Catheterization and Cardiovascular Interventions最新文献

Background: Frailty is associated with poor health outcomes in elderly population. However, its effect on midterm outcomes in elderly patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unknown.

Aims: This study aimed to evaluate the association between frailty, as classified by the Clinical Frailty Scale (CFS), and midterm adverse outcomes in elderly STEMI patients after primary PCI.

Methods: In this prospective, observational, multicenter cohort study, frailty status of 426 STEMI patients aged ≥60 years undergoing primary PCI was determined using the nine-point CFS 2 weeks before the occurrence of STEMI. Patients scoring at least four points on the CFS were considered frail. The primary outcome was a composite of cardiovascular death or readmission. Secondary outcomes included cardiovascular death, cardiovascular readmission, heart failure-related death or readmission, and myocardial reinfarction. Follow-up data were collected through medical record reviews and/or telephone interviews.

Results: Of 426 elderly patients, 116 were frail. The median follow-up period was 15 months (interquartile range 5-19 months). Primary outcome events occurred in 87 (75.0%) frail and 75 (24.2%) nonfrail patients. The adjusted hazard ratio was 3.278 after model selection using the Bayesian Model Averaging approach (95% confidence interval 2.372-4.531). Multivariate Cox proportional hazard survival analysis showed that frailty was significantly associated with a higher prevalence of all secondary outcome events after adjusting for TIMI, PAMI, and CADILLAC risk scores.

Conclusions: Frailty, as defined by the CFS, was independently associated with midterm adverse outcomes in elderly patients undergoing primary PCI for STEMI.

Background: Primary Percutaneous Coronary Intervention (PPCI) is the preferred treatment for ST-Segment Elevation Myocardial Infarction (STEMI) patients in both PCI centers and those transferred from non-PCI centers, provided it can be performed in a timely manner. The challenges in transferring patients from non-PCI centers include not only potential delays beyond 120 min but also the risk of overwhelming the resources at the PPCI hospital. We report a novel strategy implemented within the Serdang STEMI Network involving immediate transfer of patients back to the originating hospitals within 2 h post procedure.

Aims: This study aims to evaluate the clinical outcomes and practicality of immediately transferring stable STEMI patients back to their originating hospitals within 2 h postprimary PCI, within the Serdang STEMI Network. Specifically, it seeks to assess the in-hospital mortality rate and 30-day major adverse cardiac events (MACE) among these patients to determine the safety and feasibility of this novel early transfer strategy.

Methods: This retrospective cohort study involved 1374 STEMI patients participating in the Serdang STEMI network from May 2015 to December 2022, including 570 patients admitted directly to Hospital Sultan Idris Shah, Serdang (HSIS) and 804 transferred from non-PCI centers.

Results: Of the 804 transferred patients, 415 (52%) were transferred back to referring hospitals within 2 h of PPCI. These patients met specific criteria including hemodynamic stability, absence of procedural complications, and fit for transfer at the discretion of the attending cardiologist. The primary outcomes measured were in-hospital and 30-day mortality rates, as well as major adverse cardiac events (MACE). MACE was defined as a composite of death, myocardial infarction, stroke, or repeat revascularization. In the early return group, there was no in-hospital or 30-day mortality. No patient required repeat revascularization or readmission within 30 days.

Conclusions: Our results indicate that carefully selected patients can be safely returned to their originating hospitals very early following successful PPCI. These findings have important implications for large regional STEMI networks worldwide, particularly in areas where PPCI centers may have limited resources to handle high STEMI volumes.

Background: Pulmonary embolism is associated with a significant burden of morbidity, mortality, and health care costs. Catheter-directed thrombolysis has emerged as a promising option for patients with intermediate-risk pulmonary embolism which aims to improve outcomes over standard anticoagulation.

Methods: We constructed a decision-analytic model comparing the cost-effectiveness of catheter-directed thrombolysis to anticoagulation alone for the management of intermediate-risk pulmonary embolism. Cost-effectiveness was determined by calculating deaths averted and incremental cost-effectiveness ratios (ICER). Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. The main outcome was ICER (US dollars/deaths averted).

Results: In the base case analysis, derived using systemic lysis data, the cost associated with catheter-directed thrombolysis was estimated at $22,353 with a probability of survival at 1 month of 0.984. For the anticoagulation alone strategy, the cost was $25,060, and the probability of survival at 1 month was 0.958. Overall, catheter-directed thrombolysis resulted in savings of $104,089 per death averted (ICER,-$104,089 per death averted). Sensitivity analysis revealed that catheter-directed thrombolysis would no longer be cost-effective when its associated mortality is greater than 0.042. In the probabilistic analysis, at a willingness-to-pay of $100,000, catheter-directed thrombolysis had a 63% chance of being cost-effective, and in cost-effectiveness acceptability curves, it was cost-effective in 63%-78% of simulations for a willingness to pay ranging from $0 to $100,000.

Conclusions: If the assumptions made in our model are shown to be accurate then CDT would be cost-effective and may lead to considerable cost savings if used where clinically appropriate.

Background: Percutaneous coronary intervention (PCI) of left main (LM) chronic total occlusions (CTO) has received limited study.

Methods: We compared the clinical and procedural characteristics and outcomes of patients who underwent LM versus non-LM CTO PCI at 41 US and non-US centers between 2012 and 2024.

Results: During the study period 85 of 15,254 CTO PCIs (0.6%) performed in 14,969 patients were LM CTO PCIs. LM CTO PCI patients were older, had higher rates of dyslipidemia and heart failure and most (88.8%) had prior coronary artery bypass graft surgery (CABG). They were more likely to have moderately or severely calcified lesions (80.7% vs. 45.7%, p < 0.001) and had higher J-CTO (2.76 ± 1.17 vs. 2.37 ± 1.26, p = 0.008), PROGRESS-CTO MACE (3.56 vs. 2.57, p < 0.001), Mortality (2.45 vs. 1.68, p < 0.001), Pericardiocentesis (2.74 vs. 1.87, p < 0.001), Acute MI (1.72 vs. 0.89, p < 0.001) and Perforation (3.21 vs. 2.19, p < 0.001) scores. There was no difference in technical success (80.5% vs. 87.2%, p = 0.086) or major cardiovascular adverse events (MACE) (2.4% vs. 2.0%, p = 0.700). LM CTO PCI patients with and without prior CABG surgery had similar technical success and MACE. The retrograde approach in prior CABG patients was more likely to be performed through saphenous vein grafts.

Conclusions: LM CTO PCI is infrequently performed, is associated with high comorbidity burden and angiographic complexity but can be performed with high success and acceptable complication rates.

Background: Quantitative flow ratio (QFR) analysis is a simple and non-invasive coronary physiological assessment method with evidence for evaluating stable coronary artery disease with correlation to fractional flow reserve (FFR). However, there is no evidence to recommend its use in non-culprit lesions (NCLs) in myocardial infarction (MI).

Methods: We performed a systematic review and meta-analysis using the PRISMA and PROSPERO statements. The study's primary objective was to assess the diagnostic accuracy of QFR in identifying functionally significant NCLs after MI based on invasive FFR and non-hyperemic pressure ratios as references. We obtained values of the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We performed a leave-one-out sensitivity analysis for each study's impact on the overall effect.

Results: We included eight studies, with 713 patients and 920 vessels evaluated with QFR. The overall AUC was 0.941 (I² = 0.559, p < 0.002), with a sensitivity of 87.3%, a specificity of 89.4%, a PPV of 86.6%, and an NPV of 90.1%. Compared to FFR, we found an AUC of 0.957 (I² = 0.331, p < 0.194), a sensitivity of 89.6%, a specificity of 89.8%, a PPV of 88.3%, and an NPV of 91%. The sensitivity analysis showed a similar diagnostic performance in both studies.

Conclusions: QFR is effective in analyzing NCLs with a significant diagnostic yield compared to FFR, with an excellent AUC in MI patients. Performing prospective multicenter studies to characterize this population and reproduce our results is essential.

Background: Studies show mixed results regarding the effect of coronary revascularization on mortality benefit and ventricular tachycardia (VT) recurrence in patients with monomorphic VT without acute coronary syndrome (ACS). This meta-analysis aimed to assess the effect of ischemia testing and/or coronary revascularization on mortality and VT recurrence in a pooled data set.

Methods: Databases including PubMed, Google Scholar, and the Cochrane Library were searched from January 2000 to December 2023 for studies reporting event data on mortality and VT recurrence in patients without ACS who presented with monomorphic VT. Data were pooled and analyzed using random effects meta-analysis.

Results: The pooled sample consisted of a total of five studies, with 1062 patients, of whom 433 underwent ischemia testing and/or coronary revascularization and 629 did not. There was no statistically significant difference in the mortality and VT recurrence in the patients who underwent ischemia testing and/or revascularization versus those who did not (mortality odds ratio [OR]: 0.98; [95% confidence interval (CI): 0.62 to 1.53]; p = 0.92; VT recurrence OR: 1.07; [95% CI: 0.51 to 2.26]; p = 0.86). No publication bias was detected by examination of the funnel plot, Begg-Mazumdar's test (p = 0.80), and Egger's test (p = 0.91).

Conclusion: In conclusion, in patients with sustained monomorphic VT in the absence of ACS, ischemia testing and/or revascularization does not lead to improved mortality or a decrease in the incidence of VT recurrence.

Background: The Hydra CE study revealed 1-year favorable efficacy of TAVR, showing a large effective orifice area (EOA), low gradient, and acceptable complication rates.

Aims: We evaluated the 3-year clinical and hemodynamic outcomes of Hydra self-expanding transcatheter aortic valve (manufactured by Vascular Innovations Co Ltd, Nonthaburi, Thailand; a subsidiary of Sahajanand Medical Technologies Limited, India) in patients with symptomatic severe aortic stenosis at high or extremely high surgical risk.

Methods: The Hydra CE study was a prospective, multicenter, single-arm study. A total of 157 patients were enrolled in the study, out of whom 54 patients from two centers (Lithuania and Poland) had provided consent for long-term follow-up at recruitment, with a planned 5-year follow-up period. The primary endpoint was all-cause mortality, and patients were followed up for up to 3 years, with an assessment of clinical and echocardiographic outcomes.

Results: Among the 54 patients, the average age was 81.0 ± 4.1 years. The mean STS score was 3.2 ± 2.0%. At 3 years, all-cause mortality had occurred in 14.8% of patients, including 3.7% cardiovascular deaths and 1.9% device-related deaths. There was a progressive enhancement in EOA that is, 0.68 ± 0.15 cm² at baseline to 1.97 ± 0.52 cm² at 3 years (p < 0.001) as well as significant improvement in the mean aortic valve gradient that is, 53.4 ± 14.24 mmHg at baseline to 8.6 ± 2.80 mmHg at 3 years (p < 0.001). New permanent pacemaker implantation rates up to 3-year follow-up was 12.9%.

Conclusion: The 3-year results of the Hydra CE study demonstrated consistent improvements in hemodynamics over time. The study also revealed favorable safety and efficacy trends, along with low occurrences of new permanent pacemaker implantations and paravalvular leaks.

Background: Long-term clinical data on biodegradable-polymer (BP) drug-eluting stents (DES) are limited. The objective of this study was to assess the long-term safety and efficacy of the BP-DES SYNERGY compared to XIENCE V, a durable-polymer (DP)-DES.

Methods: We compared patients treated with BP-DES or DP-DES at our center from 2008 to 2020. The primary outcome was major adverse cardiac events (MACE), defined as the composite of all-cause death, Q-wave myocardial infarction (MI), and target vessel revascularization (TVR). Secondary endpoints were all-cause death, Q-wave MI, target lesion revascularization (TLR), and stent thrombosis (ST).

Results: A total of 4255 patients underwent propensity-score matching, and 380 patients from each cohort were matched. There was no significant difference between BP-DES and DP-DES concerning MACE (5-year estimates: 21.6% vs. 26.6%, log-rank p = 0.259). Furthermore, there was no difference in the TLR rate (5-year estimates: 7.3% vs. 8.6%, log-rank p = 0.781). All-cause death (5-year estimates: 13.6% vs. 12.9%, log-rank p = 0.72) and Q-wave MI (5-year estimates: 0.53% vs. 1.7%, log-rank p = 0.427) were also comparable between the two groups. Of note, the rate of very late ST was very low and similar between the groups (5-year estimates: 0.26% vs. 0.64%, log-rank p = 0.698).

Conclusion: BP-DES and DP-DES demonstrate similar safety and efficacy at 5-year follow-up. Both can be used for the effective treatment of coronary artery disease.

Background: Randomized trials of bivalirudin in patients with ST elevation myocardial infarction (STEMI) have yielded heterogeneous results.

Aims: Our aim was to evaluate the efficacy and safety of four antithrombin regimens-unfractionated heparin (UFH), bivalirudin (stopped soon after percutaneous coronary intervention [PCI]), extended bivalirudin (continued for a few hours after PCI), and combined UFH and a Gp2b3a inhibitors (GPI) in patients who present with STEMI.

Methods: A PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized clinical trials (RCTs) of the above antithrombin in patients with STEMI. The primary outcome was net adverse cardiovascular events (NACE). The primary ischemic endpoint was major adverse cardiovascular events (MACE), and the primary safety endpoint was major bleeding, and other endpoints included all-cause mortality and stent thrombosis. The primary analysis compared the effect of these antithrombin regimens in reference to UFH using a mixed treatment comparison meta-analysis.

Results: In the 14 RCTs evaluating 25,415 patients with STEMI, when compared to UFH monotherapy, extended bivalirudin lowered NACE (OR = 0.71 with 95% CI: 0.53-0.96; moderate level of confidence) driven by a significant decrease in major bleeding (OR = 0.42 with 95% CI: 0.26-0.68; high level of confidence) without any significant difference in MACE or all-cause mortality. When compared with UFH monotherapy, UFH+GPI reduced risk of MACE (OR = 0.76 with 95% CI: 0.60-0.97; high level of confidence) but at the expense of an increase in major bleeding (OR = 1.48 with 95% CI: 1.11-1.98; high level of confidence) with no difference in NACE or all-cause mortality. For major bleeding, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, UFH monotherapy ranked #3, and combined UFH and GPI ranked #4. For NACE, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, combined UFH and GPI ranked #3, and UFH monotherapy ranked #4. Cluster plots for MACE and major bleeding demonstrated that extended bivalirudin had the best balance for efficacy and safety.

Conclusions: In patients undergoing PCI for STEMI, extended bivalirudin offers the best balance for primary ischemic (MACE) and safety (major bleeding) outcomes.

Background: Coronary Artery Tree description and Lesion EvaluaTion (CatLet) angiographic scoring system is a newly developed vascular scoring for assessing the degree of coronary artery stenosis and coronary artery variability. Preliminary studies have demonstrated its superiority over the Synergy between percutaneous coronary intervention (PCI) with Taxus and Cardiac Surgery (SYNTAX) score in predicting outcome in patients with acute myocardial infarction (AMI). This study aimed to assess the predictive value of the CatLet score in long-term prognosis after PCI for chronic coronary syndrome (CCS).

Methods: A total of 201 patients, who were diagnosed with chronic coronary syndrome, undergoing coronary DES implantation and calculable Catlet score at the Second Affiliated Hospital of Wannan Medical College in China were consecutively enrolled from January 2020 to June 2021. The primary endpoint was major adverse cardiac events (MACEs), defined as a composite of myocardial infarction, recurrent angina, cardiac death, heart failure and ischemia-driven revascularization, were stratified according to CatLet score tertiles: 0 ≤ CatLet_low ≤ 23(n = 66), CatLet_mid 24-43(n = 68), and CatLet_top ≥ 44(n = 67), respectively.

Results: The CatLet score predicted long-term prognosis with a median follow-up of 3.0 years. Of 201 patients analyzed, the rates of MACEs and cardiac death were 25.37% and 3.98%, respectively. The Kaplan-Meier curves for all endpoints showed increasing outcome events with the increasing tertiles of the CatLet score, with p-value < 0.05 on the trend test. For MACE and cardiac death, the area under the curve (AUC) of the CatLet score was 0.744 (95% confidence interval [CI]: 0.668-0.820) and 0.804 (95% CI: 0.672-0.936), respectively; Alone or after adjusting for risk factors, the multivariable-adjusted hazard ratio (95% CI)/unit higher score was 9.41 (3.18-27.85) for MACEs and 1.85 (1.20-2.84) for cardiac death, respectively.

Conclusion: The CatLet score is an independent predictor of long-term clinical outcomes in patients with chronic coronary syndrome after percutaneous coronary intervention.