Cardiovascular Intervention and Therapeutics最新文献

Percutaneous coronary intervention (PCI) has evolved significantly with technological advances, allowing for higher procedural success rates and improved patient outcomes. However, the growing complexity of cases involving severely calcified lesions, tortuous vessels, and chronic total occlusions has increased procedural challenges. In such scenarios, the guide extension catheter (GEC, or guiding catheter extension) plays a critical role by enhancing device passage and providing additional backup support, making it indispensable in modern PCI. Various types of GECs offer distinct characteristics that influence their selection based on lesion type, device compatibility, and procedural requirements. The GEC is used for multiple purposes, including backup support, deep engagement, imaging device insertion, stent protection, thrombectomy, and foreign body removal. Despite its utility, GEC use is associated with potential complications, including vessel injury, thrombosis, air embolism, and hemodynamic instability. Careful technique and proper selection are critical to minimizing risks. Overall, the GEC is an essential tool in complex PCI procedures, offering significant advantages in improving procedural success.

The objective was to assess the effect of preprocedural arterial stiffness on long-term blood pressure (BP) reduction following renal sympathetic denervation (RDN). In this prospective, single-arm pilot study, patients with systolic office BP ≥ 140 mmHg and mean 24-h systolic ambulatory blood pressure (ABP) ≥ 130 mmHg despite being on a minimum of 3 antihypertensive drugs underwent radiofrequency RDN. The primary efficacy outcome was the temporal evolution of mean 24-h systolic ABP throughout 5 years post RDN. Effect modification of the primary outcome was studied for baseline magnetic resonance pulse wave velocity (MR-PWV), MR aortic distensibility (MR-AoD), ultrasound carotid femoral pulse wave velocity (CF-PWV) and clinical parameters. Analyses were performed using linear mixed-effects models to account for repeated BP measurements. A total of 30 patients were enrolled, 50% were female, mean age was 62.5 ± 10.7 years. Baseline mean 24-h ABP was 146.7/80.8 ± 13.7/12.0 despite a median of 5.0 ± 2.4 defined daily doses (DDD) of antihypertensive drugs. Baseline median MR-PWV was 6.8 [25th-75th percentile: 6.1-11.0] m/s, median MR-AoD was 1.4 × 10^-3 mmHg^-1 [25th-75th percentile: 0.9-1.8] and mean CF-PWV was 8.5 ± 2.1 m/s. Throughout 5 years following RDN, the change in mean 24-h systolic ABP was - 11.5 [95% CI - 17.0, - 5.9] mmHg (p = <0.001). MR-PWV emerged as the sole significant independent effect modifier of the change in mean 24-h systolic ABP throughout 5 years following RDN (+ 1.8 [95% CI 0.7, 2.8] mmHg per m/s per 5 years; p = 0.001). A higher level of preprocedural arterial stiffness, as measured using MR-PWV, was associated with a smaller BP lowering effect 5 years post-RDN.

Background: Stent thrombosis (ST) remains a serious complication after percutaneous coronary intervention, leading to acute myocardial infarction (AMI) in over 70% of cases. And it has been reported that the prognosis for ST is worse than for de-novo AMI. While the use of second-generation drug-eluting stents (G2-DES) has reduced ST incidence, ST remains a concern, and its incidence and prognosis in the G2-DES era have not been well studied.

Aims: To evaluate the incidence and prognosis of AMI due to ST in the G2-DES era compared with de-novo AMI.

Methods: From January 2013 to November 2022, we analyzed 6273 consecutive AMI patients from the Mie ACS Registry, including 78 ST and 6195 de-novo type 1 AMI (de-novo AMI) after exclusion of the other type of AMI. The primary endpoint was all-cause mortality, and target lesion revascularization (TLR) was the secondary endpoint.

Results: ST occurred in 1.2% (n = 78) of AMI, predominantly as very late ST (79.5%, n = 62). Thirty-day mortality was marginally lower in ST (2.6%) than de-novo AMI (6.7%, p = 0.16), with ST not being an independent predictor of 30-day mortality (HR 0.39, p = 0.19). However, ST patients had a higher 2-year TLR rate (21.4% vs. 11.9%, p = 0.02), confirmed as an independent predictor (HR 2.03, p = 0.01). Compared to previous clinical data, the reduced incidence of ST and the improved prognosis was observed.

Conclusions: While ST-related AMI prognosis has improved, with mortality comparable to de-novo AMI, the higher TLR rate in ST patients persists, and an optimized revascularization strategy is still needed.

Transradial access (TRA) is increasingly used in endovascular therapy (EVT) due to its favorable safety profile. However, its procedural efficiency compared to transfemoral access (TFA) remains under investigation. We retrospectively analyzed 132 consecutive EVT procedures for iliac artery lesions performed between April 2020 and March 2024. After excluding 11 dialysis-dependent and 3 urgent cases, 118 elective cases were included (TRA: 65; TFA: 53). Four procedural time intervals were assessed: (1) room entry to local anesthesia, (2) local anesthesia to sheath removal, (3) sheath removal to room exit, and (4) total room time. In the primary analysis, 45 matched pairs were created using propensity score matching based on five covariates: chronic total occlusion (CTO), bilateral calcification, TASC C/D lesions, stent occlusion, and covered stent use. A secondary analysis was performed in 19 matched CTO cases using three covariates. In the matched cohort, TRA demonstrated significantly shorter total room time compared to TFA (75 [60-115] vs. 105 [74-163] min, p = 0.003). Sheath removal to room exit time was also consistently shorter in the TRA group (7 [5-10] vs. 14 [12-17] min, p < 0.001). Similar findings were observed in the CTO-matched subgroup (93 [77-163] vs. 160 [110-220] min, p = 0.012). TRA significantly reduces procedural time compared to TFA in iliac artery EVT. The consistent reduction across all phases, including the post-procedural period, highlights TRA as an efficient and practical access strategy in peripheral vascular interventions.

Patients with severe aortic stenosis (AS) and small aortic annulus pose diagnostic and therapeutic challenges. To investigate the frequency of discordant grading of severe AS in patients with a small aortic annulus and to evaluate the outcomes after transcatheter aortic valve implantation (TAVI). Patients with severe AS, an aortic annulus diameter of < 21 mm on echocardiography, a mean annulus diameter of < 23 mm, and an area ≤ 4.3 cm² on cardiac computed tomography, who underwent TAVI, were retrospectively analyzed. The frequency of low-gradient severe AS was assessed. Patients were followed up for the occurrence of the composite endpoint of all-cause mortality, rehospitalizations for heart failure, non-fatal myocardial infarction, and non-fatal stroke. Among 230 patients with severe AS and a small aortic annulus (age 82 ± 6 years, 85% female), 52 (23%) had low gradient, while 120 (52%) exhibited normal flow-high gradient and 58 (25%) had low flow-high gradient. During a median follow-up of 2 years, the composite endpoint occurred in 29% of the total cohort. Patients with low-gradient severe AS experienced the worse outcome (HR = 2.46; 95% CI: 1.13-5.33; p = 0.023). Almost one-fourth of patients with severe AS and small annulus have low gradient AS. These patients experienced worse outcomes, likely reflecting advanced myocardial remodeling due to delayed referral and the diagnostic challenges posed by small annular dimensions.

Paravalvular leakage (PVL) is one of the complications of transcatheter aortic valve implantation (TAVI), and its occurrence has been reported to affect long-term prognosis. We investigated whether the aortic valve calcification measured on preoperative CT is useful in predicting PVL after TAVI using the fifth-generation self-expanding valves. We analyzed 88 consecutive patients who underwent TAVI with the fifth-generation self-expanding valve from March 2023 to March 2024. Significant PVL was defined as PVL of mild or greater based on postoperative echocardiography results. We performed logistic regression analysis to evaluate whether patient background, and aortic valve calcification volume (AVCa-Vol), maximum CT value (AVCa-Max), mean CT value (AVCa-Ave), Agatston score (AV-Aga) and left ventricular outflow tract (LVOT) calcification volume measured by ECG-gated non-contrast CT were significant predictors. Mild or greater PVL was observed in 26 patients (29.5%). AVCa-Vol (1948.9 mm³ vs 1427.9 mm³, P < 0.01), AV-Aga (2412.8 vs 1743.7, P < 0.01), and LVOT calcification volume (109.8 vs 28.6, P < 0.01) were significantly higher in the PVL group. Univariate logistic regression analysis identified AVCa-Vol and AV-Aga as significant predictors, and they remained independent predictors after adjustment for age and sex (AVCa-Vol: odds ratio (OR) 2.91 (95% Confidence Interval (CI) 1.36-6.20), P < 0.01, AV-Aga: OR 2.24 (95% CI 1.25-4.03), P < 0.01). Receiver operating characteristic analysis showed optimal cutoff values for AVCa-Vol at 1665.13 mm³ (Area under the curve (AUC) = 0.73) and AV-Aga at 1908.59 (AUC = 0.72). AVCa-Vol and AV-Aga were identified as significant predictors of PVL occurrence after TAVI using the fifth-generation self-expandable valve.

Coronary calcium significantly increases complexity in chronic total occlusion percutaneous coronary intervention (CTO-PCI). Coronary computed tomography angiography (CCTA) enables precise CTO assessment. However, no prior study has proposed a CCTA-based morphological classification of calcium patterns and assessed its procedural impact. To propose and validate a novel seven-point CCTA-derived classification of calcium morphology, ranging from "spot" (≤ 10% cross-sectional area, CSA) to "full moon" (100% CSA). We retrospectively included 167 patients undergoing CTO-PCI with prior CCTA. The primary endpoint was procedural failure. Secondary endpoints included coronary perforations, procedural and fluoroscopic time, and number of guidewires and balloons. A progressive, stepwise increase in procedural failure (from 6.2% in spot to 26.7% in full moon lesions; p = 0.007) and coronary perforation rates (from 3.1% in spot to 13.3% in full moon lesions; p = 0.03) was observed across the seven identified calcium patterns. In multivariable analysis, calcium severity was independently associated with procedural failure (OR 1.2 per step; 95% CI 1.01-1.52; p = 0.04). Increasing calcium severity was also independently associated with procedural time (B =  + 4.7 min/step; p = 0.03), fluoroscopic time (B =  + 2.2 min/step; p = 0.04), number of guidewires (B =  + 0.30/step; p = 0.03) and balloons (B =  + 0.31/step; p = 0.005). Full-scale progression from "spot" to "full moon" corresponded to + 33 min increase in procedural and + 14 min in fluoroscopic time. A novel CCTA-based calcium classification showed a strong, independent association with procedural failure and complexity. Its reproducibility and integration potential make it a valuable tool for enhancing planning and safety in CTO-PCI.