Eurointervention最新文献

Background: Treating a coronary stenosis by percutaneous coronary intervention (PCI) aims to relieve myocardial ischaemia by improving coronary blood flow. The evolution of coronary flow and resistance post-PCI is not fully understood.

Aims: This study aimed to investigate the immediate impact of PCI on absolute coronary flow (Q), and epicardial and microvascular resistance (R_epi and R_μ).

Methods: In a two-centre cohort including 52 patients, pre- and post-PCI physiological assessments were performed using continuous thermodilution, via a combination of a pressure-temperature sensor wire and a dedicated infusion microcatheter.

Results: Resting Q remained similar before and after PCI (Δ +2 [interquartile range [IQR] -9 to 21] mL/min; p=0.21), as a 193 Wood unit (WU) reduction in resting R_epi (Δ -193 [IQR -400 to -59] WU; p<0.001) was offset by a 267 WU increase in resting R_μ (Δ +267 [IQR -20 to 474] WU; p=0.002). Conversely, hyperaemic Q rose significantly (Δ +44 [IQR 16 to 92] mL/min; p<0.001), reflecting a 195 WU reduction in hyperaemic R_epi (Δ -195 [IQR -379 to -82] WU; p<0.001), while hyperaemic R_μ remained stable (Δ +3 [IQR -96 to 75] WU; p=0.87). The median microvascular resistance reserve (MRR) did not change significantly after PCI (Δ -0.2 [IQR -0.7 to 0.6]; p=0.301). Pre- and post-PCI fractional flow reserve (FFR) were strongly and inversely associated with R_epi and predicted the improvement of hyperaemic Q.

Conclusions: PCI significantly reduces epicardial resistance, leading to a pronounced increase in hyperaemic flow, which can be predicted by FFR. Resting Q remained unchanged because of compensatory increases in microvascular resistance, providing direct evidence of coronary flow autoregulation in humans. The MRR was unaffected by PCI, confirming its specificity as an index of microvascular function.

Background: The recurrences of acute coronary syndrome (ACS) and target vessel failure after percutaneous coronary intervention (PCI) remain clinical concerns. Intravascular imaging, such as optical coherence tomography (OCT) or intravascular ultrasound (IVUS), has demonstrated clinical benefits in patients with stable coronary disease; however, the benefits of its use remains unclear in patients with ACS.

Aims: This study aimed to investigate the benefit of imaging-guided PCI in patients with ACS on the recurrence of ACS using a nationwide database in Japan.

Methods: This retrospective observational study used records from the National Database between April 2014 and March 2021. We included patients hospitalised with ACS aged ≥20 years who had undergone first-time PCI and divided them into imaging-guided PCI (OCT or IVUS) and angiography-guided PCI groups. The primary outcome was ACS recurrence during a 3-year follow-up period. We analysed the association between intravascular imaging and the outcome using inverse probability of treatment weighting.

Results: Among the patients with ACS, angiography-guided PCI, OCT-guided PCI, and IVUS-guided PCI were performed in 32,044, 22,748, and 297,944 patients, respectively. During the study period, both OCT- and IVUS-guided PCI rates increased, from 4.7% to 6.9% and from 77.0% to 87.9%, respectively. OCT-guided PCI was associated with a lower risk of ACS recurrence (hazard ratio [HR] 0.81, 95% confidence interval [CI]: 0.71-0.91; p<0.001); IVUS-guided PCI was also associated with a lower risk of ACS recurrence (HR 0.76, 95% CI: 0.71-0.82; p<0.001).

Conclusions: In real-world clinical practice, the rates of both OCT- and IVUS-guided PCI have increased and have been associated with a lower risk of ACS recurrence compared with angiography-guided PCI in patients with ACS.

Background: Calcified coronary lesions impede stent expansion and are associated with poor outcomes after percutaneous coronary interventions. Intravascular lithotripsy (IVL) has emerged as a safe and effective pretreatment to optimise stent implantation.

Aims: This study assesses the LithiX lithotripsy device, which uses the Hertz contact (HC) mechanism to fragment calcium while minimising injury to surrounding soft tissue, without requiring an external energy source.

Methods: The multicentre, prospective PINNACLE-I clinical trial enrolled patients with up to two moderately to severely calcified de novo lesions. The primary endpoints were <50% residual stenosis without in-hospital major adverse cardiovascular events (MACE) and the 30-day MACE rate. Clinical events were assessed up to 6 months.

Results: Sixty patients with 63 lesions were treated with successful delivery and use of the HC-IVL catheter and a median procedure time of 59.5 min (interquartile range: 40.5-76.0). The primary endpoint was achieved in 98.3%. All patients had residual stenosis <30% after stent placement. The 30-day MACE rate was 1.7%, due to 1 periprocedural target vessel non-Q-wave myocardial infarction. There were no cardiovascular deaths, no definite or probable stent thromboses, nor any device-related events up to 6 months of follow-up. The optical coherence tomography substudy in 32 subjects identified a wide range of calcium morphologies, including calcium arcs of 96-360° and calcified nodules. Following HC-IVL, calcium fractures were achieved in 90.6% of lesions, and the mean fracture depth was 0.81±0.33 mm. Stent expansion at the minimum stent area site was 96.7±25.5%.

Conclusions: PINNACLE-I demonstrated the feasibility, safety, and efficacy of the novel HC-IVL to fracture calcified lesions and achieve optimal stent expansion in a broad range of calcium morphologies.

Background: Ticagrelor monotherapy following abbreviated dual antiplatelet therapy (DAPT) is an emerging strategy for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). However, the timing of aspirin discontinuation has not been directly compared in this setting.

Aims: We aimed to compare the clinical outcomes of aspirin discontinuation within 1 month versus at 3 months after PCI in patients with ACS.

Methods: This post hoc analysis used individual patient-level data from the TICO and T-PASS trials, which exclusively enrolled patients with ACS undergoing PCI. Of 2,953 patients who received ticagrelor monotherapy after abbreviated DAPT, 1,426 discontinued aspirin within 1 month and 1,527 at 3 months. After propensity score matching, 2,248 patients were included in the final analysis. The primary endpoint was a composite of all-cause death, myocardial infarction, stent thrombosis, ischaemia-driven target vessel revascularisation, stroke, and major bleeding at 1 year.

Results: The primary endpoint occurred less frequently in the <1-month group than in the 3-month group (3.2% vs 5.6%; hazard ratio [HR] 0.56, 95% confidence interval [CI]: 0.37-0.84; p=0.005). Ischaemic event rates were comparable (2.2% vs 2.3%; HR 0.86, 95% CI: 0.55-1.65; p=0.863), whereas major bleeding was significantly lower in the <1-month group (1.1% vs 3.3%; HR 0.32, 95% CI: 0.17-0.61; p<0.001). Landmark analysis showed that event rates diverged primarily within the first 90 days, with no significant heterogeneity between the early and late periods.

Conclusions: Aspirin discontinuation within 1 month followed by ticagrelor monotherapy improved net clinical outcomes compared with 3-month discontinuation, primarily by reducing major bleeding without increasing ischaemic risk.

Clinicaltrials: gov: NCT02494895 (TICO), NCT03797651 (T-PASS).

Background: The clinical outcomes of bioresorbable vascular scaffolds (BVS) compared with everolimus-eluting stents (EES) beyond 5-year follow-up are unknown.

Aims: This study aims to investigate clinical outcomes of BVS 7 years after implantation.

Methods: The COMPARE-ABSORB trial is an investigator-initiated, prospective randomised study. Patients at high risk of restenosis were randomly assigned to receive either a BVS or an EES. A dedicated implantation technique was recommended for BVS. The primary endpoint was target lesion failure (TLF), defined as the composite of cardiac death, target vessel myocardial infarction (TVMI), or clinically indicated target lesion revascularisation (CI-TLR). The primary and co-primary objectives were non-inferiority at 1 year and superiority of BVS at 7 years after a 3-year landmark analysis.

Results: Although enrolment was stopped at 1,670 patients (80% of the intended 2,100 patients; 848 patients receiving BVS and 822 EES) because of high thrombosis and TVMI rates in the BVS arm, non-inferiority for TLF at 1 year was met. At 7-year follow-up subsequent to a 3-year landmark analysis, the TLF rate of BVS was 6.7% versus 5.9% for EES (hazard ratio [HR] 1.14, 95% confidence interval [CI]: 0.76-1.77; p=0.53); therefore, superiority was not met. Cardiac death, TVMI, and device thrombosis rates did not differ between both groups; however, CI-TLR was significantly higher in the BVS arm (4.4% vs 2.2%; HR 1.97, 95% CI: 1.08-3.60; p=0.023).

Conclusions: After complete resorption, no benefit was observed with BVS compared with EES at 7-year follow-up, despite the use of a dedicated implantation protocol for BVS. In fact, after 3 years, more target lesion revascularisations occurred with BVS than with EES.