Eurointervention最新文献

Coronary bifurcation lesions (CBLs) represent a common and challenging subset of coronary artery disease requiring percutaneous coronary intervention (PCI). While drug-eluting stents (DES) remain the cornerstone of treatment, their use is associated with risks such as restenosis, thrombosis, side branch (SB) jailing and the need for prolonged dual antiplatelet therapy. Drug-coated balloons (DCBs) have emerged as a promising alternative, delivering antiproliferative drugs without permanent implants, thereby reducing the risk of late complications and preserving native vessel geometry. This review explores the role of DCBs in CBL management, particularly for SB treatment within the provisional stenting strategy. Evidence from clinical studies indicates that DCBs significantly reduce late lumen loss and restenosis in the SB compared to plain balloon angioplasty, while simplifying PCI procedures and avoiding extensive stenting. Furthermore, hybrid/blended strategies combining DCBs with DES have shown superior clinical and angiographic outcomes in true CBLs compared to DES-only approaches. Despite their potential, the adoption of DCBs faces challenges, including the need for optimal lesion preparation and a lack of standardised procedural techniques. Existing randomised controlled trials are limited by small sample sizes, design heterogeneity, inclusion of bare metal stents either as comparators or as part of the treatment strategy, and inconsistent use of key procedural steps such as proximal optimisation technique and kissing balloon inflation. This manuscript aims to provide interventional cardiologists with practical guidance for managing CBLs, focusing on the effective integration of DCBs into standalone and hybrid strategies. By emphasising procedural optimisation and complication reduction, this review seeks to promote more standardised and reproducible approaches in clinical practice.

Background: The COMPLETE trial demonstrated a reduction in cardiovascular (CV) death or new myocardial infarction (MI) after complete, rather than culprit-only, revascularisation in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). However, it is unknown whether this benefit varies according to baseline left ventricular ejection fraction (LVEF).

Aims: We aimed to determine the effects of complete versus culprit-only revascularisation according to LVEF.

Methods: Baseline LVEF was available for 2,214 of 4,041 randomised patients. The effect of both strategies on the first co-primary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischaemia-driven revascularisation (IDR) was determined within the prespecified LVEF ranges of <45% (N=660) and ≥45% (N=1,554). An analysis of clinical outcomes by LVEF according to thirds was also conducted.

Results: Patients with LVEF <45% experienced a significantly higher incidence of the first co-primary outcome compared with those with LVEF ≥45% (4.2%/year vs 2.8%/year; hazard ratio [HR] 1.51, 95% confidence interval [CI]: 1.15-1.98; p=0.003). Compared with a culprit-only strategy, complete revascularisation consistently reduced the first co-primary outcome in patients with LVEF <45% (3.0%/year vs 5.5%/year; HR 0.55, 95% CI: 0.36-0.86) and those with LVEF ≥45% (2.4%/year vs 3.2%/year; HR 0.74, 95% CI: 0.52-1.04; interaction p=0.31). Complete revascularisation also consistently reduced the second co-primary outcome in patients with LVEF <45% (3.5%/year vs 7.3%/year; HR 0.49, 95% CI: 0.33-0.74) and those with LVEF ≥45% (2.7%/year vs 6.3%/year; HR 0.44, 95% CI: 0.33-0.60; interaction p=0.67). Consistent results were observed for both co-primary outcomes when LVEF was further stratified into categories of LVEF ≤35%, 36-49% and ≥50%.

Conclusions: Among patients presenting with STEMI and MVD, those with reduced LVEF are at higher risk of ischaemic events than patients with preserved LVEF. There is a consistent benefit of complete revascularisation regardless of baseline LVEF.

Background: Percutaneous large-bore arteriotomy closure devices are either suture- or plug-based. The comparative efficacy and safety of both techniques and optimal patient selection remain controversial.

Aims: We aimed to conduct a patient-level meta-analysis of randomised trials comparing suture-based ProGlide versus plug-based MANTA large-bore vascular closure devices (VCDs).

Methods: We searched PubMed, the Cochrane Central Register of Controlled Trials, and Google Scholar for randomised controlled trials comparing vascular closure with the ProGlide-based and the MANTA-based technique. The primary endpoint of this analysis was access site-related vascular complications defined according to the Valve Academic Research Consortium-3 criteria.

Results: We identified 2 trials that enrolled a total of 722 patients undergoing transcatheter aortic valve implantation. The primary endpoint was significantly less common after vascular closure with the ProGlide-based technique (odds ratio [OR] 0.54, 95% confidence interval [CI]: 0.35-0.82). Access site-related bleeding events were also less common with the ProGlide-based technique (OR 0.41, 95% CI: 0.18-0.94). Prespecified subgroup analyses did not reveal any subgroup favouring the plug-based technique. Clinical outcomes with the MANTA-based technique were better in larger-sized vessels. Patients who received the ProGlide-based technique were less likely to undergo endovascular stenting or vascular surgery (OR 0.22, 95% CI: 0.06-0.79).

Conclusions: In this patient-level meta-analysis of randomised trials, the ProGlide-based technique for large-bore arterial access was superior to the MANTA-based technique in terms of vascular and bleeding complications.

Background: The drug delivery eï¬ciency of drug-coated balloons (DCBs) in de novo coronary artery disease is correlated with atherosclerotic plaque characteristics. It remains to be elucidated whether plaque composition and vulnerability can affect the efficacy of DCBs.

Aims: This study aimed to explore the association between a novel angiography-based radial wall strain (RWS) measurement for plaque vulnerability and DCB efficacy in de novo small vessel disease (SVD).

Methods: This study is a post hoc analysis of 266 SVD lesions in 260 patients treated with a paclitaxelâcoated balloon or plain old balloon angioplasty (POBA) from the PEPCAD China SVD study. The baseline maximum RWS (RWS_max) ≥13% was selected as the cutoff value for vulnerable plaques. The primary outcome was in-segment late lumen loss (LLL) at 9-month follow-up.

Results: A total of 152 and 72 lesions in the DCB and POBA groups, respectively, completed the 9-month angiographic follow-up. In the DCB group, lesions with RWS_max ≥13% had higher in-segment LLL (0.24±0.53 mm vs 0.05±0.16 mm; p=0.0009), greater binary restenosis (14.9% vs 1.9%; p=0.0040) and more target lesion failure (10.2% vs 1.6%; p=0.022) than those with RWS_max <13%. Among all the lesions with RWS_max ≥13%, no significant difference was observed in in-segment LLL (0.24±0.53 mm vs 0.32±0.48 mm; p=0.49) between the DCB and POBA groups.

Conclusions: Angiographically derived RWS has the potential to predict the angiographic and clinical outcomes of DCB treatment for de novo SVD (PEPCAD China SVD study; ClinicalTrials.gov: NCT03625830).

Background: High-risk coronary plaques (HRPs) are associated with adverse cardiovascular outcomes. However, the clinical practicality of HRP identification is challenged by their modest prevalence and low positive predictive value.

Aims: We aimed to evaluate the association between clinical risk factors and HRPs, as well as the clinical impact of HRPs across different clinical risk profiles.

Methods: This is a pooled analysis of individual patient data from the prospective observational COMBINE (OCT-FFR) and PECTUS-obs studies. A modified version of the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) was used for risk stratification. The composite endpoint of major adverse cardiovascular events (MACE) was evaluated on a patient level, and target lesion failure (TLF), also a composite endpoint, was evaluated on a lesion level.

Results: Among 810 patients, 311, 265, and 234 were at low (TRS-2P 0-1), intermediate (TRS-2P 2), and high risk (TRS-2P ≥3), respectively. The modified TRS-2P had no discriminative value for the identification of patients with an HRP (area under the receiver operating characteristic curve 0.51, 95% confidence interval [CI]: 0.47-0.56). A consistent trend towards worse clinical outcome in the presence of an HRP was observed across different clinical risk profiles (p_interaction=0.539 for MACE and 0.337 for TLF). For TLF, the highest event rate per 100 lesion-years was observed in high-risk patients with HRPs (6.28, 95% CI: 3.52-10.36; 13.6% absolute risk at 2 years).

Conclusions: HRPs are associated with a negative clinical outcome, without apparent differences between clinical risk profiles. This highlights the independent value of optical coherence tomography for prognostication beyond clinical risk factors. The high event rates in high-risk patients with HRPs necessitate the search for additional therapeutic strategies to mitigate this risk.