Catheterization and Cardiovascular Interventions最新文献

Percutaneous coronary intervention (PCI) in patients with high bleeding risk (HBR) presents a therapeutic challenge, requiring careful balancing of ischemic prevention and bleeding avoidance. The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria provide a standardized framework for identifying this population, yet optimal PCI timing, procedural strategies, and antithrombotic regimens remain uncertain. This review synthesizes data from randomized controlled trials, large-scale registries, and meta-analyses involving HBR patients undergoing PCI in settings including stable coronary artery disease, acute coronary syndromes (ACS), ST-elevation myocardial infarction (STEMI), post-resuscitation states, and malignancy-related thrombocytopenia. Special emphasis is placed on procedural approaches (radial vs. femoral access), device selection (drug-coated balloons, polymer-free drug-eluting stents), and dual antiplatelet therapy (DAPT) duration. Evidence supports the safety of abbreviated DAPT regimens (1–3 months) when combined with bleeding-sparing techniques and devices, with the greatest benefit observed in patients with a high ischemic burden (e.g., GRACE score > 140). Early invasive management in ACS has been associated with reduced ischemic endpoints and shorter hospital stays without a significant rise in major bleeding. Conversely, delayed PCI is advisable in the presence of active bleeding, recent thrombolysis, or severe coagulopathy. Persistent limitations include underrepresentation of ARC-HBR patients in trials and lack of standardized, bleeding risk–tailored timing protocols. PCI in HBR patients can be performed safely and effectively when guided by individualized, evidence-based strategies for procedural timing and antithrombotic therapy. Future directions include integrating biomarker-driven DAPT modulation and artificial intelligence-based decision frameworks to optimize outcomes in this high-risk group.

Background

Autologous transfusion of filtered, unwashed blood is a technique to mitigate the effects of blood loss during mechanical thrombectomy, but the degree of hemolysis resulting from this approach and guidance for blood return in this setting is not well understood.

Aims

To assess hemolysis in aspirated and filtered porcine blood using a commercially available syringe-based aspiration thrombectomy blood return device.

Methods

A large-bore, syringe-based aspiration thrombectomy blood return device was tested to assess extent of hemolysis in blood from a porcine model, following the manufacturer's instructions for use (IFU). The aspiration sequence consisted of three stages: blood was aspirated via the inferior vena cava (IVC) from a single animal using a 60-cc syringe through a 24 F catheter (stage 1), filtered through a blood return filter (stage 2), and processed through a transfusion filter (stage 3). Blood was sampled from each stage using a new 3-cc syringe and tested for hemolysis. This was repeated for five separate sequences using the same 60-cc syringe for a total of 15 samples. Plasma free hemoglobin (PFH) was measured as a hemolysis marker. Systemic samples were taken throughout to establish a control PFH value. Samples were compared to control and evaluated against the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Registry threshold of 20 mg/dL PFH for hemolysis.

Results

Using the blood return device, PFH levels were elevated relative to control (6.0 ± 1.8 mg/dL) in all samples, and 33.3% (5/15) of samples exceeded the 20 mg/dL INTERMACS threshold. A significant increase in mean PFH occurred across sequences (p < 0.001), while there was a statistically nonsignificant increase in mean PFH (p = 0.059) across stages.

Conclusions

Porcine blood processed through a syringe-based aspiration thrombectomy blood return device exhibited threshold-exceeding hemolysis, which increased across sequences and remained post-filtration. This study highlights the need to further assess hemolysis when returning aspirated blood to patients during thrombectomy.

Background

Injection and aspiration efficacy via microcatheter are important in complex percutaneous coronary intervention (PCI).

Aims

The aim of this study was to compare the injection and aspiration performance of different microcatheters under identical conditions.

Methods

In the injection bench test, injection volumes and times for each microcatheter were measured three times using an auto-injector. In the aspiration bench test, each microcatheter was connected to a two-way stopcock and an aspiration syringe. Times required to aspirate 5 mL (T1) and 10 mL (T2) of blood-mimicking fluid were measured. For the injection bench test, flow rates and resistance ratios were calculated, for the aspiration bench test, resistance ratios were calculated. The resistance ratio of the Finecross GT 130 cm was set as 1.0 (reference).

Results

The fastest flow rate (0.66 mL/s) and lowest resistance ratio (0.74) in the injection test were observed with the Zizai 130 cm. Conversely, dual-lumen catheters exhibited the slowest flow rates (Sasuke and Crusade Type R: 0.14 mL/s, 0.19 mL/s) and highest resistance ratios (Sasuke and Crusade Type R: 3.43, 2.53). In the aspiration bench test, the Zizai 130 cm exhibited the shortest aspiration times (T1, 73.0 s, T2, 140.7 s) and lowest resistance ratio (average R1, R2: 0.74), whereas the Corsair Pro 135 cm exhibited the longest aspiration times (T1, 174 s, T2, 330.3 s) and highest resistance ratios (R1, 1.78, R2, 1.72; average, 1.75).

Conclusion

To our knowledge, this is the first comparison of injection efficacy and aspiration resistance among various microcatheters for PCI, providing practical guidance for microcatheter selection in complex PCI.

Background

The management of very low-gradient (LG) severe aortic stenosis (AS) remains challenging. Moreover, limited evidence exists regarding the outcomes of patients with very LG severe AS following transcatheter aortic valve implantation (TAVI).

Aims

We aimed to elucidate the prognosis of patients with very LG severe AS after TAVI and the influence of flow status.

Methods

Data were retrospectively collected from the OCEAN-TAVI multicenter registry in Japan, including patients with severe AS who underwent TAVI.

Results

In total, 7103 patients were classified into three groups based on their baseline mean pressure gradient (MPG): very LG (MPG ≤ 20 mmHg), LG (20 < MPG < 40 mmHg), and high-gradient (HG) (MPG ≥ 40 mmHg). The primary endpoint was a composite of all-cause mortality and hospitalization for heart failure. During a median follow-up period of 741 days, the composite endpoint was reached in 2081 patients. Patients with very LG severe AS had a higher prevalence of comorbidities. Kaplan–Meier analysis showed that very LG severe AS was associated with significantly lower event-free survival compared to that with LG and HG severe AS. Multivariable Cox regression analysis identified very LG severe AS as an independent poor prognostic indicator, regardless of the flow state. Moreover, within the very LG severe AS group, a low body mass index and myocardial infarction history were associated with worse outcomes.

Conclusion

This study indicates that patients with very LG severe AS have worse prognoses compared to those with LG or HG severe AS following TAVI, regardless of the flow state.