Catheterization and Cardiovascular Interventions最新文献

Backgrounds

Stroke remains a serious complication of transcatheter aortic valve implantation (TAVI). The Sentinel cerebral embolic protection (CEP) system is designed to mitigate this risk by capturing embolic debris, but its clinical benefit remains uncertain.

Aims

This meta-analysis evaluated the impact of Sentinel CEP on stroke and related outcomes in TAVI.

Methods

PubMed, Embase, and Cochrane were searched for randomized controlled trials (RCTs) and propensity score-matched (PSM) studies comparing TAVI with and without Sentinel CEP. The outcomes were periprocedural ischemic stroke, total stroke, disabling stroke, 30-day mortality, in-hospital mortality, composite death or stroke, acute kidney injury (AKI), and major vascular complications. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model.

Results

Eight studies (five RCTs, three PSM studies) encompassing 33,111 patients were analyzed, with 50.1% receiving Sentinel. In pooled analysis, Sentinel CEP significantly reduced 30-day mortality (RR 0.75, 95% CI 0.58–0.97; p = 0.03) and AKI (RR 0.90, 95% CI 0.82–0.98; p = 0.01). No significant effect was observed for periprocedural ischemic stroke (RR 0.92, CI 0.79–1.07; p = 0.28), total stroke (RR 0.79, CI 0.59–1.05; p = 0.10), in-hospital mortality (RR 0.86, CI 0.57–1.31; p = 0.47), composite death or stroke, or major vascular complications. RCT-only analyses confirmed no significant effect on any outcome.

Conclusions

Sentinel CEP was associated with lower 30-day mortality and AKI in pooled cohorts, but did not reduce stroke. The absence of benefit in RCTs underscores the need for further studies in high-risk TAVI populations.

Background

In the EASY-PREDICT Study, patients were randomized to angiography-guidance or post-percutaneous coronary intervention (PCI) physiology-guidance. Discordance between resting and hyperemic physiology post-PCI might have a different relationship with clinical outcomes.

Aims

The EASY-PREDICT study showed that routine post-PCI physiology assessment was not associated with improved outcomes compared to angiography-guidance only. We aimed to assess whether resting and hyperemic post-PCI physiology had a different clinical impact.

Methods

All-comer patients referred for diagnostic angiography and possible PCI were recruited in a high-volume university hospital and randomized after uncomplicated PCI to angiography-only or target vessel physiology. We studied the concordance and discordance between resting (dPR) and hyperemic (FFR) physiologic parameters post-PCI using ischemic thresholds (dPR ≤ 0.89 and FFR ≤ 0.80) and clinical outcomes up to 18 months post-PCI.

Results

A total of 221 patients (325 lesions) with successful PCI were randomized to either group, 219 of which were included in the per protocol analysis. In the physiology group, 132 lesions with available post-PCI physiology were included and 109 (82.6%) had final concordant physiology results post-PCI. Discordance was observed in 15.15% of lesions, 2.3% FFR ischemic (dPR-|FFR+) and 12.9% dPR ischemic (dPR+|FFR-) respectively. At 18 months clinical follow-up, Target Vessel Failure (TVF) was 12.3% in the concordant sub-group whereas TVF was 40.0% in the discordant subgroup.

Conclusions

After PCI, physiology discordance between dPR and FFR occurred in ~15% of the cases. Patients with discordant physiology results post-PCI appeared to have higher TVF rates compared to concordant physiology sub-groups.

Background

A clinically applicable tool incorporating comprehensive risk factors to evaluate long-term hard endpoints post-percutaneous coronary intervention (PCI) is currently lacking.

Aims

This study aims to develop a risk score from a large contemporary cohort to assess and stratify long-term risk of major adverse cardiac and cerebrovascular events (MACCEs) post-PCI, enabling proactive management and monitoring in high-risk patients.

Methods

The study prospectively enrolled 28,683 consecutive patients undergoing PCI from 2017 to 2018, assigning the first 70% for score derivation and the remaining 30% for validation. The primary endpoint was 3-year MACCEs, including cardiovascular death, myocardial infarction, and stroke. A LASSO-Cox model identified 10 independent predictors, from which a weighted integer scoring system was developed.

Results

Within 3 years post-PCI, 1013 MACCEs (3.5%) were observed. A risk score incorporating three demographic factors (age, severe coronary artery disease history, hypertension duration), two clinical characteristics (left ventricular ejection fraction, clinical presentation), two angiographic features (affected vessels, calcification severity), and three laboratory results (glycated hemoglobin, N-terminal pro-B-type natriuretic peptide, estimated glomerular filtration rate) demonstrated strong predictive performance (c-index 0.764, AUC 0.831, goodness-of-fit p = 0.34). Patients were stratified into low (score 0–4, risk ≤ 2%), moderate (score 5–8, 2% < risk ≤ 5%), and high risk (score ≥ 9, risk > 5%), with corresponding 3-year MACCE incidences of 1.6%, 4.0%, and 10.1%.

Conclusions

A contemporary simple risk score integrating 10 readily available variables accurately predicts long-term hard outcomes in PCI patients, facilitating personalized risk assessment and informed treatment decisions.

Transcatheter aortic valve implantation (TAVI) is the gold standard therapy for high-risk patients with severe, symptomatic aortic valve stenosis, particularly in patients with impaired left ventricular systolic function or those with previous cardiac surgery. However, TAVI with non-dedicated devices in patients with native severe AR is challenging. Patients frequently have a bicuspid aortic valve, large dimensions of the aortic annulus, and a low aortic valve calcification load. These features increase the risk of significant paravalvular regurgitation and prosthesis migration. We present two cases of severe aortic valve regurgitation due to cusp migration of previously implanted surgical aortic valves and flail cusps. After discussion with the Heart team based on the patient's clinical profile and the high risk of surgical repair, self-expandable-TAVI was performed using the Navitor trans-catheter heart valve in the first case and the Accurate Neo 2 in the second case. During TAVI and before valve release, acute LM coronary artery occlusion was noted. Successful further TAVI implantation and PCI was a lifesaving strategy. The 3-month follow-up was uneventful. Transcatheter valve implantation expands its indications for more complex anatomy, off-label use in severe aortic regurgitation and patient's comorbidity. In the case of flail cusp during TAVI, LM coronary artery obstruction must be considered an expected complication, and LM protection maneuvers should be considered in difficult anatomies.

Background

Increased vessel tortuosity may hinder the success of transradial procedures. Longer thin-walled, hydrophilic sheaths ≥ 75 cm can be placed into the ascending aorta and have the potential to avoid femoral access crossover.

Methods

We studied consecutive cases of patients undergoing left heart catheterization (LHC) where a 75 cm long thin-walled, hydrophilic sheath was used from 1/1/22 to 9/30/24. Patient and procedural characteristics were collected. Procedural data included indication, contrast load, radiation dose, procedural time, procedural complications, and the need to convert to femoral access.

Results

Our study sample included 71 patients (mean age 69, 45% male). Comorbidities included hypertension (82%), hyperlipidemia (76%), and congestive heart failure (30%). Previous coronary artery disease was present in 31% of patients, and 20% of patients had undergone previous percutaneous coronary intervention (PCI). Indications for LHC included symptoms of stable ischemic heart disease (21%), abnormal non-invasive ischemic testing (52%), acute coronary syndrome (18%), and pre-operative evaluation for surgery (8%). The reason to switch to the long thin-walled, hydrophilic sheath was inability to engage the coronaries due to subclavian/brachiocephalic artery tortuosity (86%) or radial artery spasm (14%). After switching to the long thin-walled, hydrophilic sheath, 62/71 (87%) cases successfully engaged the coronaries without converting to femoral access. The mean procedure time was 36 min for diagnostic LHC cases (n = 46) and 72 min for PCI cases (n = 25). No procedural complications occurred.

Conclusion

This case series suggests that use of the long thin-walled, hydrophilic radial sheaths can avoid femoral access crossover in selected cases.

Background

The volume of percutaneous coronary intervention (PCI) at ambulatory surgical centers (ASC) is expected to increase.

Methods

We surveyed US interventional cardiologists with a 58-question, anonymous online survey to evaluate their knowledge of and perspectives on ASC PCI.

Results

A total of 114 interventional cardiologists (9 fellows) responded. Participants were most commonly between 45 and 54 years old (33%). Most participants identified as male (95%), white (58%), non-Hispanic (95%), and with an academic affiliation (61%); 13 participants (11%) were PCI operators at an ASC. Most participants (59%) were in support of ASC PCI, 63% were very confident in their ability to decide if a patient is well-suited for ASC PCI, and 43% were not familiar with national and state-level laws/regulations of ASC PCI. Perceived benefits of ASC PCI included positive patient experience (69%), greater efficiency (79%), and lower costs for patients (50%) and institutions (53%). Participants reported a high level of concern about private equity involvement in ASC PCI (58%), occurrence of adverse events away from the hospital (47%), lower quality of care (39%), inappropriate patient selection (40%), inadequate regulatory standards (35%), and institutional pressures (47%). Supporters of ASC PCI reported a better self-assessed knowledge of it and perceived more benefits with fewer concerns.

Conclusions

Most survey participants expressed support for ASC PCI, citing benefits such as improved patient experience, greater efficiency, and reduced costs. However, participants expressed concern for private equity involvement and the risk of adverse events occurring away from the hospital setting.