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Mitral annular calcification (MAC) is a particularly challenging pathological condition that can prove difficult to address. It consists of calcium depositions in the mitral valve ring, secondary to chronic inflammation and complex molecular pathogenetic mechanisms of injury and cellular response. MAC has been associated with worse survival in patients with valvulopathies compared to individuals without MAC, as well as with an enhanced risk for cardiovascular events and all-cause mortality. MAC also complicates interventions in the aortic and mitral valves, with several reports showcasing suboptimal results after transcatheter aortic valve implantation (TAVI). For mitral interventions, it is currently being evaluated whether transcatheter edge-to-edge repair (TEER) or transcatheter mitral valve replacement (TVMR) would best suit these patients, in the presence of severe mitral regurgitation (MR), with both procedures showing benefit in early study results. However, the limitations of each procedure for certain phenotypes and anatomies necessitate more extensive research, aiming to identify the most suitable candidates for each intervention. The purpose of this review is, thus, to present a summary of the factors that affect MAC, explore available diagnostic and therapeutic approaches, and provide a framework to anticipate and overcome the potential challenges that may arise during MAC-associated mitral valve disease treatment.

Background: The reverse wire technique (RWT), with a guidewire shaped in a swan-neck configuration, is used to address challenging side branch (SB) wiring in complex coronary bifurcation lesions (CBLs). However, its success is not guaranteed.

Aims: This study aimed to identify factors associated with RWT failure and to assess the feasibility of the balloon blocking technique (BBT) in the distal main vessel (MV) as an alternative.

Methods: Thirty-two consecutive complex CBLs with difficult SB wiring were retrospectively analysed. Patients were divided into two groups: those with successful RWT (RWT-S, n=17) and those who underwent BBT, either after RWT failure or as a primary approach (RWT-F/BBT, n=15). Risk factors for RWT failure were examined.

Results: The success rate of SB wiring with BBT was 80%. RTW-F/BBT was associated with less involvement of the left anterior descending artery (40% vs 71%), smaller-diameter MV stent implantation (2.8±0.5 mm vs 3.2±0.5 mm), wider bifurcation angle (BA) between the distal MV and middle SB (BA-β: 51.6±29.8° vs 36.4±18.6°), and smaller minimum lumen diameter (MLD) in the distal MV (1.72±0.68 mm vs 2.14±0.58 mm). SB calcification (33% vs 0%; p=0.01), severe bending in the distal MV (53% vs 12%; p=0.02) and severe bending in the SB (73% vs 24%; p=0.01) were more common in the RTW-F/BBT group. A receiver operating characteristic curve analysis showed that a combination of preprocedural BA-β >34.1°, distal MV MLD <1.77 mm, and SB calcification had good discrimination ability for predicting RWT failure (area under the curve 0.85, 95% confidence interval: 0.71-0.98).

Conclusions: RWT is challenging in complex CBLs with calcification, significant tortuosity, and small vessels. BBT offers a viable alternative in these cases.

Background: Transcatheter aortic valve implantation (TAVI) is a minimally invasive option for severe aortic stenosis (AS). The Crea Aortic Valve (CAV) is a new self-expanding transcatheter aortic valve implant that has been successfully tested in preclinical studies.

Aims: We aimed to assess the technical success, device performance, and early safety of the CAV System in a first-in-human study for the device in patients with severe AS.

Methods: We prospectively evaluated the CAV using the Valve Academic Research Consortium (VARC)-3 criteria in three high-risk patients with severe AS. A computed tomography angiography and transthoracic echocardiographic (TTE) assessment were carried out, which was followed by TAVI according to standard protocol. TTE was performed before and after the procedure, before discharge, and at the 1- and 6-month clinical follow-ups to monitor the aortic valve area, the maximum velocity (Vmax), the mean (MG) and peak pressure gradients, and paravalvular leak (PVL).

Results: The CAV was successfully implanted, using the cusp-overlap technique for patient 1 and the coplanar view for patients 2 and 3, with good usability of the delivery system for optimal positioning, reduction of the Vmax to <2 m/s and MG to <10 mmHg, and trivial PVL. An atrioventricular block necessitating a permanent pacemaker occurred in one patient. There was no incidence of stroke, heart failure, or renal failure at 6 months of follow-up.

Conclusions: The CAV was implanted with success, and the system performed as intended as per VARC-3 criteria. The device should be evaluated in a larger clinical study for further efficacy and safety data.

Background: Despite the significant advancements in interventional cardiology, there is a need for new, metal-free bioresorbable stent systems that preserve the vasomotor function of the treated vessel and decrease the risk of restenosis associated with metal stents and the risk of thrombosis associated with first-generation bioresorbable scaffolds.

Aims: The aim of this study was to assess the safety and efficacy of the MeRes100 bioresorbable scaffold in complex de novo and in-stent restenotic coronary lesions.

Methods: We conducted a retrospective single-centre study that included 86 patients with coronary artery disease who had been implanted with a next-generation MeRes100 sirolimus-eluting bioresorbable vascular scaffold system and followed up to 12 months after the procedure.

Results: The scaffold was successfully delivered to the target lesion with satisfactory stent expansion in 98.84% of cases. Only one patient died, and the in-hospital mortality rate was as low as 1.16% (cardiac death). No cases of major adverse cardiac events, cardiac death, myocardial infarction, ischaemia-driven target lesion revascularisation, or scaffold thrombosis were reported during the follow-up.

Conclusions: Our preliminary data suggest that the thin-strut sirolimus-eluting bioresorbable scaffold appears to be a clinically acceptable, safe, reliable and reproducible strategy to treat both de novo and in-stent restenotic coronary artery lesions. Long-term follow-up of a larger patient population is warranted.

Background: Long stents reduce the risk for in-stent restenosis associated with percutaneous coronary interventions in long, tapered coronary lesions.

Aims: The Morph India study investigated the long-term safety and clinical performance of the BioMime Morph sirolimus-eluting stent (SES), a tapered stent used for treating long coronary lesions.

Methods: This is a prospective, multicentre, single-arm, real-world, post-marketing surveillance study conducted among patients with long coronary lesions (length >26 mm to ≤56 mm, reference vessel diameter 2.25-3.50 mm) implanted with the BioMime Morph SES. The primary endpoint was freedom from target lesion failure (TLF). The incidence of target vessel failure (TVF) - defined as a composite of cardiac death related to the target vessel, target vessel myocardial infarction (TVMI), and ischaemia-driven target vessel revascularisation (ID-TVR) - was the secondary endpoint. An angiographic follow-up was conducted at 9 months, and subjects were followed up for 3 years.

Results: Out of 448 enrolled patients, 420 patients completed the 3-year follow-up. The rate of freedom from TLF was 99.31% at 12 months and 98.80% at 3 years. In 3 years, there were 4 events each of TVMI, TVR (including ID-TVR) and ischaemia-driven target lesion revascularisation (all 0.95%). Quantitative coronary angiography analysis at a mean of 9.2 months revealed in-segment late lumen loss (LLL) of 0.29±0.23 mm and in-device LLL of 0.35±0.11 mm. The in-device minimal lumen diameter improved from 0.63±0.42 mm at preprocedure to 2.13±0.37 mm (p<0.001) at 9.2 months.

Conclusions: The 3-year safety and clinical outcomes of BioMime Morph SES for treating long coronary lesions were satisfactory. Further long-term comparative studies are necessary to validate these results.