Eurointervention最新文献

Background: Prolonged lipid-lowering therapy has demonstrated its ability to induce plaque regression and improve the plaque morphology of mild atherosclerotic lesions.

Aims: This trial aimed to assess the short-term effect of evolocumab in addition to high-intensity statin therapy (HIST) on relevant non-culprit coronary artery lesions using fractional flow reserve (FFR) measurements and multimodality intracoronary imaging.

Methods: Patients with an acute coronary syndrome (ACS) and relevant multivessel disease were randomised to receive either evolocumab or placebo for 12 weeks in addition to HIST. Patients underwent serial FFR and intravascular ultrasound (IVUS)-near-infrared spectroscopy imaging of a non-culprit vessel. The primary endpoints were the differences in the change in FFR and in the maximum lipid core burden index within any 4 mm segment (maxLCBI_4mm). The secondary endpoints were the differences in the change in IVUS-derived atheroma volume parameters.

Results: Among 150 patients (mean age 64.2±8.5 years; 27 [18.0%] female) randomised to evolocumab (n=74) or placebo (n=76), 143 underwent follow-up coronary angiography. After 12 weeks of treatment, the adjusted mean change in FFR was 0.00 (95% confidence interval [CI]: -0.02 to 0.02) with evolocumab versus 0.01 (95% CI: -0.01 to 0.03) with placebo (adjusted mean difference: -0.01, 95% CI: -0.03 to 0.01; p=0.6). The adjusted mean change in the maxLCBI_4mm was -27.8 (95% CI: -72.2 to 16.6) for evolocumab-treated patients versus -35.6 (95% CI: -82.5 to 11.4) for placebo-treated patients (adjusted mean difference: 7.8, 95% CI: -40.9 to 56.4; p=0.8). No between-group differences in any IVUS-derived parameter were found.

Conclusions: In patients with ACS and relevant non-culprit coronary artery lesions, the addition of evolocumab to HIST for 12 weeks, compared to placebo, did not result in improvement of FFR or maxLCBI_4mm. (ClinicalTrials.gov: NCT04141579).

Background: Patients with coronary microvascular dysfunction (CMD) exhibit impaired vasodilatation of the microcirculation. This manifests as reduced microvascular resistance reserve (MRR) due to either increased resting flow (Q_rest; functional CMD) or decreased hyperaemic flow (Q_hyper; structural CMD). However, coronary flow is intimately linked to myocardial mass, potentially confounding the interpretation of flow and resistance measurements.

Aims: We investigated the relationship between subtended myocardial mass, microvascular resistance, and coronary flow to determine whether the disturbed resistance and flow patterns seen in CMD persisted after indexing by subtended myocardial mass.

Methods: We recruited 100 patients with angina with non-obstructive coronary arteries who underwent coronary computed tomography angiography to quantify vessel-specific subtended myocardial mass. Continuous intracoronary thermodilution was used to quantify absolute coronary flow and microvascular resistance, both at rest and during hyperaemia. Among patients with an MRR <3.0, hyperaemic microvascular resistance (R_μ,hyper) ≥475 Wood units (WU) defined structural CMD (versus functional CMD). Flow and resistance measurements were analysed both in absolute terms and after indexing by subtended mass.

Results: Mass and flow were analysed in 100 patients in the left anterior descending artery. The mean subtended myocardial mass in the structural CMD group (47.00±13.83 grams) was significantly lower than in the control group (59.64±21.69 grams; p=0.027), with no significant difference between the control group and the functional CMD group (53.75±13.99 grams; p=0.339). After indexing by the subtended mass, patients with structural CMD still had higher R_μ,hyper (control: 20.68±7.99 WUâ¢kg vs structural CMD: 30.58±11.63 WUâ¢kg; p<0.001) and lower Q_hyper (control: 4.56±2.20 ml/min/g vs structural CMD: 3.20±0.90 ml/min/g; p=0.013). Conversely, patients with functional CMD exhibited similar indexed values of R_μ,hyperand Q_hyper to controls.

Conclusions: Despite significantly lower subtended mass, patients with structural CMD exhibit abnormal indexed R_μ,hyper and Q_hyper, supporting the notion of hyperaemic flow restriction at the tissue level that is independent of subtended mass. However, patients with functional CMD have similar subtended myocardial mass to controls and exhibit no flow restriction during hyperaemia.

Background: Residual shunt (RS) after transcatheter patent foramen ovale (PFO) closure has been associated with an increased risk of recurrent stroke over long-term follow-up. However, RS prevalence, anatomical characteristics, and treatment strategies are poorly understood.

Aims: This study aimed to assess the prevalence and causes of RS, as well as to evaluate the safety and feasibility of its percutaneous treatment.

Methods: Patients with RS at transcranial Doppler after transcatheter PFO closure in three Italian high-volume centres between 2000 and 2022 were included. The prevalence and anatomical characteristics of RS, its relationship with the original occluding device, and the procedural details of percutaneous treatment were assessed.

Results: Among the 2,362 patients who underwent PFO closure, any grade and significant RS were diagnosed in 8.8% and 3.6% of patients, respectively. It was more frequently found after use of the NobleStitch system than after double-disc device implantation (20.0% vs 8.5%; p<0.00001). Among double-disc device implantations, a higher rate of shunt was found with stiffer devices (9.8% vs 7.1%; p<0.05) and with devices larger than 25 mm (13.9% vs 6.6%; p<0.00001). Intradiscal RS (type 1) was most common (43.6%), followed by extradiscal RS (type 2; 35.1%) and RS due to unusual causes (type 3; 14.9%). Percutaneous treatment was successful in 89.4% of patients using different, anatomically tailored devices.

Conclusions: RS is commonly found after transcatheter PFO closure and is significantly associated with the type and size of the occluding device implanted. It results from different mechanisms and can be safely and effectively treated by a percutaneous, patient-tailored approach in a high percentage of cases.

Background: Transcatheter aortic valve implantation (TAVI) in pure aortic regurgitation (AR) remains challenging because of inadequate anchoring forces. Traditional approaches, which rely solely on virtual annulus oversizing, have demonstrated limited success. We propose a novel anatomical classification system and dual-anchoring theory to optimise the TAVI strategy in patients with pure AR.

Aims: We aimed to evaluate the efficacy and safety of TAVI in pure AR using a novel anatomical classification system and dual-anchoring theory.

Methods: The AURORA trial is a prospective, multicentre, single-arm study conducted across 16 centres in China. Patients with severe pure AR underwent comprehensive anatomical assessment using multidetector computed tomography (CT). Based on the ability to provide adequate anchoring forces (≥10% of oversizing) in three zones (left ventricular outflow tract, anatomical annulus, and ascending aorta), patients were classified into 4 types. Those with anatomical types 1-3 were enrolled and underwent TAVI using the VitaFlow valve system. The primary efficacy endpoint was device success, and the primary safety endpoints included 30-day mortality and major complications.

Results: Among 187 screened patients, 100 patients with suitable anatomy (types 1-3) were enrolled. The mean age was 72.7±7.2 years, and the mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 9.10±5.81%. Device success was achieved in 91% of cases, with no procedural mortality. The new permanent pacemaker implantation rate was 9%. Postprocedural CT analysis in 43 patients revealed that the maximum contact forces were primarily localised between the virtual annulus and the sinotubular junction (83.7% of cases). No device failure occurred in later cases.

Conclusions: The AURORA classification system shows that comprehensive anatomical assessment can lead to favourable outcomes in pure AR using conventional TAVI devices. The low pacemaker implantation rate and the absence of device failure in later cases suggest that optimal anatomical matching may be superior to aggressive oversizing strategies.