Eurointervention最新文献

Background: Abbreviated antiplatelet therapy (APT) can reduce bleeding without increasing ischaemic harm in high bleeding risk (HBR) patients undergoing percutaneous coronary intervention (PCI). The impact of chronic kidney disease (CKD) on the safety and effectiveness of abbreviated APT remains unknown.

Aims: We aimed to investigate the comparative effectiveness of abbreviated (1 month) versus standard (≥3 months) APT in HBR patients with and without CKD.

Methods: This was a prespecified analysis from the MASTER DAPT trial, which randomised 4,579 HBR patients (1,428 [31%] with CKD) to abbreviated or standard APT. CKD was defined as an estimated glomerular filtration rate <60 mL/min/1.73 m². Co-primary outcomes were net adverse clinical events (NACE; a composite of all-cause death, myocardial infarction [MI], stroke, and major bleeding), major adverse cardiac or cerebral events (MACCE; all-cause death, MI and stroke), and Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding at 11 months.

Results: NACE did not significantly differ with abbreviated and standard APT among CKD patients (hazard ratio [HR] 0.91, 95% confidence interval [CI]: 0.66-1.24) and non-CKD patients (HR 0.96, 95% CI: 0.73-1.27; pinteraction=0.78). Similarly, MACCE did not differ in CKD patients (HR 0.91, 95% CI: 0.64-1.27) and non-CKD patients (HR 1.09, 95% CI: 0.78-1.51; pinteraction=0.45). Abbreviated APT was associated with consistently lower BARC 2, 3, or 5 bleeding in both patients with CKD (HR 0.74, 95% CI: 0.52-1.07) and without it (HR 0.66, 95% CI: 0.51-0.85; pinteraction=0.59).

Conclusions: Abbreviated APT was associated with similar NACE and MACCE rates and reduced bleeding compared with standard APT in HBR patients undergoing PCI, regardless of the presence or absence of CKD. (ClinicalTrials.gov: NCT03023020).

Calcified nodules (CNs) represent significant challenges in percutaneous coronary intervention (PCI) due to their complex morphology, variable treatment responses, and association with stent failure due to reprotrusion or stent underexpansion. CNs are classified into eruptive and non-eruptive subtypes, each with distinct histological features and prognostic implications. Eruptive CNs are biologically active, being associated with a disrupted fibrous cap, overlying thrombus, and intraplaque haemorrhage, and they are thus more readily deformable by balloon dilation during PCI. Non-eruptive CNs, or nodular calcifications, tend to be stable, with an intact fibrous cap, and their deformability varies depending on the composition and base of the nodules. Enhanced angiography and intravascular imaging have greatly improved our understanding of CNs and may help to accurately identify nodule subtypes and guide treatment. Furthermore, understanding the deformability of CNs is crucial for optimising treatment outcomes. In this review, we discuss the identification and management of CNs in the context of PCI.

Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) represents a unique clinical syndrome, comprising non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. NSTEMI, as the more common and serious form of NSTE-ACS, is particularly noteworthy because of its diverse clinical presentation, electrocardiogram changes, and angiography findings, which may pose challenges in diagnosis and treatment and may subsequently influence prognosis. This review offers a comprehensive overview of current evidence-based approaches to NSTE-ACS management, focusing on diagnosis, risk stratification, and treatment strategies while highlighting emerging trends and ongoing challenges in optimising patient outcomes.

Background: Transcatheter aortic valve implantation (TAVI) in patients with small aortic annuli (SAA) is associated with an increased risk of prosthesis-patient mismatch (PPM).

Aims: This study assesses the 30-day performance of the novel, balloon-expandable DurAVR transcatheter heart valve (THV), which features a unique single-piece biomimetic leaflet design, in patients with SAA.

Methods: This pooled analysis derived from first-in-human and early feasibility studies includes all patients with SAA (defined as an aortic annular area from 346 to 452 mm2) treated with the Small size DurAVR THV. The mean computed tomography (CT)-derived aortic annulus area was 404 ± 37 mm², with an average diameter of 22.7 ± 1.0 mm. Outcomes at 30 days, including PPM, were evaluated per Valve Academic Research Consortium-3 (VARC-3) criteria, with independent adjudication of clinical events and core laboratory analysis of post-implant transthoracic echocardiograms.

Results: Amongst 100 patients (mean age 77.0 ± 7.3 years; 78% female; mean Society of Thoracic Surgeons [STS] score 4.7 ± 4.0%) treated with the DurAVR THV, the overall technical success rate was 93%. At 30 days, device success was achieved in 91% of patients, with no reported deaths and a stroke rate of 2%. Echocardiographic haemodynamic assessment showed a mean transprosthetic gradient of 8.2 ± 3.1 mmHg, a mean effective orifice area of 2.2 ± 0.3 cm², and a doppler velocity index of 0.60 ± 0.10. The incidence of moderate or greater PPM was 3%, and no patients experienced more than mild paravalvular leak. The rate of new permanent pacemaker implantation was 6%.

Conclusions: In patients with SAA, the DurAVR THV demonstrated promising clinical and echocardiographic outcomes at 30 days. Longer-term follow-up in larger cohorts is needed to confirm these encouraging early results.

Background: Transcatheter mitral valve replacement (TMVR) offers a potential treatment option for select patients with mitral regurgitation (MR) deemed unsuitable for surgery or transcatheter repair, but data is limited on long-term durability and performance.

Aims: We evaluated 5-year outcomes from the global Pilot study (NCT02322840) with the Intrepid transapical (TA) TMVR system.

Methods: This multicenter, single-arm study evaluated the early-generation Intrepid TA system in patients with symptomatic ≥ moderate-severe MR at high risk for mitral valve (MV) surgery. Echocardiograms and clinical events were independently adjudicated, and patients were followed through 5 years.

Results: Ninety-five patients were enrolled at 21 sites between 2015 and 2019. Mean age was 74.0±9.2 years, 43.2% female, mean STS-PROM 6.5±4.8%, 57.9% had prior heart failure hospitalization (HFH), and 88.4% were in NYHA Class III/IV. Secondary MR was present in 78.7%, and 76.6% had a left ventricular ejection fraction ≤50%. Through 5 years, all-cause mortality was 66.7% and HFH 55.4%, with one 30-day MV reintervention (1.1%). Hemodynamic valve deterioration occurred in 1.4%, median MV mean gradient remained stable at 3.6 mmHg (Q1, Q3: 3.0, 4.8 mmHg), with ≤ mild MR in 100% of patients, and none had paravalvular leak. NYHA Class I/II was maintained at 84.6%.

Conclusions: In this 5-year follow-up of the early generation Intrepid TA TMVR system, we observed sustained MR reduction, durable hemodynamic valve performance, and improved functional status among survivors. The APOLLO (NCT03242642) and APOLLO-EU (NCT05496998) trials using the transfemoral system will determine the role of TMVR in managing this high-risk patient population.

Up to one-third of patients referred for transcatheter tricuspid valve intervention (TTVI) have a transvalvular pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) lead in place. Both the electrophysiology and interventional cardiology communities have been alerted to the complexity of decision-making in this situation due to potential interactions between the leads and the TTVI material, including the risk of jailing or damage to the leads. This document, commissioned by the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions of the ESC, reviews the scientific evidence to inform Heart Team discussions on the management of patients with a PPM or ICD who are scheduled for or have undergone TTVI. Graphical abstract.