Eurointervention最新文献

Intracoronary (IC) imaging-guided percutaneous coronary intervention (PCI) improves clinical outcomes in patients with high clinical and anatomical risk when compared to interventions guided by angiography alone. Recent Class I recommendations for the use of IC imaging guidance when performing PCI in left main stem or complex lesions may result in a significant uptake as the technology is embraced as standard of care. Routine application of IC imaging will provide interventional cardiologists with a wealth of high-fidelity intracoronary data on plaque composition and distribution. When paired with emerging data regarding the importance of plaque anatomical characteristics, developments in artificial intelligence and computational fluid dynamics, lesion stratification with IC imaging may herald the next paradigm shift in this field. In this review, we will explore this important emerging application of IC imaging to inform morphology-guided PCI, identify high-risk lesions for targeted therapies, and consider the prospects of harnessing automated image interpretation with artificial intelligence technologies to achieve an integrated physiological and morphological assessment. Lesion stratification with IC imaging has the potential to shape the future of interventional cardiology practice to guide therapies within and beyond the confines of the cardiac catheterisation laboratory.

Background: Medium- and long-term outcomes after transcatheter paravalvular leak (PVL) closure remain poorly documented, with limited prospective data on predictors of morbidity and mortality.

Aims: This study aimed to assess medium-term outcomes and identify key predictive factors of mortality or surgical reintervention at 2 years after transcatheter PVL closure.

Methods: The prospective Fermeture de Fuite ParaProthétique (FFPP) Registry included consecutive symptomatic patients undergoing transcatheter PVL closure across 24 European centres between 2017 and 2019. Predictive factors for mortality and surgical reintervention were analysed over a 2-year follow-up.

Results: A total of 213 symptomatic patients underwent 237 procedures. The mean age was 68±11 years, with a median European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of 6 (interquartile range [IQR] 4-10). PVL involved the mitral valve in 64.6% of cases and mechanical prostheses in 53.3%. Heart failure and haemolytic anaemia were present in 89.5% and 49.8% of patients, respectively. The transapical approach was used in 6.8% of cases. Technical success was achieved in 87.3% of procedures, and clinical success at 1 month was achieved in 70.5% of patients. The median follow-up was 24.4 months (IQR 23.2-26.4). The survival rate at 2 years without the need for surgical reintervention was 66.1% (95% confidence interval [CI]: 60.1-72.7). Multivariate analysis identified mitral PVL, mechanical valves, and haemolytic anaemia as independent risk factors for adverse outcomes during follow-up. The absence of clinical success at 1 month was the strongest predictor of adverse outcomes (hazard ratio 5.00, 95% CI: 2.70-9.09; p=0.001).

Conclusions: Transcatheter PVL closure offers a durable therapeutic option for high-risk patients when early clinical success is achieved. Mitral valve involvement, mechanical prostheses, and haemolytic anaemia remain key predictors of poor outcomes over a 2-year follow-up.

Background: Independent predictors and prognostic correlates of structural valve deterioration (SVD) after transcatheter aortic valve implantation (TAVI) have not been investigated beyond 5-year follow-up.

Aims: We aimed to investigate the association between the early residual mean postprocedural gradient (ERMPG) after TAVI and long-term SVD rates as well as the association of SVD with bioprosthetic valve failure (BVF) and 10-year mortality rates.

Methods: Patients with severe aortic valve stenosis enrolled in the Medtronic One Hospital Clinical Service at 10 Italian centres were included in the study. ERMPG was measured with echo-Doppler at hospital discharge or within 3 months from TAVI.

Results: Between September 2007 and December 2014, 1,291 patients undergoing TAVI with a CoreValve/Evolut valve met the enrolment criteria of the study. After a median follow-up of 59.4 months, there were 46 patients with SVD (cumulative incidence rate 3.6%). A significant stepwise increase in the risk of SVD was apparent across tertiles of ERMPG (p=0.009), and in the multivariable analysis, ERMPG was an independent predictor of SVD (adjusted subdistribution hazard ratio [sHR] 1.05, 95% confidence interval [CI]: 1.01-1.08; p=0.004). Among the 46 patients with SVD, 25 (54.3%) had or developed BVF. SVD was associated with increased 10-year rates of all-cause mortality (adjusted hazard ratio 2.12, 95% CI: 1.49-3.00; p<0.001) and cardiac mortality (adjusted sHR 5.78, 95% CI: 2.63-12.71; p<0.001) compared with no SVD.

Conclusions: Echo-Doppler-derived ERMPG measured within 90 days from TAVI is an independent predictor of SVD. SVD is associated with high rates of BVF, and it is an independent predictor of all-cause mortality and cardiovascular mortality.

Background: Transcatheter edge-to-edge repair (TEER) is among the treatments for functional mitral regurgitation (FMR), but its benefits over guideline-directed medical therapy (GDMT) alone are discordant. We conducted a meta-analysis of randomised trials comparing long-term outcomes between these treatment strategies.

Aims: We aimed to compare long-term clinical outcomes between TEER plus GDMT and GDMT alone in symptomatic moderate-to-severe FMR.

Methods: Major electronic databases were searched for randomised trials comparing TEER plus GDMT with GDMT alone in FMR. The primary outcome was death or first hospitalisation due to heart failure at 24 months. The key secondary outcome was first hospitalisation due to heart failure at 24 months. Summary hazard ratios (HRs) with 95% confidence intervals (CIs) were computed by mixed-effects Cox models based on reconstructed time-to-first event individual patient data and random-effects models based on study-level data.

Results: Three randomised trials (MITRA-FR, COAPT, and RESHAPE-HF2) were included, for a total of 1,422 patients assigned to TEER plus GDMT (n=703) or GDMT alone (n=719). The primary outcome was significantly lower in the TEER plus GDMT group compared with the GDMT-alone group by one-stage analysis (HR 0.72, 95% CI: 0.56-0.92; p=0.010). However, the two-stage analysis marginally failed to confirm this result (HR 0.72, 95% CI: 0.51-1.00; p=0.052) and showed substantial heterogeneity (I²=80.3%; p=0.006). Hospitalisation due to heart failure was significantly lower in the TEER plus GDMT group, regardless of the statistical method used (one-stage: HR 0.65, 95% CI: 0.48-0.88; p=0.006; two-stage: HR 0.66, 95% CI: 0.45-0.96; p=0.031). However, heterogeneity was substantial (I²=81.2%; p=0.005). All-cause death and cardiovascular death at 24 months were not significantly different between treatment groups but became significant after excluding MITRA-FR in the leave-one-out analysis.

Conclusions: In symptomatic moderate-to-severe FMR, TEER plus GDMT significantly reduces death or hospitalisation due to heart failure and hospitalisation due to heart failure at 24 months.