopically assessed in the 3 cusp and cusp overlap views using the S3 commissural post height and the pigtail as a reference for calibration. The correlation between the 2 methods and computed tomography was evaluated.

Results: Forty patients were included. On the bench, the commissural post height measured 3.3, 3.5, 4.0, and 4.5 mm for the 20 mm S3, 23 mm S3, 26 mm S3, and 29 mm S3, respectively. The Pearson correlation coefficient (r) with computed tomography for measuring the inflow, mid-portion, and outflow THV diameter was 0.98, 0.97, and 0.98 for the commissural post height method and 0.82, 0.81, and 0.78 for the pigtail method, respectively. Unlike the pigtail method, the correlation between the commissural post height method and computed tomography remained strong across all THV sizes and in both the 3 cusp and cusp overlap views.

Conclusions: The commissural post height method is a novel real-time fluoroscopic tool that has the potential to assess THV expansion and guide further optimization after balloon-expandable transcatheter aortic valve replacement.

Background: Intravascular imaging (IVI) is widely recognized to improve outcomes after percutaneous coronary intervention (PCI). However, IVI is underutilized and is not yet established as a performance measure for quality PCI.

Methods: We examined temporal trends of IVI use for all PCIs performed at Veterans Affairs hospitals in the United States from 2010 to 2022 using retrospective observational cohorts. IVI was defined as intravascular ultrasound or optical coherence tomography. A contemporary subset of PCIs from 2020 to 2022 was used to examine clinical characteristics associated with IVI use and test the reliability of IVI as a pass/fail performance measure. We then used a generalized linear mixed model to estimate the proportion of IVI use variability attributable to the hospital, physician, and patient level. Cox proportional hazard models were used to assess the association of IVI with clinical outcomes at 1 year.

Results: IVI use increased from 12.3% in 2010 to 43.1% in 2022 in 136 071 PCIs included in the study. Among 22 918 PCIs in the contemporary cohort, IVI was more frequent with nonemergent presentations, chronic total occlusions, and left main lesions but usage variability was primarily attributable to hospital (54%) and physician (33%) levels. As a pass/fail performance measure, reliability was high (>0.96) at hospital and physician levels. However, IVI use was not associated with statistically significant differences in mortality or major adverse cardiovascular events in this cohort.

Conclusions: IVI use for PCI is increasing rapidly at Veterans Affairs hospitals in the United States but with marked variation at the hospital and physician levels. IVI meets established criteria for an effective performance measure and should be measured and reported by local and national organizations to encourage further uptake. Ongoing training and quality improvement may be required to maximize the benefit of IVI as it is more widely utilized.

Some patients with aortic stenosis may require multiple valve interventions in their lifetime, and choosing transcatheter aortic valve replacement (TAVR) as the initial intervention may be appealing to many. If their transcatheter heart valve degenerates later in life, most will hope to undergo redo-TAVR. However, if redo-TAVR is not feasible, some may have to undergo surgical explantation of their transcatheter heart valve (TAVR-explant). With rising numbers of TAVR in younger patients, we address the practical implications of choosing a TAVR-first strategy. In this review we explore potential factors contributing to higher-than-expected mortality after TAVR-explant, synthesize available outcomes data for TAVR-explant for structurally degenerated valves, and describe strategies to standardize and optimize surgical techniques for TAVR-explant. We also discuss clinical outcomes of redo-TAVR within the context of limitations in currently published series and highlight the potential benefit of virtual planning to assess the feasibility of future redo-TAVR before implanting the first valve. Finally, we highlight areas for future investigation to inform management strategies in patients who may require multiple aortic valve interventions.

Background: Despite fractional flow reserve (FFR)-guided deferral of revascularization, recurrent events in patients with diabetes or after myocardial infarction remain common. This study aimed to assess the association between FFR-negative but high-risk nonculprit lesions and clinical outcomes.

Methods: This is a patient-level pooled analysis of the prospective natural-history COMBINE (OCT-FFR) study (Optical Coherence Tomography Morphologic and Fractional Flow Reserve Assessment in Diabetes Mellitus Patients) and PECTUS-obs study (Identification of Risk Factors for Acute Coronary Events by OCT After STEMI and NSTEMI Patients With Residual Non- Flow Limiting Lesions). Optical coherence tomography was performed on all FFR-negative (FFR >0.80) native nonculprit lesions. Patients or lesions with a high-risk plaque were compared with those without a high-risk plaque. A high-risk plaque was defined in the presence of at least 2 prespecified criteria: (1) lipid arc ≥90^o, (2) minimum fibrous cap thickness <65 µm, and (3) presence of either plaque rupture or thrombus. The primary end points were native major adverse cardiovascular events (composite of all-cause mortality, nonfatal myocardial infarction, or unplanned revascularization excluding stent-failure-related events and nonattributable events) and target lesion failure (composite of cardiac death, target vessel myocardial infarction, or target lesion revascularization).

Results: Among 810 patients, 450 (55.6%) had a history of diabetes and 482 (59.5%) presented with myocardial infarction. At least 1 high-risk plaque was identified in 271 (33.5%) patients and 287 (30.6%) lesions. Over a median follow-up of 761 (interquartile range, 731-1175) days, the presence of a high-risk plaque was associated with patient-level native major adverse cardiovascular events (hazard ratio, 2.127 [95% CI, 1.451-3.120]; P<0.001) and lesion-level target lesion failure (hazard ratio, 2.623 [95% CI, 1.559-4.414]; P<0.001). The risk of adverse outcomes increased with the copresence of multiple high-risk features.

Conclusions: FFR-negative but high-risk nonculprit lesions are associated with adverse patient- and lesion-level clinical outcomes. These findings emphasize the additional value of intracoronary imaging in patients with FFR-negative nonculprit lesions.

Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT02989740; Unique identifier: NCT03857971.