Cardiovascular Revascularization Medicine最新文献

Background/purpose: Transcatheter aortic valve replacement (TAVR) with ACURATE neo2 showed better hemodynamic outcomes by mitigating paravalvular leakage (PVL) compared with ACURATE neo, and revealed promising one-year outcomes in single-arm studies. However, studies comparing the hemodynamic and clinical outcomes of the two valves are still scarce. Therefore, this study aimed to compare the one-year hemodynamic and clinical outcomes between the neo2 and neo.

Methods/materials: We analyzed 562 patients who underwent TAVR with ACURATE neo2 (n = 207) or ACURATE neo (n = 355). The primary outcome was one-year all-cause mortality. The secondary outcomes were hemodynamic outcomes at hospital discharge, 3-month, and one-year post-procedure.

Results: In propensity score matching comparison (172 pairs), there was no significant difference in one-year all-cause mortality between the two groups (neo2: 7.0 % vs. neo: 6.4 %, Log-rank p = 0.8101). While the mean aortic valve pressure gradient was significantly higher in the neo2 group at discharge, the difference was not detected after one year (8.1 ± 3.8 mmHg vs. 8.2 ± 3.7 mmHg, p = 0.8862). The PVL grade did not differ between the two groups at any time point. However, the incidence of moderate or severe PVL significantly decreased at one-year post-procedure compared with that at discharge only in the neo2 group (discharge: 7.2 % vs. one year: 1.5 %, p = 0.0455).

Conclusions: The one-year all-cause mortality rate for ACURATE neo2 was similar to that of ACURATE neo. ACURATE neo2 showed the subsequent improvement of significant PVL, which might result in better long-term clinical outcomes than ACURATE neo.

Summary for annotated table of contents: This study compared one-year all-cause mortality and hemodynamic outcomes after TAVR between ACURATE neo2 and ACURATE neo implantation. One-year all-cause mortality rate and significant improvement in the mean APG after TAVR for ACURATE neo2 were similar to those of ACURATE neo. ACURATE neo2 revealed the subsequent improvement of significant PVL for one year, which might result in better long-term clinical outcomes than ACURATE neo.

Background: Percutaneous left atrial appendage occlusion (pLAAO) presents an alternative to anticoagulation (AC) for stroke prophylaxis in atrial fibrillation (Afib) patients with high bleeding risk. pLAAO was associated with lower rates of disabling stroke which was mainly attributed to the reduction of hemorrhagic stroke (HS). Little is known about the impact of pLAAO on the severity of ischemic strokes which we sought to study.

Methods: The study is a retrospective analysis of the National Readmission Database for the years 2016-2020. All 6-month readmissions with IS after pLAAO admissions were identified. The control group comprised patients with Afib on AC who were admitted for IS. Patients with intracranial hemorrhage or those who underwent surgical LAAO were excluded. A propensity score matching system was utilized to match both groups. Treatment effects were presented as percentages and odds ratio (OR) with 95 % confidence interval (CI).

Results: A total of 342 observations in each group were matched (weighted estimate: 583 in the pLAAO group and 663 in the control group). pLAAO group was associated with a decreased risk of fatal stroke (5.1 % vs. 10.0 %, OR: 0.48, 95 % CI [0.26-0.88], P = 0.018), and a decreased risk of non-fatal severe stroke (50.5 % vs. 59.6 %, OR: 0.69, 95 % CI [0.50-0.96], P = 0.029) at 6 months follow-up.

Conclusion: Compared with patients on AC, patients with pLAAO admitted with ischemic strokes are less likely to have severe and fatal stroke. Further studies are needed to validate our findings.

Background: Angina with non-obstructive coronary artery disease (ANOCA) is commonly observed in patients with stable angina undergoing coronary angiography. Current guidelines recommend non-invasive stress testing as the first step in diagnosing coronary microvascular disease (CMD). This study aims to evaluate the diagnostic value of non-invasive stress testing in patients invasively diagnosed with CMD.

Methods: We conducted a retrospective analysis of prospectively collected data. Eligible subjects were patients with angina who underwent NIST evaluation (echocardiography/ electrocardiography stress test or single-photon emission computerized tomography) prior to coronary angiography. All patients underwent invasive evaluation of microvascular function, which included the assessment of Coronary Flow Reserve, Index of Microcirculatory Resistance, and Resistive Reserve Ratio.

Results: Overall, 140 patients (77 women, 67 ± 10 y/o) underwent NIST evaluation prior to coronary angiography, of whom 81 % were positive for ischemia. There was no difference in the prevalence of positive NIST between patients with abnormal compared with normal microvascular function tested invasively (81 % vs 82 %, p = 0.94). The prevalence of CMD was similar between patients with positive versus negative NIST (51 % vs 50 %, p = 0.94). Among 114 patients with positive NIST, 56 (49.2 %) had normal microvascular function, regardless of the type of stress test used (p = 0.94), the suspected territory of ischemia (p = 0.15), or the estimated severity of the ischemia (p = 0.63).

Conclusion: Non-invasive stress testing may have a limited predictive value in the diagnosis of CMD in ANOCA patients. Larger prospective studies are required for better understanding of the role these tests in the diagnosis and definition of CMD.

Introduction: The optimal revascularization strategy for patients with myocardial infarction (MI) and multivessel coronary artery disease (CAD) remains an area of research and debate. Fractional flow reserve (FFR)-guided complete revascularization (CR) by percutaneous coronary intervention (PCI) has emerged as an alternative to traditional culprit-only PCI.

Objective: To investigate the outcomes of FFR-guided CR versus culprit-only PCI in patients with MI and multivessel CAD.

Methods: We systematically searched PubMed, Scopus and Cochrane Central databases for randomized controlled trials (RCTs) comparing FFR-guided CR versus culprit-only PCI in MI patients with multivessel CAD. Outcomes included a composite of all-cause death, MI, stroke and repeat revascularization, these individual outcomes, cardiac death, stent thrombosis (definite or probable), and contrast-induced acute kidney injury (CIAKI). Random effects models were used to generate risk ratios (RRs) with 95 % confidence intervals (CIs).

Result: The search identified 5 RCTs including 4618 patients with a median follow-up duration of 3 years. Compared with culprit-only PCI, FFR-guided CR was associated with less composite adverse events (RR 0.73; 95%CI 0.57-0.92; p = 0.009), cardiac death (RR 0.73; 95%CI 0.55-0.97; p = 0.03), and repeat revascularization (RR 0.61; 95%CI 0.44-0.84; p = 0.003). Both strategies were similar in terms of all-cause death, MI, stroke, stent thrombosis, and CIAKI.

Conclusion: FFR-guided complete revascularization appears to be superior to culprit-only PCI in reducing composite adverse events, cardiac death, and the need for repeat revascularization in patients with MI and multivessel CAD without a significant impact on recurrent myocardial infarction rates.

Social media abstract: 4618-patient meta-analysis: in MI w/ multivessel #CAD, #FFR-guided complete revascularization yields less composite adverse events, cardiac death & repeat revascularization than culprit-only #PCI.

Objective: The study investigates long-term outcomes of unselected inpatients undergoing invasive coronary angiography (CA) with and without diabetes mellitus type II (T2DM).

Background: Due to continual shifts in demographics and advancements in treating cardiovascular disease, there has been a notable evolution in the types of patients undergoing CA over the past decades. Comprehensive data on the extended outcomes of CA patients, both with and without concurrent T2DM, remains scarce.

Methods: Consecutive inpatients undergoing invasive CA from 2016 to 2022 were included at one institution. The prognosis of T2DM in patients undergoing CA was investigated with regard to the risk rehospitalization for heart failure (HF), acute myocardial infarction (AMI) and coronary revascularization at 36 months of follow-up. Statistical analyses included Kaplan-Meier uni- and multivariable Cox proportional regression analyses.

Results: From 2016 to 2022, 7150 patients undergoing CA were included with a prevalence of T2DM of 31.2 %. Compared to non-diabetics, patients with T2DM had a higher prevalence (78.0 % vs. 64.3 %; p = 0.001) and extent (3-vessel disease: 36.9 % vs. 23.8 %; p = 0.001) of coronary artery disease (CAD). At 36 months, patients with T2DM had a higher risk rehospitalization for worsening HF (29.0 % vs. 18.2 %; p = 0.001), AMI (9.9 % vs. 6.6 %; p = 0.001), alongside with a higher need for coronary revascularization (10.7 % vs. 7.2 %; p = 0.001) compared to patients without. Even after multivariable adjustment, the risk of rehospitalization for HF (HR = 1.229; 95 % CI 1.099-1.374; p = 0.001), AMI (HR = 1.270; 95 % CI 1.052-1.534; p = 0.013) and coronary revascularization (HR = 1.457; 95 % CI 1.213-1.751; p = 0.001) was higher in patients with T2DM. Especially in patients with left ventricular ejection fraction (LVEF) ≥ 35 %, T2DM was associated with a higher risk of AMI- (HR = 1.395, 95 % CI: 1.104 - 1.763, p = 0.005) and PCI-related rehospitalization (HR = 1.442, 95 % CI: 1.185 - 1.775, p = 0.001).

Conclusion: In unselected patients undergoing CA, T2DM represents an independent predictor of HF-related rehospitalization, AMI- and for PCI- at 36 months.

Background: A considerable number of symptomatic patients leave the cardiac catheterization lab without a definitive diagnosis for their symptoms because no epicardial stenoses are found. The significance of disorders of coronary microvasculature and vasomotion as the cause of symptoms and signs of ischemia has only recently been appreciated. Today we have a wide spectrum of invasive coronary physiology tools but little is known about when and how these tools are used in clinical practice.

Study design and methodology: SoutheAsTern eUrope microciRculATION (SATURATION) registry will study the regional practice of patient selection for coronary function testing, indications, non-invasive ischemia testing, medications, procedural aspects of invasive physiology evaluation, and treatment changes after testing. The registry is expected to include 1600 patients in participating centers in Southeastern Europe from 2024 to 2029, using the thermodilution technique for evaluation of microcirculation. Major adverse cardiovascular events as well as patient-centered outcomes such as burden of angina and quality of life using Seattle Angina Questionnaire (SAQ) and EQ-5D-5L will be recorded. The study will include patients with different stages of coronary artery disease (presence of disease or degree of stenosis) to elucidate the effect of coronary microcirculation on the outcomes in this broad group.

Conclusion: The registry will provide information regarding the current practice of invasive coronary physiology assessment in populations at high cardiovascular risk in Southeastern Europe. This could lead to a better understanding of coronary microvascular dysfunction and its relationship to various degrees of coronary atherosclerosis together with potential interventions that can be beneficial.

Background: Coronary sinus reducer (CSR) implantation is emerging as a novel effective percutaneous therapy for patients with refractory angina. Limited data exists examining the factors influencing successful CSR implantation. As CSR implantation becomes more widely adopted, a greater understanding of the procedural challenges which operators encounter is required.

Aim: To evaluate the patient and procedural characteristics influencing successful CSR implantation.

Methods: This was a retrospective cohort study of consecutive patients with refractory angina undergoing clinically indicated CSR implantation (February 2016 to August 2024) at a high-volume implanting centre in the UK. Patient and procedural characteristics affecting procedural difficulty were systematically analysed. Procedural difficulty was determined by 1) increasing total procedural time or 2) features of challenging equipment handling such as bellying, swan-necking or complete equipment fallout from the coronary sinus (CS).

Results: 102 out of 105 (97 %) patients underwent a successful CSR implant at the first attempt. Patients had a high rate of previous revascularisation (PCI: 85 %; CABG 64 %) and diabetes (58 %). Significant improvements in Canadian Cardiovascular Society (CCS) class were observed with 36 % of patients improving by ≥2 CCS classes and 71 % improving by ≥1 CCS class. A C- or non-C-shape of the CS was not associated with differences in procedural time (P = 0.52). However, the presence of both a valve and ridge in the CS was associated with significantly longer procedural times (P = 0.03). A ridge, alone or together with a valve, predicted features of procedural difficulty, such as bellying (ridge - OR: 2.69, P = 0.02; valve and ridge - OR: 4.58, P = 0.0006) and swan-necking (ridge - OR: 5.43, P = 0.001; valve and ridge - OR: 4.74, P = 0.002). Bellying, swan-necking, and complete fallout of equipment from the CS were associated with longer procedural times, but also with each other, suggesting their utility as indicators of procedural complexity.

Conclusion: In our experience, CSR implantation is safe and associated with high rates of procedural success. However, patient and procedural factors can influence the difficulty of CSR implantation. The presence of a ridge may make implantation more challenging. Bellying, swan-necking and complete equipment fallout may indicate increased procedural complexity. Greater awareness of these features will encourage operators to remain vigilant and adapt their implantation strategy when encountering challenging cases.