Cardiovascular Revascularization Medicine最新文献

Background: Post-infarction ventricular septal defect (PiVSD) is a rare but fatal complication of myocardial infarction (MI). Percutaneous closure via conventional venous access and venoarterial rail increases procedural complexity and time, exerts strain on surrounding septal tissue, and results in device angulation. Whilst such drawbacks can be mitigated with the transaxillary arterial approach, the acute safety and long-term efficacy are unreported.

Methods: We included all patients undergoing percutaneous transaxillary transarterial PiVSD closure in two large tertiary centres in England from April 2020 to May 2025. Procedural data, periprocedural, in-hospital and 1-year mortality were determined through review of local and national electronic records.

Results: Nine patients with comorbid cardiogenic shock were included. The median duration from MI to PiVSD closure was 4 (interquartile range 3-11) days. Right axillary access was used in all cases. The device implanted was either a 24 mm Amplatzer P.I. Muscular VSD Occluder or a larger Amplatzer Septal Occluder (Abbott, USA) necessitating an 80 cm 12F introduction sheath. Closure of the PiVSD was technically successful in all patients with reduction of the interventricular shunt to mild or less in eight of them. One patient died periprocedurally due to device erosion and cardiac tamponade. In-hospital death occurred in seven patients (77.8 %), in five of whom (55.6 %) death was attributed to cardiovascular causes. The two surviving patients had no further adverse events during 36 months of follow-up.

Conclusion: Transaxillary access is a technically reasonable approach for transarterial PiVSD closure. Periprocedural mortality is acceptable in a severely sick population. Survivors to discharge do well on longer-term follow-up.

Background: Previous randomized trials have demonstrated the safety of P2Y₁₂ inhibitor monotherapy after 1-3 months of dual antiplatelet therapy (DAPT) compared with 12-month DAPT following percutaneous coronary intervention (PCI) in patients with acute coronary syndromes. However, the safety of initiating prasugrel monotherapy at the time of primary PCI in patients presenting with ST-segment elevation myocardial infarction (STEMI) remains unknown.

Methods/design: The PREMIUM (Prasugrel monotherapy following primary percutaneous coronary intervention for ST-elevation myocardial infarction) trial is an investigator-initiated, open-label, multicenter randomized controlled trial. A total of 2268 STEMI patients indicated for primary PCI with current generation platinum‑chromium everolimus-eluting stents were randomized 1:1 to either prasugrel monotherapy (20 mg loading, 3.75 mg daily) initiated before PCI or standard 12-month DAPT with aspirin plus prasugrel. The primary endpoint is a composite of all-cause death, myocardial infarction, or stroke at 12 months tested for noninferiority. The major secondary endpoint is Bleeding Academic Research Consortium type 3 or 5 bleeding at 12 months tested for superiority.

Summary: The PREMIUM trial is the first large-scale randomized study to evaluate an upfront aspirin-free strategy with prasugrel monotherapy compared with standard 12-month DAPT in STEMI undergoing contemporary imaging-guided PCI. The trial is designed to determine noninferiority for ischemic outcomes and to assess superiority in reducing major bleeding at 12 months in East Asian patients.

Trial registration: NCT05709626; jRCTs052220145.

Background: Limited evidence has been available on the long-term prognosis and valve durability of balloon-expandable transcatheter heart valve (BE-THV) and self-expandable transcatheter heart valve (SE-THV) in patients with large aortic annulus (LAA).

Objectives: To compare the long-term outcomes between the BE-THV and SE-THV.

Methods: We retrospectively analyzed 1054 patients undergoing transfemoral transcatheter aortic valve implantation (TAVI) for tricuspid aortic valve stenosis with LAA, defined as an annulus area > 430 mm², using either a BE-THV (SAPIEN 3, Edwards Life Sciences) or SE-THV (Evolut R/PRO, Medtronic). The 7-year cumulative incidences of all-cause mortality and bioprosthetic valve failure (BVF) were evaluated in the overall cohort and the propensity score (PS)-matched cohort.

Results: Among the 1054 patients with LAA, 829 (78.7 %) received a BE-THV. The PS-matched population resulted in 218 pairs. The cumulative incidence of all-cause mortality 7 years after TAVI was comparable between the BE-THV and SE-THV groups in the overall cohort (58.6 % vs. 67.6 %, log-rank P = 0.848) and the PS-matched cohort (53.2 % vs. 69.9 %, log-rank P = 0.173). In the overall cohort, the BE-THV group demonstrated a lower exposure-adjusted BVF rate as compared with the SE-THV, although the difference was not significant (6.1 vs. 9.6 events per 1000 patient-years, P = 0.258). This trend became pronounced after PS matching (3.3 vs. 9.9 events per 1000 patient-years, P = 0.017), which was also confirmed by Gray's test (P = 0.032).

Conclusions: In the current analysis focusing on patients with LAA, the BE-THV and SE-THV groups had a comparable long-term prognosis, but the BE-THV group had a lower BVF rate than did the SE-THV group.

Clinical trial registration: UMIN000020423.

Background: Calcific coronary nodules (CNs) are a challenging form of coronary artery disease, often linked to acute coronary syndromes (ACS) and resistant to standard lesion preparation. While intravascular lithotripsy (IVL) and rotational atherectomy (RA) are used for plaque modification, the optimal strategy remains unclear. This study compares procedural characteristics and mid-term outcomes of IVL alone versus IVL combined with RA (IVL + RA) in patients with CNs.

Methods: In this prospective, single-center study, 120 patients with angiographically confirmed CNs undergoing PCI were analyzed after 1:1 propensity score matching (PSM) to compare IVL (n = 60) versus IVL + RA (n = 60). Clinical, angiographic, and procedural data were collected. The primary endpoint was major adverse cardiovascular events (MACE) at 6 months, including cardiovascular death, ACS, or target vessel revascularization. Secondary endpoints included intraprocedural complications and 30-day outcomes.

Results: Baseline characteristics and lesion complexity were well matched between groups. Procedural success and stent deployment metrics were similar. Rates of intraprocedural complications were low and not significantly different (6.7 % IVL vs. 8.3 % IVL + RA; p = 0.68). At 6 months, MACE rates were comparable (8.3 % vs. 10.3 %; p = 0.68), with no differences in cardiovascular death (5.0 % vs. 6.9 %) or ACS (6.7 % vs. 8.6 %).

Conclusions: In patients with calcific nodules, both IVL alone and the IVL + RA combination showed similar safety and efficacy, with low complication rates and comparable mid-term outcomes. Further randomized studies are needed to determine the optimal treatment approach for this high-risk group.

Background: Assessing coronary artery disease in severe aortic stenosis (AS) is challenging due to altered hemodynamics, causing discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). The role of angiographic lesion characteristics in predicting this discordance remains unclear.

Objectives: To identify angiographic predictors of FFR/iFR discordance and define distinct angiographic phenotypes using unsupervised machine learning.

Methods: This prospective, single-center registry evaluated 401 intermediate coronary lesions from 221 patients with severe AS (aortic valve area < 1.0 cm², mean gradient >40 mmHg) using FFR and iFR. Quantitative coronary angiography measured percent diameter stenosis (%DS), lesion length (LL), and other parameters. The primary outcome was FFR/iFR discordance. Receiver operating characteristic and decision curve analyses evaluated %DS predictive utility. K-means clustering was applied to %DS and LL to identify lesion phenotypes.

Results: FFR/iFR discordance occurred in 30 lesions (7.5 %), exclusively as FFR-negative/iFR-positive pattern. Higher %DS was the only independent angiographic predictor of discordance (adjusted OR 1.35 per 10 % increase; 95 % CI 1.12-1.64; p = 0.002), with modest discriminative ability (AUC = 0.69). Cluster analysis identified three phenotypes: Cluster 0 (High %DS [median 75.0 %]/Intermediate LL [median 15.0 mm], n = 103); Cluster 1 (Low %DS [median 49.0 %]/Short-Intermediate LL [median 13.6 mm], n = 220); and Cluster 2 (Intermediate %DS [median 63.5 %]/Long LL [median 32.4 mm], n = 78). Discordance incidence was highest in Cluster 0 (16.5 %) versus Clusters 1 (2.7 %) and 2 (9.0 %) (p < 0.001).

Conclusions: In severe AS, FFR/iFR discordance manifests solely as FFR-negative/iFR-positive pattern. While %DS modestly predicts this mismatch, unsupervised clustering reveals that "High %DS / Intermediate Length" lesions primarily drive physiological discordance, identifying cases where iFR may overestimate severity due to AS-related hemodynamics.

Transposition of the great arteries (TGA) is a complex congenital heart defect with two primary anatomical subtypes: dextro-TGA and levo-TGA. Advances in neonatal surgical techniques, particularly the arterial switch operation, have significantly improved survival rates. However, as this population ages, late complications such as heart failure and valve dysfunction present new clinical challenges. Transcatheter interventions have emerged as valid alternatives to surgical reintervention for these patients, providing effective symptom relief and improved quality of life, reducing the need for repeated sternotomies. As more adults with repaired TGA reach advanced ages, long-term studies are needed to assess the durability and safety of transcatheter therapies. Expanding the indications, refining procedural techniques, and developing specialized devices will be essential in optimizing outcomes for this growing patient population.