Circulation: Cardiovascular Interventions最新文献

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.

Background: The pullback pressure gradient (PPG) is a novel physiological metric that quantifies coronary artery disease patterns as focal or diffuse on a scale from 0 to 1. This study assessed the relationship between PPG and residual angina at 1 year.

Methods: PPG Global is a prospective, investigator-initiated, single-arm, multicenter study that enrolled patients with at least 1 lesion with a fractional flow reserve ≤0.80 intended to be treated with PCI. After the PPG calculation, physicians could revise treatment assignment to medical therapy or coronary artery bypass graft surgery instead of PCI. Focal and diffuse disease were defined based on the median PPG value of 0.62. Patient-reported outcomes were assessed using the Seattle Angina Questionnaire at baseline and 1-year follow-up.

Results: The study included 947 patients with PPG and the Seattle Angina Questionnaire at 1 year. The mean age was 67.6±10.2 years, 24% were female, and 29% had diabetes. At 1 year, patients with focal coronary artery disease reported less angina than those with diffuse coronary artery disease (Seattle Angina Questionnaire angina frequency score, 95.3±9.9 versus 92.5±15.0; P=0.006). PPG was independently associated with improvement in angina (P=0.017).

Conclusions: In patients with flow-limiting coronary artery disease, the presence of focal disease defined by high PPG was associated with greater symptomatic relief at 1 year compared with diffuse disease (low PPG). By reflecting the physiological pattern of disease and its relation to symptom relief after treatment, PPG may help inform revascularization strategies.

Background: Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement field have been obtained from retrospective studies. This prespecified secondary analysis of the LYTEN randomized trial (Comparison of the Balloon-Expandable Edwards Valve and Self-Expandable CoreValve Evolut R or Evolut PRO System for the Treatment of Small, Severely Dysfunctional Surgical Aortic Bioprostheses) aims to compare the 3-year hemodynamic performance and clinical outcomes between balloon-expandable valves (BEV) SAPIEN 3/ULTRA (Edwards Lifesciences) and self-expanding valves (SEV) Evolut R/PRO/PRO+ (Medtronic) in valve-in-valve transcatheter aortic valve replacement.

Methods: Patients with a failed small (≤23 mm) surgical valve undergoing valve-in-valve transcatheter aortic valve replacement were randomized to receive a SEV or a BEV. Patients had a clinical and valve hemodynamic (Doppler echocardiography) evaluation at 3-year follow-up. Study outcomes were defined according to VARC (Valve Academic Research Consortium)-2/VARC-3 criteria. Intended performance of the valve was defined as mean gradient <20 mm Hg, peak velocity <3 m/s, Doppler velocity index ≥0.25, and less than moderate AR.

Results: Ninety-eight patients underwent transcatheter aortic valve replacement (46 BEV-SAPIEN 3/ULTRA-, 52 SEV-Evolut R-PRO-PRO+). At 3 years, patients receiving a SEV had a higher rate of intended valve performance (BEV: 27.6% versus SEV: 82.4%; P<0.001), with lower mean gradients (BEV: 20.40±9.12 versus SEV: 13.12±8.56 mm Hg; P=0.002), and larger indexed effective orifice area (BEV: 0.69±0.27 versus SEV: 0.93±0.32 cm²/m²; P=0.002). The rate of moderate aortic regurgitation was 0% in the BEV group versus 2.9% in the SEV group (P=0.582). Functional status and quality of life improved similarly in both groups. No differences were observed in the composite end point of death, stroke, or heart failure-related hospitalization (BEV: 32.6% versus SEV: 25.5%; P=0.489). Mortality was also not statistically different between groups (BEV: 23.3% versus SEV: 15.7%; P=0.375). No significant differences were observed in other adverse events.

Conclusions: In patients undergoing valve-in-valve transcatheter aortic valve replacement for failed small aortic bioprostheses, SEV demonstrated a superior valve hemodynamic performance at 3-year follow-up, with similar clinical outcomes and functional improvement compared with BEV.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03520101.

Background: Current clinical guidelines recommend considering both obstructive and nonobstructive causes of myocardial ischemia in patients with chronic coronary syndrome. Wire-based physiological assessment constitutes a valid approach for this purpose, but it remains underutilized. We evaluated the diagnostic yield and clinical impact of an alternative wire-free approach for this purpose.

Methods: This is a subanalysis of the multicenter, prospective AID-ANGIO study (Advanced Invasive Diagnosis for Patients with Chronic Coronary Syndromes Undergoing Coronary Angiography), evaluating the impact of a wire-free advanced invasive diagnosis (AID) strategy in the diagnostic workflow of patients with chronic coronary syndrome admitted to the catheterization laboratory. The wire-free AID strategy combined quantitative flow ratio for epicardial evaluation, contrast angiography-derived index of coronary microcirculatory resistance for microvascular assessment, and acetylcholine testing for the endothelial-dependent coronary function.

Results: The study included 262 patients. The wire-free AID strategy identified a cause of myocardial ischemia in 84.3% of patients, representing a 2-fold increase in the identification of a cause of myocardial ischemia, compared with coronary angiography alone (P<0.0001). In addition, the wire-free AID strategy demonstrated substantial agreement compared with the wire-based AID strategy (Cohen κ 0.78). The wire-free AID strategy led to a change in the initial therapeutic plan in 55.3% of patients compared with coronary angiography. Nevertheless, the wire-free AID strategy maintained good concordance with the wire-based AID strategy (16.8% of therapeutic changes).

Conclusions: This study supports the clinical utility of a wire-free AID strategy in patients with chronic coronary syndrome, demonstrating its potential to improve diagnostic yield and guide clinical decision-making compared with coronary angiography alone. In addition, it shows substantial agreement with the wire-based approach.