Eurointervention最新文献

Background: The role of optical coherence tomography (OCT) guidance during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) remains inconclusive.

Aims: This study aimed to evaluate the impact of OCT-guided PCI in ACS patients with complex lesions.

Methods: The Optical CoherenCe Tomography-gUided Coronary Intervention in Patients With Complex Lesions (OCCUPI) Trial compared PCI with OCT guidance versus angiography guidance in patients who required drug-eluting stent implantation for complex lesions. This post hoc analysis focused on participants presenting with ACS. The primary outcome was 1-year major adverse cardiac events (a composite of cardiac death, myocardial infarction, stent thrombosis, or ischaemia-driven target vessel revascularisation).

Results: Out of 1,604 randomised patients, 790 (49.3%) and 814 (50.7%) presented with ACS and chronic coronary syndrome (CCS), respectively. Among patients with ACS, the incidence of the primary outcome was 4.9% in the OCT-guided group and 9.5% in the angiography-guided group (hazard ratio [HR] 0.50, 95% confidence interval [CI]: 0.29-0.87; p=0.011). Among patients with CCS, its incidence was 4.4% and 5.4%, respectively (HR 0.80, 95% CI: 0.43-1.50; p=0.479). No significant interaction between clinical presentation and imaging guidance strategy was observed for the primary outcome (p_interaction=0.273). Among patients with ACS randomised to OCT guidance, the achievement of stent optimisation by OCT was associated with a lower incidence of the primary outcome compared with suboptimisation (2.9% vs 9.7%; HR 0.29, 95% CI: 0.12-0.72; p=0.004).

Conclusions: In ACS patients with complex lesions, OCT-guided PCI demonstrated an evident cardiovascular benefit over angiography-guided PCI, a finding endorsed by current guidelines. (ClinicalTrials.gov: NCT03625908).

Background: In 2020, the Danish national guidelines changed to recommend prasugrel over ticagrelor in patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI), prior to the 2023 update to the European guidelines.

Aims: We aimed to assess whether the shift from routine use of ticagrelor to prasugrel was implemented on a national level and whether prasugrel was associated with lower rates of major adverse cardiovascular events (MACE) and with similar bleeding rates compared to ticagrelor.

Methods: This register-based cohort study identified MI patients treated with PCI from 2019 to 2022 using Danish nationwide registries. Patients without contraindications were included if they were alive and redeemed a prasugrel or ticagrelor prescription within 7 days from discharge.

Results: In total, 10,984 patients redeemed prasugrel (38.0%) or ticagrelor (62.0%). In 2019, >99% of patients were treated with ticagrelor. By 2022, 89% of patients were treated with prasugrel. Prasugrel-treated patients were younger, more often male, had ST-segment elevation MI (STEMI) more frequently, and had fewer cardiovascular comorbidities than ticagrelor-treated patients. P2Y12 inhibitor adherence was high, and 4.3% of patients switched from prasugrel and 18.8% from ticagrelor. Prasugrel was associated with reduced 1-year rates of MACE (adjusted hazard ratio [adjHR] 0.67, 95% confidence interval [CI]: 0.47-0.95) and MI (adjHR 0.65, 95% CI: 0.44-0.96) compared with ticagrelor, without differences in bleeding after adjustment. These findings were replicated in a propensity score-matched population, in patients aged ≥75 years, and in non-STEMI patients.

Conclusions: A shift from ticagrelor to prasugrel occurred between 2019 and 2022 among real-world MI patients post-PCI. Prasugrel was associated with reduced rates of MACE and MI and with similar bleeding rates compared with ticagrelor, supporting current guideline recommendations.

Coronary bifurcation lesions (CBLs) represent a common and challenging subset of coronary artery disease requiring percutaneous coronary intervention (PCI). While drug-eluting stents (DES) remain the cornerstone of treatment, their use is associated with risks such as restenosis, thrombosis, side branch (SB) jailing and the need for prolonged dual antiplatelet therapy. Drug-coated balloons (DCBs) have emerged as a promising alternative, delivering antiproliferative drugs without permanent implants, thereby reducing the risk of late complications and preserving native vessel geometry. This review explores the role of DCBs in CBL management, particularly for SB treatment within the provisional stenting strategy. Evidence from clinical studies indicates that DCBs significantly reduce late lumen loss and restenosis in the SB compared to plain balloon angioplasty, while simplifying PCI procedures and avoiding extensive stenting. Furthermore, hybrid/blended strategies combining DCBs with DES have shown superior clinical and angiographic outcomes in true CBLs compared to DES-only approaches. Despite their potential, the adoption of DCBs faces challenges, including the need for optimal lesion preparation and a lack of standardised procedural techniques. Existing randomised controlled trials are limited by small sample sizes, design heterogeneity, inclusion of bare metal stents either as comparators or as part of the treatment strategy, and inconsistent use of key procedural steps such as proximal optimisation technique and kissing balloon inflation. This manuscript aims to provide interventional cardiologists with practical guidance for managing CBLs, focusing on the effective integration of DCBs into standalone and hybrid strategies. By emphasising procedural optimisation and complication reduction, this review seeks to promote more standardised and reproducible approaches in clinical practice.

Background: The COMPLETE trial demonstrated a reduction in cardiovascular (CV) death or new myocardial infarction (MI) after complete, rather than culprit-only, revascularisation in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). However, it is unknown whether this benefit varies according to baseline left ventricular ejection fraction (LVEF).

Aims: We aimed to determine the effects of complete versus culprit-only revascularisation according to LVEF.

Methods: Baseline LVEF was available for 2,214 of 4,041 randomised patients. The effect of both strategies on the first co-primary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischaemia-driven revascularisation (IDR) was determined within the prespecified LVEF ranges of <45% (N=660) and ≥45% (N=1,554). An analysis of clinical outcomes by LVEF according to thirds was also conducted.

Results: Patients with LVEF <45% experienced a significantly higher incidence of the first co-primary outcome compared with those with LVEF ≥45% (4.2%/year vs 2.8%/year; hazard ratio [HR] 1.51, 95% confidence interval [CI]: 1.15-1.98; p=0.003). Compared with a culprit-only strategy, complete revascularisation consistently reduced the first co-primary outcome in patients with LVEF <45% (3.0%/year vs 5.5%/year; HR 0.55, 95% CI: 0.36-0.86) and those with LVEF ≥45% (2.4%/year vs 3.2%/year; HR 0.74, 95% CI: 0.52-1.04; interaction p=0.31). Complete revascularisation also consistently reduced the second co-primary outcome in patients with LVEF <45% (3.5%/year vs 7.3%/year; HR 0.49, 95% CI: 0.33-0.74) and those with LVEF ≥45% (2.7%/year vs 6.3%/year; HR 0.44, 95% CI: 0.33-0.60; interaction p=0.67). Consistent results were observed for both co-primary outcomes when LVEF was further stratified into categories of LVEF ≤35%, 36-49% and ≥50%.

Conclusions: Among patients presenting with STEMI and MVD, those with reduced LVEF are at higher risk of ischaemic events than patients with preserved LVEF. There is a consistent benefit of complete revascularisation regardless of baseline LVEF.

Background: Percutaneous large-bore arteriotomy closure devices are either suture- or plug-based. The comparative efficacy and safety of both techniques and optimal patient selection remain controversial.

Aims: We aimed to conduct a patient-level meta-analysis of randomised trials comparing suture-based ProGlide versus plug-based MANTA large-bore vascular closure devices (VCDs).

Methods: We searched PubMed, the Cochrane Central Register of Controlled Trials, and Google Scholar for randomised controlled trials comparing vascular closure with the ProGlide-based and the MANTA-based technique. The primary endpoint of this analysis was access site-related vascular complications defined according to the Valve Academic Research Consortium-3 criteria.

Results: We identified 2 trials that enrolled a total of 722 patients undergoing transcatheter aortic valve implantation. The primary endpoint was significantly less common after vascular closure with the ProGlide-based technique (odds ratio [OR] 0.54, 95% confidence interval [CI]: 0.35-0.82). Access site-related bleeding events were also less common with the ProGlide-based technique (OR 0.41, 95% CI: 0.18-0.94). Prespecified subgroup analyses did not reveal any subgroup favouring the plug-based technique. Clinical outcomes with the MANTA-based technique were better in larger-sized vessels. Patients who received the ProGlide-based technique were less likely to undergo endovascular stenting or vascular surgery (OR 0.22, 95% CI: 0.06-0.79).

Conclusions: In this patient-level meta-analysis of randomised trials, the ProGlide-based technique for large-bore arterial access was superior to the MANTA-based technique in terms of vascular and bleeding complications.

Background: The drug delivery eï¬ciency of drug-coated balloons (DCBs) in de novo coronary artery disease is correlated with atherosclerotic plaque characteristics. It remains to be elucidated whether plaque composition and vulnerability can affect the efficacy of DCBs.

Aims: This study aimed to explore the association between a novel angiography-based radial wall strain (RWS) measurement for plaque vulnerability and DCB efficacy in de novo small vessel disease (SVD).

Methods: This study is a post hoc analysis of 266 SVD lesions in 260 patients treated with a paclitaxelâcoated balloon or plain old balloon angioplasty (POBA) from the PEPCAD China SVD study. The baseline maximum RWS (RWS_max) ≥13% was selected as the cutoff value for vulnerable plaques. The primary outcome was in-segment late lumen loss (LLL) at 9-month follow-up.

Results: A total of 152 and 72 lesions in the DCB and POBA groups, respectively, completed the 9-month angiographic follow-up. In the DCB group, lesions with RWS_max ≥13% had higher in-segment LLL (0.24±0.53 mm vs 0.05±0.16 mm; p=0.0009), greater binary restenosis (14.9% vs 1.9%; p=0.0040) and more target lesion failure (10.2% vs 1.6%; p=0.022) than those with RWS_max <13%. Among all the lesions with RWS_max ≥13%, no significant difference was observed in in-segment LLL (0.24±0.53 mm vs 0.32±0.48 mm; p=0.49) between the DCB and POBA groups.

Conclusions: Angiographically derived RWS has the potential to predict the angiographic and clinical outcomes of DCB treatment for de novo SVD (PEPCAD China SVD study; ClinicalTrials.gov: NCT03625830).