Catheterization and Cardiovascular Interventions最新文献

Background: Women's Heart Centers (WHC) are comprehensive, multidisciplinary care centers designed to close the existing gap in women's cardiovascular care. The WHC at The Christ Hospital Heart and Vascular Institute (TCH-WHC) in Cincinnati, Ohio was established in October of 2020, and is a specialized coronary microvascular and vasomotor dysfunction (CMVD) program.

Methods: The TCH-WHC focuses its efforts across five pillars: patient care, research, education, community outreach and advocacy, and grants and philanthropy. These areas, centered around providing specalized CMVD care and treatment have allowed for substantial growth.

Results: From October 2020-December 2023, TCH-WHC saw a total of 3219 patients, 42% of which were apart of the CMVD program. Since establishment, patient volume has consistently increased year over year.

Conclusion: The CMVD program at TCH-WHC is one of the fastest growing in the U. S. and is nationally recognized for specialized clinical care, diagnostics, and research. The goal of this review is to provide an overview of the TCH-WHC structure that allows for the establishment and growth of a CMVD program and to outline core activities supporting the TCH-WHC approach.

Background: Transcatheter mitral valve replacement (TMVR) is emerging in the context of annular calcification (valve-in-MAC; ViMAC), failing surgical mitral annuloplasty (mitral-valve-in-ring; MViR) and failing mitral bioprosthesis (mitral-valve-in-valve; MViV). A notorious risk of TMVR is neo left ventricular outflow tract (neo-LVOT) obstruction. Three-dimensional computational models (3DCM) are derived from multi-slice computed tomography (MSCT) and aim to predict neo-LVOT area after TMVR. Little is known about the accuracy of these neo-LVOT predictions for various mitral phenotypes.

Methods: Preprocedural 3DCMs were created for ViMAC, MViR and MViV cases. Throughout the cardiac cycle, neo-LVOT dimensions were semi-automatically calculated on the 3DCMs. We compared the predicted neo-LVOT area on the preprocedural 3DCM with the actual neo-LVOT as measured on the post-procedural MSCT.

Results: Across 12 TMVR cases and examining 20%-70% of the cardiac phase, the mean difference between predicted and post-TMVR neo-LVOT area was -23 ± 28 mm² for MViR, -21 ± 34 mm² for MViV and -73 ± 61 mm² for ViMAC. The mean intra-class correlation coefficient for absolute agreement between predicted and post-procedural neo-LVOT area (throughout the whole cardiac cycle) was 0.89 (95% CI 0.82-0.94, p < 0.001) for MViR, 0.81 (95% CI 0.62-0.89, p < 0.001) for MViV, and 0.41 (95% CI 0.12-0.58, p = 0.002) for ViMAC.

Conclusions: Three-dimensional computational models accurately predict neo-LVOT dimensions post TMVR in MViR and MViV but not in ViMAC. Further research should incorporate device host interactions and the effect of changing hemodynamics in these simulations to enhance accuracy in all mitral phenotypes.

Transfemoral aortic valve replacement (TAVR) is an effective way to treat severe aortic valve stenosis, especially in patients who are high-risk for surgery. Dislocation of an endoluminal aortic bifurcation stent graft during TAVR is an extremely rare complication. We present a case on how management of this complication was successfully done. An 86-year-old man presented at the ER after syncope. He was admitted to the cardiology department for further examinations. Transthoracic echocardiography (TTE) revealed severe aortic stenosis. Other comorbidities included endovascular stent graft repair due to an infrarenal abdominal penetrating aortic ulcer. During the following TAVR procedure dislocation of the endoluminal stent graft was observed. Using a snare loop this foreign material was fixated in the right common iliac artery. The patient was hemodynamically stable and endoluminal aortic valve replacement could successfully commence. After implantation of aortic valve bioprothesis, the foreign material was retrieved from the right femoral artery. The patient remained asymptomatic and stable postprocedural. Dislocation of an endoluminal stent graft during TAVR remains a rare complication. This complication can arise due to several factors, including patient-specific anatomical challenges and procedural complexities. Decisions are based on the individual patient but are also made in consensus with the interventional cardiologist' team.

Background: The long-term efficacy of drug-coated balloon (DCB) angioplasty for large bifurcation lesions, particularly those involving the left main trunk (LMT), remains unclear.

Aims: This study aimed to evaluate the long-term outcomes of directional coronary atherectomy followed by DCB (DCA/DCB) for large bifurcation lesions.

Methods: This retrospective multicenter study analyzed 129 cases from the DCA/DCB registry, with 80.4% involving LMT bifurcation lesions. Building on previously reported 12-month outcomes, this study assessed long-term results. The primary endpoint was clinically driven (CD) target lesion revascularization (TLR) at 36 months. Secondary endpoints included CD target vessel revascularization (TVR); CD target vessel failure (TVF); and adverse events, such as all-cause mortality, cardiac death, target vessel acute myocardial infarction (AMI), and the need for coronary artery bypass grafting (CABG), at 24 and 36 months.

Results: The mean follow-up was 53.4 ± 23.9 months. The CD-TLR rate was 5.0% at 24 months, and the primary endpoint was 5.9% at 36 months. CD-TVR rates were 14.0% at 24 months and 15.0% at 36 months, while CD-TVF rates were 14.9% at 24 months and 16.7% at 36 months. Adverse events included all-cause mortality rates of 0.8% at 24 months and 1.8% at 36 months, and cardiac death rates of 0.8% at both 24 and 36 months. No target vessel AMI or CABG procedures were reported.

Conclusion: The consistently low CD-TLR rate at 36 months supports the efficacy of the DCA/DCB strategy for large bifurcation lesions, including LMT, indicating its sustained effectiveness. These findings highlight the viability of this treatment approach.

Background: An enhanced classification of primary mitral regurgitation (PMR) based on extramitral cardiac involvement may refine patient selection and optimize the timing of transcatheter edge-to-edge repair (TEER).

Aims: This study aimed to assess the prognostic significance of a recently established classification system that characterizes the extent of extramitral cardiac damage in patients undergoing TEER for PMR.

Methods: Consecutive PMR patients who received MitraClip implantation were categorized according to the presence of extramitral cardiac damage, determined through preprocedural echocardiography. The classifications included no damage or only left ventricular dilatation (group 0), left atrial involvement (group 1), right ventricular volume/pressure overload (group 2), right ventricular failure (group 3), or left ventricular failure (group 4). Cox-proportional hazard models were used to ascertain the impact of PMR groups on the primary composite outcome of all-cause mortality or rehospitalization for heart failure (HHF) over 2 years.

Results: In a cohort of 322 eligible PMR patients undergoing TEER (median age: 83 years; 41% female) between 2013 and 2020, the following distribution emerged: group 0 (10 patients, 3%), group 1 (96 patients, 30%), group 2 (117 patients, 36%), group 3 (56 patients, 18%), and group 4 (43 patients, 13%). Kaplan-Meier analysis demonstrated a significant decline in freedom from the primary outcome as group severity increased (log-rank p = 0.030). On multivariate analysis, the degree of extramitral cardiac involvement was significantly associated with the primary outcome (HR: 1.30; 95% CI: 1.02-1.67; p = 0.043), primarily driven by HHF.

Conclusions: This innovative classification system for PMR, based on extramitral cardiac involvement, carries significant prognostic implications for clinical outcomes following TEER. Integrating this classification system into clinical decision-making could enhance risk stratification and optimize the timing of TEER in these patients.

Background: Traditional transradial access (TRA) is widely used for coronary and non-coronary interventions with significant improvements in procedural outcomes; however, it is associated with RAO that precludes repeat use of the same artery for possible future TRI and other purposes. Distal radial access (DRA) has been proposed as an effective alternative to decrease RAO rates. Published literature describing the RAO rate after DRA versus TRA from various RCT and clinical registries has shown conflicting results.

Objectives: This study compared the forearm radial artery occlusion (RAO) rate assessed by Doppler ultrasound between distal and conventional radial access at 1-year follow-up after the initial procedure.

Methods: TENDERA was a multicenter, randomized controlled study comparing DRA versus TRA for coronary diagnostic and interventional procedures using 5 or 6F hydrophilic-coated sheaths. The primary endpoint was forearm RAO at 12 months after radial access. The secondary endpoints included puncture time, sheath insertion and total procedure time, radiation dose, and vascular access site-related complications.

Results: Eight hundred and fifty patients were randomized to either TRA (n = 418) and DRA (n = 432) groups. In the intention-to-treat analysis, the rate of forearm RAO at 12 months was observed in 39 patients (4.6%) and was significantly reduced in the DRA group compared with the TRA group (2.5% vs. 6.7%, RR 2.59 [95% CI 1.29-5.59], p = 0.010). Analysis in per protocol population has shown consistent results with forearm RAO rate 2.8% in the DRA group versus 6.5% in the TRA group (p = 0.008). The crossover rate was higher (4.6% vs. 1%, p = 0.013) and median hemostasis time was shorter (156.5 min vs. 180 min, p < 0.001) with DRA. Overall bleeding (BARC 1-2) and postprocedure hematoma > 5 cm occurred less frequently in the DRA group compared with the TRA group (3.2% vs. 20.5%, p < 0.001% and 9.0% vs. 27.0%, p < 0.001, respectively). No significant differences were observed in total procedure time and radiation dose between groups.

Conclusions: DRA for coronary diagnostic and interventional procedures is associated with reduced forearm RAO rate and shorter hemostasis time, but a longer sheath insertion time and higher crossover rate compared with TRA.

Trial registration: ClinicalTrials.gov: NCT04211584.

Background: Distal trans-radial access (dTRA) for percutaneous coronary interventions (PCI) is increasingly gaining attention due to its potential to mitigate radial artery occlusion (RAO). However, a comprehensive understanding of the mechanical impact of the devices on the radial artery (RA) wall remains limited. Using a complete intravascular ultrasound (IVUS) evaluation of the RA, including also the vascular access site, we aimed to evaluate all the consequences related to the catheterization on the RA wall, starting from the vascular access, comparing conventional sheath and sheathless approaches.

Methods: This is an observational, prospective, multicenter study aimed to assess the entire RA wall immediately after IVUS-guided PCI via-dTRA. IVUS assessment included quantitative measurements (minimal lumen area [MLA], minimal vessel area [MVA]) and qualitative observations (dissections, vasospasm). Study objectives included delineating RA wall structure post-PCI and comparing findings between conventional and sheathless approaches.

Results: Fifty patients (21 [42%] with conventional sheath, 29 [58%] sheathless) were enrolled between March 2023 and February 2024. Female patients were more prevalent in the convention sheath group (38% vs. 7%, p < 0.001). Sheathless approach utilized 7-French guiding catheters more frequently (33% vs. 86%, p < 0.001). Post-procedural IVUS identified dissections in 12% of cases, with no significant difference between approaches. Arterial vasospasm was present in a quarter of patients, numerically higher in the conventional sheath group (29% vs. 21%, p = 0.5). MLA and MVA were comparable between groups, though MLA and MVA were lowest at the proximal segment of the RA only in the conventional sheath group (p < 0.001). No RAO was documented during the IVUS evaluation.

Conclusions: The intravascular assessment of dTRA after coronary interventions, utilizing either conventional or sheathless approaches, including large-bore guiding catheters, demonstrated a relatively low incidence of access-related complications such as dissection and vasospasm, without affecting the flow and patency of the proximal RA.

Coronary atherosclerotic lesions at the ostium and proximal coronary arteries pose significant challenges in percutaneous coronary interventions (PCI), especially in the left main coronary artery (LMCA). Guide catheter-induced damage can lead to severe complications such as vessel dissection or myocardial infarction. Ostial stent placement with drug-eluting stents offers mechanical support and reduces restenosis but is technically challenging due to the anatomical complexity of the ostium. Complications like longitudinal stent deformation and hydraulic dissection from contrast media are specific concerns. The aortic free-floating wire technique, expanded in this article to Wire in Aorta for Localization and Protection of the Ostium (WALPO), provides a method for safely locating and protecting the ostium during PCI, aiming to improve the safety and efficacy of PCI at this location.

Background: Despite the improvements in drug eluting stents (DES) technology, suboptimal results have been observed in certain higher-risk subsets of patients, as in diabetes mellitus (DM). Drug-coated balloons (DCB) could represent an alternative to DES in complex populations and anatomies, as in DM.

Aims: The present meta-analysis aimed at assessing the role of DCBs in patients with diabetes mellitus.

Methods: Studies comparing DCB versus percutaneous coronary revascularization (PCI) with/without DES for PCI in high-risk populations (>30% DM) were included. The primary efficacy endpoint was overall mortality, secondary endpoints were myocardial infarction, target lesion revascularization (TLR), and major adverse cardiovascular events (MACE).

Results: We included 10 studies, comprising 2026 patients. Among them, 1002 patients (49.5%) were treated with DCB and 1024 with DES implantation. Among the included studies, 6 only enrolled diabetic patients and 2 had a prevalence of diabetes of 50%. At a mean follow-up of 15.3 months, mortality rate was 3.8% (82 patients), significantly lower with DCB (3.2% vs. 4.9% with DES; odds ratio [OR] [95% confidence interval {CI}] = 0.61 [0.38, 0.97], p = 0.04 p_het = 0.34. A similar reduction in favor of DCB was observed for MACE (13.6% vs. 17.6%; OR [95% CI] = 0.79 [0.61, 1.04], p = 0.09, p_het = 0.25), while TLR was significantly reduced only in the diabetic-restricted sub-analysis.

Conclusion: In the present meta-analysis, we showed a significant survival benefit and an absolute reduction in MACE and TLR with a DCB-based strategy as compared to DES in high-risk patients, mostly with DM. Future large-scale randomized trials, dedicated to this population, are deserved to confirm our findings.

What is known: Complex coronary anatomies and diabetes mellitus (DM) represent the pitfall of drug eluting stents (DES), mainly due to inflammatory and thrombotic complications, which should be reduced with drug-coated balloons (DCB).

What is new: We confirmed a significant advantage of DCB versus DES in the treatment of de novo lesions in high-risk patients and mainly in DM, reducing overall mortality, MACE and target lesion revascularization.

Background: Provisional single stenting strategy (PSS) is a default strategy for percutaneous coronary intervention (PCI) of unprotected left main distal bifurcation lesions (ULMD). Previous study reported that a bifurcation angle change (BAC) between end diastole and systole was associated with outcomes after PCI with double stent strategy (DSS) for ULMD. However, there are no data comparing outcomes after PCI with PSS versus DSS according the degree of BAC.

Objectives: We evaluated outcomes after PCI with PSS versus DSS for true ULMD with small and large BAC.

Methods: We identified 566 patients with true ULMD underwent PCI in three high-volume centers. We calculated the BAC in ULMD between end-diastole and systole before stenting with 2-dimensional quantitative coronary angiographic assessment. We defined small (BAC < 7.0°) and large BAC (≥7.0°) group. We compared clinical outcomes after PCI with PSS versus DSS in each cohort after propensity score adjustment. The primary endpoint was target-lesion failure (TLF), which was defined as a composite of cardiac death, target lesion revascularization, and myocardial infarction.

Results: In small BAC cohort, TLF rate was significantly lower in DSS group than in PSS group (12.5% vs. 20.1%, adjusted HR 0.45; 95% CI, 0.26-0.79; p = 0.006). In contrast, in large BAC cohort, TLF rate was significantly higher in DSS group than in PSS group (54.9% vs. 29.0%, adjusted HR 2.25; 95% CI, 1.50-3.38; p < 0.001).

Conclusions: The TLF rate after PCI with DSS was significantly lower in true ULMD with small BAC compared to PSS even after propensity score adjustment. In contrast, it was significantly higher in those with large BAC.