Cardiovascular Revascularization Medicine最新文献

Background: Embolic protection devices were developed to reduce the risk of common complications encountered during percutaneous coronary intervention (PCI) of saphenous vein grafts, however, in the setting of contemporary multi-modality medical management, their overall efficacy has been called into question. This study aimed to assess the evolving utilization and clinical outcomes associated with distal filter wire embolic protection devices in saphenous vein PCI.

Methods: Consecutive patients undergoing PCI to a saphenous vein graft in a registry were included. Peri-procedural and long-term outcomes including 12-month mortality and 30-day MACCE rates were compared between PCI using a distal filter wire embolic protection device and unprotected PCI.

Results: From 2005 to 2020, a total of 753 patients underwent PCI to a saphenous vein graft with 256 using a distal filter wire embolic protection device. At one year, the use of a distal filter wire embolic protection devices was not associated with a decrease in mortality (4.7 % vs 5.4 %, p = 0.19) and there was no difference in 30-day MACCE rates between protected and unprotected saphenous vein PCI (3.1 % vs 5.8 %, p = 0.10).

Conclusion: In this 12-month analysis of saphenous vein graft PCI, there was no evidence that distal filter wire embolic protection devices improved short term post procedural or long-term mortality outcomes.

Background: Bioprosthetic surgical aortic valve replacement (SAVR) using the Trifecta valve was frequently chosen because of its large opening area and low transvalvular gradient. However, long-term follow-up revealed the potential for early structural valve deterioration. To further assess the long-term clinical outcomes and management considerations for patients implanted with the Trifecta valve, a real-world study using Medicare fee-for-service claims data was conducted with a focus on Trifecta valve reintervention.

Methods: De-identified patients undergoing SAVR with the Trifecta™ valve (Abbott) in the U.S. between 1/1/2011-12/31/2021 were selected by ICD-9/10 procedure codes and then linked to a manufacturer device tracking database. All-cause mortality and freedom from Trifecta valve reintervention with repeat SAVR or valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) were evaluated at 10-years using the Kaplan Meier method. Independent predictors for reintervention and clinical outcomes following reintervention were assessed.

Results: Among 242,160 Medicare beneficiaries undergoing SAVR during the study period, 23,197 were implanted with the Trifecta valve. Mean age was 75.2 ± 7.4 years. At 10-years survival was 32.3 % (95 % CI, 31.4 %-33.3 %) and the freedom from valve reintervention was 82.4 % (95 % CI, 81.1 %-83.5 %). Independent predictors for reintervention included younger age, female, obesity, and implants with a small valve size (19 mm, 21 mm). Reintervention with ViV-TAVI (N = 796) was associated with better operative survival (3.8 % vs. 12.5 %, p < 0.001) than repeat SAVR (N = 577).

Conclusion: This real-world nationwide study of Medicare beneficiaries receiving the Trifecta valve demonstrates >80 % freedom from all-cause valve reintervention at 10-years post-implant with reintervention using ViV-TAVI having improved operative survival compared to repeat SAVR.

Background: The J-CTO investigators recently developed angiographic difficulty scores for each of the three major coronary arteries in patients undergoing first-attempt chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in de novo occlusions.

Methods: We examined the performance of the individual J-CTO scores in a large multicenter registry.

Results: The CTO lesion location was as follows: right coronary artery (RCA) 3,805 (54%), left anterior descending artery (LAD) 2,303 (33%), and left circumflex (LCX) 935 (13%). Patients in the PROGRESS-CTO registry were younger, more likely to be female, and had higher J-CTO scores compared with the J-CTO registry. Increasing difficulty scores were associated with lower technical success in the PROGRESS-CTO registry (score 0: 94.4 % - score ≥3: 82.6% for the RCA difficulty score; score 0: 96.4% - score ≥3: 86.1 for the LAD difficulty score; and score 0: 95.4% - score ≥3: 81.2% for the LCX difficulty score). The C-statistic of the coronary artery specific J-CTO scores in the PROGRESS-CTO registry were: LAD 0.69 (95% confidence intervals [CI], 0.64-0.73), LCX 0.63 (95% CI, 0.57-0.69), and RCA 0.61 (95-% CI, 0.58-0.64) with good calibration (Hosmer-Lemeshow p-value >0.05 for all). The AUC of the classic J-CTO score for LAD lesions was similar with the LAD J-CTO score (p-for-difference = 0.26), but worse for LCX (p-for-difference = 0.04) and RCA lesions (p-for-difference = 0.04).

Conclusion: In the PROGRESS-CTO registry, the coronary artery specific J-CTO scores did not improve prediction of the technical success of CTO-PCI compared with the classic J-CTO score.

Background: This study investigated the association of the Survival After VA-ECMO (SAVE) score, Sequential Organ Failure Assessment (SOFA) score, and post-cannulation lactate levels with mortality among patients treated with veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock (CS).

Methods: We performed a retrospective review of adult patients who underwent peripheral VA-ECMO cannulation from January 2018 to September 2022 at a quaternary care center. All-cause in-hospital mortality was assessed and compared to predicted mortality by SAVE and SOFA scores prior to cannulation, with adjusted odds ratio of risk factors for mortality identified by multivariate logistic regression analysis. Additionally, the prognostic value of 8-h post-cannulation serum lactate levels was analyzed by receiver operating characteristic (ROC) curve and Kaplan Meier analysis of 30-day survival.

Results: 244 patients were included in final analysis. All-cause in-hospital mortality was 70 %, and 54 % of patients died while on ECMO or within 24 h of decannulation. Pre-cannulation SAVE score (OR 0.93 per unit increase, 95 % CI 0.86-0.99, p = 0.008), SOFA score (OR 1.54 per unit increase, 95 % CI 1.32-1.75), and 8-h post-cannulation lactate levels (OR 1.20 per mmol/L increase, 95 % CI 1.04-1.36, p = 0.008) were independently associated with all-cause in-hospital mortality. 8-h post-cannulation lactate levels ≥5.3 mmol/L demonstrated high specificity for in-hospital mortality (90.0 %), while levels ≥7.8 mmol/L were demonstrated high specificity for VA-ECMO death (91.1 %). These thresholds were significantly associated with 30-day all-cause mortality (p < 0.001).

Conclusion: Pre-cannulation SAVE and SOFA scores are useful prognostic tools in patients with CS. 8-h post-cannulation serum lactate levels are a pragmatic biomarker and can further assist in prognostication of patients on VA-ECMO, and the cutoffs of 5.3 mmol/L and 7.8 mmol/L have high specificity for all-cause mortality and VA-ECMO mortality, respectively. The development of accurate prognostic tools is critical in managing and optimizing care for patients with CS.

Background: The incidence of iatrogenic injuries in peripheral arteries is increasing due to the expanding opportunities of managing various cardiovascular diseases by means of percutaneous intervention. Thus, endovascular repair with implantation of covered stent (CS) after vascular injury is gaining importance as an alternative to open surgery. In cases of smaller side-branch injuries, stenting of the main vessel with subsequent exclusion and sealing of the side-branch is associated with unfavourable revascularization rates and unpredictable ischemic complications in the corresponding supply area.

Objective: This study reports the procedural and clinical outcomes of patients with iatrogenic vascular side-branch injuries treated with coronary-CS directly at the site of injury.

Methods: This is a retrospective, multicentre registry study, including 40 patients with acute iatrogenic injuries of arterial side-branches undergoing implantation of single-layer polytetrafluorethylene (PTFE)-CS at 3 different centres in Europe between June 2014 and June 2023. Endpoints were procedural success, death, target vessel reintervention (TVR), bleeding and the need for surgical conversion.

Results: A total of 40 patients underwent implantation of single-layer PTFE-CS in the lower (97.5 %) and the upper limbs (2.5 %). The most common mechanisms were injuries after punctures, caused by needle and/or sheath (80 %), balloon-dilations (7.5 %) and during/after non-cardiac surgery (7.5 %). Procedural success was achieved in all cases (100 %). The rate of in-hospital mortality was 7.5 %. The median duration of hospitalization after the CS procedure was 4 days [2; 5.3]. At a median follow-up of 202.5 days [97.3-711.8], 36 patients (90 %) were alive and main vessel patency was 100 %. There were no cases of TVRs, bleedings or surgical conversions. Access-site related complications occurred in 5 % of all cases.

Conclusions: In this study, the use of new-generation single-layer PTFE-covered coronary stents in non-coronary side-branch lesions after iatrogenic arterial injury shows a high technical success rate and favourable clinical efficacy and safety.

The two surgical options for mitral valve regurgitation are replacement and repair, with annuloplasty being the cornerstone of correction. In cases of repair failure, especially in high surgical risk patients, transcatheter mitral valve-in-ring (MViR) procedures represent emerging and challenging options. Among the several complications linked to this treatment, this paper delves into the role that native mitral leaflets may play in precipitating acute bioprosthesis dysfunction in the MViR procedure. The literature extensively covers complications related to the anterior leaflet, including risks such as outflow tract obstruction and residual mitral insufficiency due to interaction between native and prosthetic leaflets. Conversely, complications involving the posterior leaflet are less understood and often overlooked. In this gap in the literature, we present a clinical case highlighting how a redundant native posterior mitral leaflet can unexpectedly lead to acute severe mitral insufficiency by interfering with prosthetic leaflets.