Cardiovascular Revascularization Medicine最新文献

Technological advancements have improved safety and efficacy outcomes in patients undergoing complex and high-risk percutaneous coronary intervention (PCI). Increasingly, patients present to the cardiac catheterization laboratory both acutely and electively with advanced age, multiple comorbidities, and complex anatomy, representing a higher-risk group of patients who also may have the most to gain from percutaneous revascularization, as their response to medical therapy is usually limited and surgical risks may be prohibitive. These patients typically face thrombosis, slow flow, and other adverse events during and after PCI, which carry significant risk, especially given patients' poor surgical candidacy. Accordingly, optimal antiplatelet and anticoagulant therapies are pivotal to limiting periprocedural thrombotic risk. Oral P2Y₁₂ inhibitors have proven effective in reducing short-term and long-term cardiovascular events, although reduced bioavailability and delayed onset of action limit their efficacy during the procedural and immediate aftermath phases of PCI. Although intravenous glycoprotein IIb/IIIa receptor inhibitors are effective in reducing thrombotic events, bleeding risks have attenuated their use, and recent guidelines relegate their use to bailout. Best practices concerning intraprocedural antiplatelet therapies in patients undergoing complex PCI therefore remain unclear. The inherently high risks of thrombosis and bleeding among these patients must be balanced and considered when determining an antiplatelet strategy. Given the potential advantages of achieving potent but rapidly reversible P2Y₁₂ inhibition in high-risk PCI, we review the data surrounding intravenous P2Y₁₂ inhibition in this setting and provide best practice recommendations for clinical use.

Left atrial appendage occlusion (LAAO) has emerged as an alternative to long-term anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation deemed high risk for bleeding. LAAO is performed via a transseptal approach with the placement of an occlusion device in the left atrial appendage (LAA) to seal it. Intraoperative imaging with echocardiography is needed to guide and complete the procedure. Historically, Transesophageal echocardiography (TEE) has been the most frequently used modality for intraprocedural guidance. Recently, there has been a growing interest in the use of intracardiac echocardiography (ICE) as an adjunct to, or even an alternative to, transesophageal echocardiography (TEE), with several unique advantages and potential challenges. Several publications have highlighted the safety and feasibility of ICE in LAAO (Hemam et al., 2019; Morcos et al., 2022; Zhang et al., 2023 [2, 5, 7]). The most recent SCAI/HRS consensus statement recommends using TEE or ICE in procedural guidance (Saw et al., 2023 [8]). To date, no prospective randomized controlled trials have addressed the safety and feasibility of ICE-guided LAAO, compared to TEE guidance. The ICE TEE trial is a single-center, prospective, randomized, parallel-controlled, open-label clinical trial that will assess the efficacy and safety of ICE-guided LAAO compared to traditional TEE-guided LAAO. Patients are randomized in a 1:1 fashion. The primary endpoint of the study is the procedural success of LAAO device implantation, defined as the appropriate device implantation as per the IFU, without device-related complications, and no peri-device leaks >5 mm on color Doppler, according to the Munich consensus. Secondary endpoints include periprocedural complications, procedural characteristics, and cost of hospitalization. Patients will be assessed at 45 days with a TEE to evaluate for any peri-device leak (PDL). The trial aims to assess the efficacy and potential complications of using ICE to guide the implantation of percutaneous left atrial appendage occlusion (LAAO) devices compared to the traditional transesophageal echocardiography (TEE)- guided LAAO.