Circulation: Cardiovascular Interventions最新文献

Background: Racial differences in the use and outcomes of intravascular imaging (IVI) and invasive physiology (IP) during percutaneous coronary intervention (PCI) are underreported in the United States.

Methods: Medicare Fee-For-Service claims data were used to examine the use and outcomes of IVI- and IP-guided PCI by Black versus White race (2016-2023). Multivariable logistic regression was used to assess the association between race and IVI/IP use. The primary outcome was major adverse cardiovascular events, which included myocardial infarction, repeat revascularization, and death. Outcomes were compared by race according to the device used (IVI versus none; IP versus none; and among all IVI/IP recipients). Cox regression was used to estimate the association between race and 2-year outcomes, adjusting for all baseline characteristics.

Results: The study included 1 481 343 PCI patients (5.9% Black patients, 63.6% male, mean age 75.3±7.0 years). IVI was used in 17.6% of PCIs in White patients and 15.0% in Black patients; IP use was 7.1% and 5.7%, respectively. After adjustment, Black adults were less likely to receive IVI (odds ratio, 0.94 [95% CI, 0.93-0.96]) or IP (odds ratio, 0.83 [95% CI, 0.81-0.85]). IVI- and IP-guided PCI had lower major adverse cardiovascular event risk at 2-years in both racial groups compared with angiography alone: IVI (White patients: hazard ratio [HR], 0.93 [95% CI, 0.92-0.94]; Black patients: HR, 0.85 [95% CI, 0.84-0.87]) and IP (White patients: HR, 0.95 [95% CI, 0.92-0.98]); Black patients: HR, 0.87 [95% CI, 0.83-0.91]). However, despite global benefits with IVI/IP, Black adults had a higher adjusted risk of major adverse cardiovascular events compared with White adults (HR, 1.02 [95% CI, 1.01-1.03]).

Conclusions: IVI- and IP-guided PCI were associated with improved outcomes in both Black and White beneficiaries, yet these technologies were less frequently used in Black adults, and overall PCI outcomes remained worse for this group.

Background: Pediatric intraluminal pulmonary vein stenosis (PVS) occurs in a heterogeneous patient population but is unified by its cellular composition in affected pulmonary veins. Enhanced delineation of the hemodynamic and physiological vein consequences of PVS and its impact on vein lumen, vein pressure, wall structure, vein compliance, and wall shear stress has not been studied. The objective is to assess PVS characteristics using multimodal catheterization techniques (angiography, pulmonary vein pressure, intravascular ultrasound, balloon compliance testing, and wall shear stress calculation) and determine their association with vein outcomes.

Methods: The study is a prospective trial applying a standardized catheterization assessment to patients under 13 years of age who are undergoing cardiac catheterization for PVS. The primary outcome is vein status at 12 months, assigned by an end point committee. The secondary outcome is transplant-free survival.

Results: Overall, 50 patients with a median age of 2.7 years (range, 0.3-11.8) underwent assessment and included angiography of 200 veins, 171 pressure assessment, 169 intravascular ultrasound, 58 balloon compliance testing, and 141 wall shear stress calculations. The probability of a worse vein outcome increased as angiographic severity score, percent wall thickness by intravascular ultrasound, postintervention gradient, or postintervention wall shear stress increased. Multivariable analysis demonstrated veins with angiographic upstream luminal narrowing (odds ratio, 3.26 [95% CI, 1.38-7.7]; P=0.007), ostial diameter <6 mm (odds ratio, 3.93 [95% CI, 1.29-12]; P=0.016), and ≥35% upstream wall thickness by intravascular ultrasound (odds ratio, 5.05 [95% CI, 2.03-12.5]; P<0.001) are associated with a worse vein outcome. A 3-point Invasive Pulmonary Vein Score prediction tool was created. Transplant-free survival was 92% at 12 months.

Conclusions: A multimodal pulmonary vein catheterization assessment determined angiographic and intravascular ultrasound findings to be the most predictive of 12-month pulmonary vein outcome.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04696289.

Background: Patients with post-percutaneous coronary intervention (PCI) angina are challenging to manage. Comprehensive coronary function testing (CFT) can identify occult coronary abnormalities in patients with angina and nonobstructive coronary arteries. Its utility in patients with post-PCI persistent angina who have no obstructive coronary artery disease is unexplored.

Methods: We assessed 46 patients with a prior PCI experiencing persistent angina. CFT evaluated the presence of endothelial dysfunction, epicardial and microvascular spasm, low fractional flow reserve, coronary microvascular dysfunction, and myocardial bridging by intravascular ultrasound. The Seattle Angina Questionnaire measured symptom severity before and 1-year post-CFT.

Results: The median age was 60 (53-69) years, with 63% being women. Pre-PCI lesion stenosis was 80 (70-90)% and pre-PCI fractional flow reserve (n=7) was 0.72 (0.67-0.74). Left anterior descending artery PCI was performed in 47.8%. The median duration between PCI and CFT was 19.5 (11.2-57.2) months. Patients reported severe anginal symptoms and poor quality of life on the Seattle Angina Questionnaire. CFT revealed a median fractional flow reserve of 0.84 (0.82-0.87), and 19.6% had a fractional flow reserve ≤0.8. Endothelial dysfunction was diagnosed in 36.9%, of whom 64.7% had moderate to severe endothelial dysfunction. Epicardial and microvascular spasm were present in 56.5% and 17.4%, respectively. Coronary microvascular dysfunction was present in 43.5%, and 63% had myocardial bridging. Patients reported significant improvement in Seattle Angina Questionnaire scores 1-year post-CFT.

Conclusions: Patients with post-PCI persistent angina have severe symptoms and poor quality of life, with the majority exhibiting endothelial dysfunction, epicardial spasm, coronary microvascular dysfunction, and myocardial bridging. Comprehensive CFT should be considered in these patients to help diagnose an underlying cause of their persistent angina and guide therapy for a better outcome.

Background: Coronary artery spasm (CAS) is a common cause of angina with nonobstructive coronary arteries (ANOCA). While acetylcholine provocation testing is the diagnostic gold standard, protocol variations have led to discrepancies in diagnostic accuracy. This study aimed to compare the diagnostic validity of conventional versus high-dose acetylcholine regimens in patients with ANOCA.

Methods: Multivessel acetylcholine provocation testing was systematically performed in patients with ANOCA and a control cohort undergoing invasive coronary angiography for noncoronary indications. Incremental acetylcholine doses in the left (20-200 μg) and right (20-80 μg) coronary arteries were manually injected over 20 seconds to induce CAS.

Results: The study included 62 patients with ANOCA with typical CAS symptoms and 20 controls. Conventional-dose acetylcholine testing identified CAS in 67.1% (55/82) of patients, while high-dose testing detected CAS in 79.3% (65/82). Among patients with inducible spasm, 93.4% (61/65) had typical angina consistent with CAS. High-dose acetylcholine demonstrated significantly higher sensitivity (98% versus 87%, P=0.008), but a nonsignificant trend toward lower specificity (80% versus 95%, P=0.08). The high-dose regimen also showed a higher negative predictive value (94% versus 70%, P=0.01), while positive predictive values were comparable (93% versus 98%, P=0.12).

Conclusions: High-dose acetylcholine provocation improves the detection of CAS in patients with ANOCA but may increase the risk of overdiagnosis. This approach should be reserved for patients with a high clinical suspicion of CAS, with the results interpreted within the broader clinical context.