Cardiovascular Revascularization Medicine最新文献

Background: Recently, angiography-derived index of microvascular resistance (angio-IMR) has emerged as a less invasive alternative to estimate CMD during cardiac catheterization. Whether CMD differs across vessel territories and populations remains disputed.

Methods: Consecutive all-comer patients undergoing coronary angiography for chronic coronary syndrome (CCS) or non-ST-elevation myocardial infarction (NSTEMI) enrolled in the PIONEER-IV trial at the University Medical Center Groningen were included. Angio-IMR was retrospectively calculated using quantitative flow ratio (QFR) software in all three major coronary vessel territories pre- and post-PCI, if applicable. Angio-IMR levels were compared between coronary vessels, indication, and sex. The association between angio-IMR and LV function on AI-derived echocardiography analyses were assessed.

Results: In 220 patients, mean age was 65 ± 9 years, 18.3 % were women, and 20.3 % presented with NSTEMI. CMD was common: 80.0 % had baseline angio-IMR ≥25 mmHg·s/cm. Angio-IMR was similar in the LAD, RCA and LCX in both target and non-target vessels (p > 0.05). In the LAD, angio-IMR increased significantly post-PCI (p < 0.001), while RCA and LCX showed no significant change. Whilst NSTEMI patients showed similar baseline angio-IMR as CCS patients, they had lower post-PCI angio-IMR (p = 0.011). Women had lower average post-PCI angio-IMR (27 vs. 37 mmHg·s/cm, p < 0.001) and showed improved microvascular resistance post-PCI. Angio-IMR was not associated with cardiac function overall, but in NSTEMI patients, higher baseline angio-IMR correlated with worse LV function.

Conclusion: Angio-IMR is similar in all coronary vessels, but lower in NSTEMI patients than in CCS and lower in women. In NSTEMI patients, higher IMR was associated with worse LV function.

Background: Approximately one-tenth of patients undergoing percutaneous coronary intervention (PCI) of a chronic total occlusion(CTO) have chronic kidney disease (CKD). There are limited data on outcomes in patients with CKD undergoing elective CTO PCI and our aim was to investigate the short-term outcomes of these patients.

Methods: We utilized Nationwide Inpatient Sample (NIS) database (years 2010-11) to identify all hospitalizations associated with elective single-vessel CTO PCI. Afterwards, patients were categorized into two groups according to CKD status, with the CKD group further stratified by stage. Primary outcome was in-hospital mortality and secondary outcomes were periprocedural complications. We also investigated the length of hospital stay and costs. Discharge weights were used to produce national estimates.

Results: We identified 6164 adult patients who underwent single-vessel CTO PCI. There were 604 patients (9.85 %) with CKD. They were older, with higher prevalence of hypertension, diabetes mellitus, atrial fibrillation, peripheral artery disease and chronic obstructive pulmonary disease. CKD was independently associated with higher in-hospital mortality, demonstrating a 74 % increase in odds per category (non-CKD, moderate-severe CKD (encompassing CKD stage 3-5) and end-stage renal disease requiring chronic dialysis). Patients with CKD had significantly higher rates of periprocedural myocardial infarction, acute kidney injury (AKI) and need for initiation of dialysis, as well as composite outcome of periprocedural complications. Consequently, this resulted in longer hospital stay and higher hospitalization costs.

Conclusion: CKD is independently associated with higher in-hospital mortality among patients undergoing elective single-vessel CTO PCI, demonstrating increasing odds with worsening CKD. Presence of CKD is associated with a higher rate of periprocedural complications, prolonged hospital stay and increased hospitalization costs.

Background: Routine manual aspiration thrombectomy has shown limited benefit in patients with acute coronary syndrome (ACS). Selective application of mechanical thrombectomy in patients with ACS and high thrombus burden may improve coronary flow and myocardial perfusion. We aimed to compare safety and efficacy between manual (MaT) and mechanical aspiration thrombectomy (MeT) in this population.

Methods: Retrospective review of 70 patients presenting with ACS between May 2019 and February 2024, with 27 receiving MaT and 43 MeT. Our comparative analysis included Thrombolysis in Myocardial Infarction (TIMI) thrombus grade, TIMI flow grade, Myocardial Blush grade, survival to discharge and stroke.

Results: There was no difference in the clinical characteristics of the two groups except higher prevalence of hypertension in the MaT group (93 % vs 70 % in MeT, p = 0.02). Baseline thrombus burden did not differ between groups. Both MaT and MeT resulted in a significant reduction in thrombus burden and improvement in coronary flow and myocardial blush. MaT and MeT had similar post-thrombectomy rates of TIMI thrombus grade 0 (63 % vs 77 %, p = 0.3), TIMI flow grade 3 (70 % vs 67 %, p = 1) and Myocardial Blush grade 3 (44 % vs 51 %, p = 0.6). One stroke was reported in the MeT group. Finally, Survival to discharge was similar (MaT 88 % vs MeT 84 %, p = 0.7).

Conclusions: Selective thrombectomy in ACS patients with high thrombus burden is safe and effectively reduces thrombus burden while improving coronary flow and myocardial perfusion. Manual and mechanical thrombectomy show similar efficacy and safety profiles.

Background: Fractional flow reserve (FFR) derived from coronary computed tomography angiography (FFR_CT) facilitates virtual PCI planning and informs stent length selection based on predicted post-PCI FFR_CT. This approach was previously validated against pressure-wire based FFR. Whether angiographic FFR can be used to ascertain the target post-PCI FFR_CT predicted from CCTA is uncertain.

Methods: Observational cohort study of patients undergoing coronary computed tomography angiography (CCTA) with an FFR_CT ≤ 0.80 that were referred to CCTA-guided PCI using the FFR_CT-based virtual planner (HeartFlow Inc.) for pre-procedural guidance and FFR_angio (CathWorks Ltd.) for intra- and post-procedural assessment. Virtual FFR pullbacks (FFR measurements every 1 mm across the vessel length) were analyzed and compared for both FFR_CT and FFR_angio modalities. We evaluated the agreement between pre- and post-PCI FFR_CT and FFR_angio at matched locations using the Pearson correlation coefficient and Bland-Altman analysis. Virtual FFR pullbacks (FFR measurements every 1 mm across the vessel length) were analyzed and compared for both FFR_CT and FFR_angio modalities.

Results: A total of 2290 post-PCI FFR values were derived from 20 vessels that underwent CCTA-guided PCI virtual PCI followed by post-PCI FFR_angio. FFR values were matched across FFR pullback tracings that allowed the comparison of predicted post-PCI FFR_CT to observed post PCI FFR_angio results. The left anterior descending artery (LAD) (45 %) was the most common target vessel. A strong correlation was observed between FFR_CT and FFR_angio (R = 0.74; p < 0.001). The mean difference at matched locations was -0. 01 FFR units, with a standard deviation of 0.04 and limits of agreement ranging from -0.10 to 0.07.

Conclusion: Predicted post-PCI FFR_CT values derived from CCTA-based virtual PCI have an excellent correlation with observed post-PCI FFRangio values derived from invasive coronary angiography after stenting. These findings highlight the novel concept of wireless end-to-end physiology guided PCI, integrating pre-PCI FFR_CT and post-PCI angiographic FFR as complementary tools.

Background and aims: Suture-based vascular closure devices (S-VCD) plus the liberal use of an additional small plug-based VCD have been demonstrated to be superior to "pure" plug-based VCD (P-VCD) in patients treated with transcatheter aortic valve implantation (TAVI). Preliminary data suggests that the systematic use of the arteriotomy-site ballooning plus concomitant manual compression following P-VCD (MANTA, Teleflex) delivery may optimize the device apposition and should be adopted to improve the final hemostatic efficacy.

Methods: Consecutive patients undergoing transfemoral TAVI at two Italian centers between were included. Patients treated with S-VCD and balloon assisted P-VCD were matched for major variables. The primary outcome was the occurrence of any in-hospital vascular complication. All outcomes were defined according to the Valve Academic Research Consortium (VARC)-3 statement.

Results: Overall, 799 patients were included (S-VCD: 451; balloon-assisted P-VCD: 348). Patients in the S-VCD group received 2 ProGlides (Abbott Vascular Inc.) plus the liberal use of an additional small plug-based VCD. Patients in the P-VCD group received the systematic use of the arteriotomy-site ballooning plus concomitant manual compression. After matching, 123 pairs of subjects were selected. The primary outcome occurred in 11.4 % of patients in the S-VCD group and 6.5 % in the balloon assisted P-VCD group (OR 0.56, 95 % CI (0.22-1.40); p = 0.217). Major VARC-3 vascular complications were more frequent in the S-VCD cohort (OR 0.12, 95 % CI (0.01-0.96); p = 0.048). No differences were found for the composite of major vascular complications and in-hospital death (OR 0.59, 95 % CI (0.19-1.88); p = 0.377). Any VARC-3 access related bleedings were slightly more frequent in the S-VCD group (OR 0.27, 95 % CI (0.07-0.99); p = 0.048), while no differences were evident for major bleedings (OR 0.28, 95 % CI (0.06-1.40); p = 0.122).

Conclusions: The balloon-assisted P-VCD showed similar vascular outcomes compared to traditional S-VCD in patients undergoing transfemoral TAVI.

Background: Quantitative flow ratio (QFR) is a recent, non-invasive method for functional coronary assessment, providing estimates of lesion-specific ischemia without the need for pressure wires or hyperemic agents. While its diagnostic concordance with fractional flow reserve (FFR) has been previously explored, data comparing QFR to non-hyperemic pressure ratios (NHPRs), such as instantaneous wave-free ratio (iwFR) and resting full-cycle ratio (RFR), remain limited.

Objectives: This study aimed to evaluate the diagnostic agreement between QFR and NHPRs in real-world patients undergoing physiological assessment for intermediate coronary stenoses.

Methods: Lesions from the CAST registry with available iwFR or RFR and analyzable angiograms for QFR computation were included. Ischemia was defined as NHPRs ≤0.89 or QFR ≤0.80. Diagnostic performance was assessed using sensitivity, specificity, predictive values, and ROC analysis (AUC via DeLong's method). Agreement was evaluated with Cohen's kappa and Bland-Altman analysis. McNemar's test assessed asymmetry in discordant pairs. Spearman's correlation and logistic univariate and multivariable regressions identified predictors of QFR-NHPRs discordance.

Results: A total of 174 lesions from 142 patients were included in the final analysis. QFR demonstrated a diagnostic accuracy of 79 %, with a sensitivity of 90 % and a negative predictive value of 82 %, in respect of NHPRs. Specificity and positive predictive value were 63 % and 78 %, respectively. The area under the ROC curve was 0.80 (95 % CI, 0.733-0.867). QFR underestimated ischemia in 14.9 % of lesions (false negatives), and overall diagnostic discordance with NHPRs occurred in 20.7 % of cases. Longer lesion length was independently associated with higher concordance (OR 0.95, 95 % CI 0.91-0.99, p = 0.012), while bifurcation lesions were predictors of discordance (OR 4.81, 95 % CI 1.30-21.12, p = 0.024).

Conclusions: QFR shows moderate concordance with NHPRs and may serve as a useful, wire-free alternative for excluding functionally significant stenoses. While it demonstrated high sensitivity, the risk of false negatives in certain anatomical subsets highlights the value of a cautious, individualized approach, possibly integrating QFR with invasive indices or imaging modalities in selected cases.

Background: Provisional single stenting is the recommended default strategy for complex left main (LM) bifurcation lesions. However, double stenting may improve side branch patency in such cases, though its effect on myocardial performance remains uncertain. We compare 30-day changes in non-invasive myocardial work (MW) indices following double versus provisional single stenting in patients with complex LM bifurcations.

Method: In this prospective, single-center analysis, 282 patients with complex LM bifurcation lesions undergoing PCI between October 2023 and June 2025 were included. Patients were treated with either double stenting (culotte, nano-inverted-T, or TAP; n = 141) or provisional single stenting (n = 141) and matched 1:1 by propensity score. Echocardiography was performed at baseline and 30 days post-PCI. MW indices, including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), were derived from non-invasive pressure-strain analysis.

Results: Baseline characteristics and echocardiographic indices were comparable between groups. Both strategies improved GWI and GCW and reduced GWW (all p < 0.0001). However, double stenting was associated with greater improvements in all MW indices [ΔGWI 218.3 ± 93.3 vs. 117.2 ± 83.4 mmHg% and ΔGCW177.7 ± 75.4 vs. 99.7 ± 83.6 mmHg% (both p < 0.001); ΔGWW -44.9 ± 31.0 vs. -23.8 ± 32.1 mmHg% (p < 0.001), and ΔGWE +3.1 ± 1.9 vs. +1.4 ± 1.9 % (p < 0.001)].

Conclusions: In complex LM bifurcation lesions, double stenting leads to superior 30-day recovery of MW compared with provisional single stenting, suggesting enhanced left ventricular efficiency.