Eurointervention最新文献

Background: Quantitative flow ratio (QFR) is a guideline-recommended angiography-based estimation of fractional flow reserve (FFR) for functional lesion evaluation. The FAVOR III Europe trial raised concerns regarding the safety and efficacy of QFR compared with FFR. Whether the poor clinical outcomes in the trial were attributable to software limitations or suboptimal in-procedure QFR analysis is unknown.

Aims: We aimed to compare in-procedure and core laboratory QFR, and to evaluate the quality of in-procedure QFR analyses.

Methods: The 1,008 patients randomised to QFR in FAVOR III Europe were assessed for eligibility. Core laboratory QFR analyses were performed by two blinded observers. The quality of in-procedure QFR analyses were evaluated during patient enrolment. Quality scores from 1 (very poor) to 5 (very good) were assigned based on adherence to the standard operating procedure (SOP).

Results: Of 1,233 vessels with in-procedure QFR, 1,191 (96.6%) were analysable in the core laboratory and were included in the paired analysis. The median in-procedure QFR was 0.81 (interquartile range [IQR] 0.71-0.90) and core laboratory QFR was 0.84 (IQR 0.73-0.91). The mean difference was 0.02 (95% limits of agreement: -0.26 to 0.29). Spearman's rank correlation coefficient was 0.58, and diagnostic agreement was 72%. Most in-procedure QFR analyses demonstrated very good (19%), good (45%), or acceptable (28%) SOP adherence, while 8% were rated as poor or very poor. Suboptimal angiographic quality, poor in-procedure QFR analysis quality, high SYNTAX score, and diabetes were predictors of increased variability.

Conclusions: In FAVOR III Europe, agreement between in-procedure and core laboratory QFR was modest. Measurement variability increased with reduced angiographic quality, poor in-procedure QFR analysis quality, and more advanced coronary artery disease.

Background: The role of non-culprit plaque rupture (a sign of pancoronary vulnerability) on long-term clinical outcomes remains unclear.

Aims: We aimed to investigate the association between non-culprit plaque rupture and long-term clinical outcomes.

Methods: ST-segment elevation myocardial infarction (STEMI) patients who had undergone 3-vessel optical coherence tomography before interventional therapy were studied. Patients and lesions were categorised into groups with and without non-culprit plaque rupture. Furthermore, non-ruptured thin-cap fibroatheroma (TCFA) was defined as a lesion with TCFA but not plaque rupture. All enrolled patients were followed for up to 5 years. The study endpoint was major adverse cardiac events (MACE), including cardiac death, non-fatal myocardial infarction, and unplanned ischaemia-driven revascularisation.

Results: A total of 930 STEMI patients with 3,660 non-culprit lesions were included. Non-culprit plaque rupture was detected in 165 patients and 209 lesions. During a median 4.1-year follow-up, non-culprit lesion-related MACE occurred more frequently in patients with versus without plaque rupture (hazard ratio [HR] 2.25, 95% confidence interval [CI]: 1.13-4.49; p=0.021). However, non-culprit lesion-related MACE were similar for lesions with versus without plaque rupture (HR 0.05, 95% CI: 0.00-24.68; p=0.336). Furthermore, non-ruptured TCFA was identified in 214 patients and 281 lesions. Multivariable analysis demonstrated that non-ruptured TCFA was significantly associated with non-culprit lesion-related MACE, whereas plaque rupture was not, at both the patient and lesion levels.

Conclusions: Patients with non-culprit plaque rupture had a poor long-term prognosis, which is predominantly due to the effect of non-ruptured TCFA. Non-ruptured TCFA, not plaque rupture, can identify lesions at increased risk of subsequent events.

Endomyocardial biopsy (EMB) has evolved from a single-indication test for the early diagnosis and monitoring of heart transplant rejection to the gold-standard technique to reach a definite and aetiological diagnosis in different cardiac disorders such as myocarditis and cardiomyopathies. It is currently considered a fundamental tool in the diagnostic workup of unexplained acute heart failure with haemodynamic compromise. For interventional cardiologists, EMB represents a unique opportunity to bridge invasive diagnostics with personalised care. By embracing technological advancements, integrating EMB with non-invasive modalities, the field advances towards more precise and effective management of complex cardiac conditions. However, safety remains a concern when performing EMB; indeed, although rare, major complications occur in about 1-5% of cases. Correct indication for the procedure and specific expertise to minimise the risk of complications are fundamental to obtain an acceptable risk/benefit profile. Therefore, this review examines the contemporary use of EMB from the perspective of interventional cardiologists to provide a practical resource for clinical practice and to better understand when and how to perform both right and left ventricular EMB in current practice.

Background: Despite its high prevalence and major prognostic implications, coronary microvascular disease (CMD) is frequently underdiagnosed owing to the complexity and invasiveness of current diagnostic procedures.

Aims: This study aimed to introduce and validate the usefulness of a non-invasive index of microcirculatory resistance (IMR) derived from coronary computed tomography angiography (CCTA), called IMR_CT, for accurate diagnosis of CMD.

Methods: This retrospective cohort study comprised consecutive patients referred for invasive coronary functional assessments who underwent CCTA within the 30 days preceding an invasive evaluation between January 2022 and March 2024. IMR_CT was calculated by blinded evaluators and compared against invasively determined IMR, with IMR values ≥25 indicating CMD, to assess its diagnostic performance.

Results: A total of 176 patients (216 vessels) were included in the analysis. IMR_CT showed good correlation with invasively measured IMR, both at the vessel level (r=0.71, 95% confidence interval [CI]: 0.62-0.76; p<0.001) and the patient level (r=0.72, 95% CI: 0.64-0.78; p<0.001). At the vessel level, diagnostic accuracy, sensitivity, specificity, and area under the curve were 81.9%, 80.8%, 82.5%, and 0.82, respectively; corresponding values at the patient level were 80.7%, 81.5%, 80.2%, and 0.81. In patients with non-obstructive coronary artery disease defined by CCTA stenosis <50%, coronary angiogram stenosis <50%, or fractional flow reserve>0.8, IMR_CT reduced underdiagnosis rates from 38.8%, 35.3%, and 36.3% to 4.5%, 5.9%, and 5.6%, respectively.

Conclusions: IMR_CT serves as a valuable complement to current diagnostic approaches, addressing their limitations and offering a promising alternative for the diagnosis of CMD, with the potential to significantly reduce misdiagnosis rates.