Eurointervention最新文献

Background: Coronary intravascular lithotripsy (IVL) safely facilitates stent implantation in severely calcified lesions.

Aims: This analysis sought to determine the relative impact of IVL on acute and long-term outcomes specifically in calcified nodules (CNs).

Methods: Individual patient-level data (N=155) were pooled from the Disrupt CAD optical coherence tomography (OCT) substudies. Severely calcified lesions with and without CNs were compared by OCT for acute procedural results and for target lesion failure (TLF) at 2 years - a composite of cardiac death, target vessel myocardial infarction, and ischaemia-driven target lesion revascularisation.

Results: A CN was identified in 18.7% (29/155) of lesions. When comparing lesions with and without CNs, there were no significant differences in preprocedure minimal lumen area or diameter stenosis; however, the mean calcium angle and calcium volume were greater in CN lesions. Despite a higher calcium burden, the final minimal stent area (CN: 5.7 mm² [interquartile range [IQR] 4.4, 8.3] vs non-CN: 5.7 mm² [IQR 4.7, 7.2]; p=0.80) and stent expansion (CN: 79.3% [IQR 64.3, 87.0] vs 80.2% [IQR 68.9, 92.4]; p=0.30) were comparable between the two groups. In the CN group, the final stent area and expansion at CN sites were 7.6 mm² (IQR 5.5, 8.5) and 89.7% (IQR 79.8, 102.5), respectively. The cumulative incidence of TLF at 2 years was 13.9% and 8.0% in the CN and non-CN groups, respectively (p=0.32).

Conclusions: Despite a greater calcium volume in CNs, IVL use was associated with comparable stent expansion and luminal gain in both CN and non-CN lesions. Further studies powered for clinical outcomes comparing different plaque modification techniques in this lesion subset are warranted.

Background: Mechanical thrombectomy is the most effective treatment for restoring reperfusion in large vessel occlusion acute ischaemic stroke, even in patients with posterior circulation. However, the strategy for optimal treatment of patients with acute basilar artery occlusion (BAO) in difficult-to-treat cases in which thrombectomy has failed is unknown.

Aims: The purpose of this study was to evaluate the clinical efficacy and safety of rescue intracranial stenting (RIS) in patients with acute BAO treated with thrombectomy.

Methods: Stroke patients with acute BAO who had undergone failed mechanical thrombectomy in the ATTENTION registry were enrolled in this study. Univariable and multivariable regression analyses were performed to assess the clinical efficacy and safety of RIS.

Results: A total of 477 patients were included in the analysis, and 346 patients underwent RIS, of whom 167 (35.0%) patients had a favourable outcome. Symptomatic intracranial haemorrhage (sICH) occurred in 24 (5.0%) patients, and 172 (36.1%) patients died. There were no significant differences between the two groups of patients in the outcomes of modified Rankin Scale (mRS) 0-1 (p=0.541), mRS 0-2 (p=0.374), mRS 0-3 (p=0.600), or death (p=0.706). Patients in the RIS+ group had a significantly higher incidence of sICH (1.5% vs 6.4%; p=0.031). Nevertheless, after adjusting for confounders, RIS was not found to be an independent risk factor for sICH (adjusted odds ratio 4.189, 95% confidence interval: 0.960-18.286; p=0.057).

Conclusions: In this national, multicentre, prospective study, RIS in patients with acute BAO who had undergone failed first-line thrombectomy was feasible, but we could not show significance regarding improved long-term outcomes.

Trial registration number: ChiCTR2000041117.

Background: Redo-transcatheter aortic valve implantation (TAVI) may be unfeasible because of the risk of compromising coronary flow or coronary access by the pinned back leaflets of the index transcatheter aortic valve.

Aims: We aimed to evaluate the feasibility of redo-TAVI using the balloon-expandable SAPIEN 3 (S3) implanted within the self-expanding ACURATE neo2 (ACn2) valve and to identify predictors associated with a high risk of compromising coronary flow.

Methods: A total of 153 post-ACn2 TAVI cardiac computed tomography scans were analysed. Redo-TAVI using an S3 was simulated in two positions: S3 outflow to the ACn2 upper crown (low implant) and S3 outflow to the base of the ACn2 commissural posts (high implant). The risk for coronary flow compromise and inaccessibility was determined by the height of the neoskirt created by the pinned back leaflets and the valve-to-aorta distances.

Results: At a low S3 implant position, risk of coronary flow compromise was predicted in only 8% of patients and this increased to 60% with a high S3 position. In accordance, coronary access was predicted to be unrestricted in 52% versus 13% of patients with a low versus high S3 implantation. Female sex, a small aortic annular dimension and a sinotubular junction-to-aortic annulus mean diameter ratio <1.15 were independent predictors associated with a high risk for coronary flow compromise.

Conclusions: The feasibility of redo-TAVI with an S3 in an ACn2 depends on the implant depth of the S3 and the geometry of the surrounding aorta. A low S3 implant may reduce the risk of coronary flow compromise and inaccessibility.

Background: Little is known about the effects of left ventricular ejection fraction (LVEF) worsening after transcatheter edge-to-edge valve repair (TEER) for mitral regurgitation (MR).

Aims: This study investigated the predictors and clinical impact of LVEF worsening after TEER for primary MR (PMR) and secondary MR (SMR).

Methods: This study included 2,019 patients (493 with PMR and 1,526 with SMR) undergoing successful TEER (postprocedural MR grade ≤2+) in the OCEAN-Mitral registry. The patients were categorised into worsened LVEF (wEF), defined as a relative decrease of >12.9% in LVEF at discharge, and preserved LVEF (pEF). The serial changes in left ventricular (LV) function at 1 year were also evaluated.

Results: Following TEER, 657 (32%) patients demonstrated wEF. The pEF group demonstrated both decreased left ventricular end-diastolic volumes (LVEDV) and end-systolic volumes (LVESV), and the wEF group showed significantly increased LVESV at discharge. Higher LVEF, larger LVEDV, higher B-type natriuretic peptide levels, and moderate/severe aortic regurgitation predicted wEF. Compared with baseline, the wEF group still demonstrated lower LVEF (46% to 43%; p<0.001) but significantly increased stroke volume (48 mL to 53 mL; p=0.001) at 1 year. The incidence of death or heart failure hospitalisation was similar between the wEF and pEF groups (hazard ratio 1.14, 95% confidence interval: 0.72-1.80; p=0.84) and also in patients with PMR and SMR.

Conclusions: LVEF worsening after TEER was not uncommon and was caused by the increased LVESV. LV volumes and some patient-specific factors predicted worsened LVEF which was not associated with long-term clinical outcomes. OCEAN-Mitral registry: UMIN-CTR ID: UMIN000023653.

Background: In patients undergoing transcatheter aortic valve implantation (TAVI), the presence of a low-flow, low-gradient (LFLG) status has been associated with higher mortality at short-term follow-up.

Aims: We aimed to evaluate long-term survival after TAVI in patients with classical (cLFLG) and paradoxical LFLG (pLFLG) aortic stenosis (AS) compared to high-gradient (HG)-AS.

Methods: Patients undergoing TAVI at our centre with a hypothetical minimum 5-year follow-up were divided into 3 groups: (1) HG-AS (mean gradient [MG] >40 mmHg), (2) cLFLG-AS (MG <40 mmHg, ejection fraction [EF] <50%), and (3) pLFLG-AS (MG <40 mmHg, EF ≥50%). The primary endpoint of the study was all-cause mortality. Propensity score-weighted survival analysis was performed to adjust for possible baseline confounders.

Results: A total of 574 subjects were included (73% HG-AS, 15% pLFLG-AS, 11% cLFLG-AS). The median survival time was 4.8 years, with a maximum of 12.3 years. Patients with cLFLG-AS presented the highest baseline cardiovascular risk. At unadjusted survival analysis, patients with cLFLG-AS showed the worst long-term prognosis, with a rapid decrease in survival within the first year, while pLFLG- and HG-AS patients presented similar survival rates (p=0.023). At weighted long-term analysis, cLFLG- and HG-AS had similar survival rates. Baseline EF was not related to long-term mortality, while patients with a post-TAVI left ventricular ejection fraction (LVEF) improvement >10% lived significantly longer (p=0.02).

Conclusions: Classical LFLG-AS patients had lower long-term survival rates as compared to pLFLG-AS and HG-AS patients. However, after adjustment for possible baseline confounders, a low-flow status per se did not have an impact on long-term mortality after TAVI. Post-TAVI LVEF recovery was associated with improved long-term outcome.