Catheterization and Cardiovascular Interventions最新文献

Background

Frailty is associated with poorer short-term outcomes after transcatheter aortic valve implantation (TAVI), and national guidelines recommend an assessment of frailty as part of the decision-making process. However, multiple frailty indices are currently used in clinical practice, and it is unclear which has the best discrimination in TAVI patients and whether this extends into the long term.

Aims

We therefore aimed to compare three commonly used frailty indices in a large TAVI cohort and examine their ability to predict 5-year outcomes.

Methods

The study population included 1059 patients from a high-volume UK TAVI center from 2007 to 2019. Data were collected prospectively using a data set recommended by the British Cardiovascular Intervention Society (BCIS). Frailty was assessed using the Rockwood Clinical Frailty Scale (CFS), Karnofsky Performance Index, and the Katz Index of Activities of Daily Living. Follow-up data were obtained from the NHS Spine.

Results

One, three, and five-year survival was 86.5%, 66.7%, and 44.9%, respectively. In univariate analysis, all three frailty indices were predictive of 5-year survival (Rockwood CFS HR: 1.34 [p < 0.01]; Katz HR: 1.23 [p < 0.01]; Karnofsky HR: 1.21 [p < 0.01]). Three separate multivariable Cox regression models were constructed for each frailty index. In each model, the frailty indices remained predictive of 5-year survival. ROC curve comparison, however, demonstrated the Rockwood CFS model as the best discriminator of 5-year survival (Rockwood CFS model: AUC = 0.59, Karnofsky model: AUC = 0.55, Katz model: AUC = 0.55, p = 0.04); pairwise analysis further confirmed the superiority of the Rockwood CFS model.

Conclusion

Our study confirms that frailty is an important predictor of long-term outcome following TAVI. Our study suggests that of the three most commonly used scoring systems, the most useful discriminator of long-term outcome is the Rockwood CFS.

Background

Previous studies reported comparable outcomes between paclitaxel-coated balloons (PCBs) and paclitaxel-eluting stents (PESs) for femoropopliteal artery disease. However, data comparing the clinical performance of these paclitaxel devices for longer lesions in real-world clinical settings remains limited.

Methods

In this multicenter, retrospective study, the clinical performance of the PCBs (IN.PACT and Ranger) without bailout stenting and PESs (Eluvia) were assessed in cases of femoropopliteal artery disease with lesion length ≥ 150 mm. From the database, 376 lesions in 376 individuals were assigned to the PCB group, and 268 lesions in 268 individuals were assigned to the PES group. Propensity score-matching analysis was performed to adjust for baseline individual and lesion characteristics. The primary outcome was 2-year primary patency (PP), mainly determined using duplex ultrasound, and the secondary outcomes were clinically driven target lesion revascularization, acute limb ischemia, major amputation, and mortality.

Results

Propensity score matching identified 134 pairs with no significant intergroup differences in baseline individual and lesion characteristics. Average lesion length was 252.0 and 253.2 mm in the PCB and PES groups, respectively. Within 2 years, the PES group demonstrated significantly higher PP than the PCB group (80.1% vs. 68.4%, p = 0.037). In contrast, the secondary outcomes did not significantly differ between the groups. No baseline characteristics showed a significant interaction effect on the association of PCBs vs PES with loss of PP.

Conclusion

PP was significantly higher in the PES group than the PCB group in real-world populations with longer, complex lesions, whereas other outcomes did not significantly differ between the two groups.

Background

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is being performed frequently for patients with bioprosthetic aortic valve (AV) degeneration. There is little guidance on appropriate antithrombotic selection after ViV TAVR. We aimed to analyze the impact of different antithrombotic strategies on AV hemodynamics and clinical outcomes following ViV TAVR.

Methods

Consecutive patients who underwent ViV TAVR at our center from January 1, 2019, to June 30, 2023, were included. Patients were divided into antiplatelet plus anticoagulant (AP + AC) or antiplatelet (AP) only groups based on the therapies prescribed on discharge. AV hemodynamics at discharge, 1 month, and 1 year, along with 1-year clinical outcomes, were compared between AP + AC and AP groups.

Results

This study included 104 patients with 74 patients (71.2%) in the AP + AC group and 30 patients (28.8%) in the AP group. Atrial fibrillation history (p = 0.003) was associated with AP + AC whereas GI bleeding history (p = 0.01) was associated with AP alone. There was no significant difference in antithrombotic therapy selection by TAVR type, but patients without a pre-existing indication for AC were more often discharged on AP + AC after receiving smaller diameter Sapien valves (p = 0.036). Additionally, patients were discharged on AP + AC more often if they required leaflet modification during TAVR (p = 0.043). There were no significant differences in AV gradients or clinical outcomes between antithrombotic strategies throughout follow-up.

Conclusions

Anticoagulation was used more often than AP alone following ViV TAVR, but there were no significant differences in AV hemodynamics by echocardiography or clinical outcomes between antithrombotic groups through 1 year of follow-up.

Background

Coronary artery calcification (CAC) is frequently observed in the ageing population, affecting 90% of men and 67% of women, and poses significant challenges during percutaneous coronary interventions (PCIs). CAC impedes stent passage, compromises drug delivery, and limits stent expansion, contributing to decreased PCI efficacy and heightened risks of complications such as restenosis, thrombosis, and procedural issues.

Aims

The study aims to evaluate the real-world clinical outcomes of orbital atherectomy (OA) in patients with severe CAC undergoing PCI.

Methods

This retrospective study analyzed 20 patients (14 males and 6 females) who underwent OA at a single center. OA employed a 1.25 mm diamond-coated burr at 80,000 and 120,00 rpm in selected cases. Baseline characteristics, lesion specifics, and procedural outcomes, as well as changes in minimal lumen diameter (MLD), minimal lumen area (MLA), and minimal stent area (MSA), were assessed along with procedural complications and adverse events.

Results

After OA, a statistically significant increment was observed in MLD and MLA, with mean changes of 2.00 mm and 7.17 mm², respectively. The postprocedural MSA was reported as 6.33 ± 2.85 mm². At 30 days and 6 months after the procedure, only one major adverse cardiac event (MACE), due to stent thrombosis was observed. At 12 months, three MACE (15%) were reported.

Conclusion

OA is a promising intervention for managing severe CAC, enhancing procedural success, optimizing luminal gain, and improving stent delivery and expansion while reducing procedural complications.

Background

The primary retrograde approach is an established strategy for chronic total occlusion (CTO), yet the optimal direction of wire advancement after successful channel crossing has not been systematically evaluated. In long CTOs, knuckle wiring and R-CART often facilitate lesion crossing, whereas in short CTOs, hematoma extension and limited R-CART points often hinder lesion crossing. We developed a novel algorithm for CTOs < 20 mm and validated it using the Japanese CTO Expert Registry.

Aims

This study aimed to validate an algorithm for wire crossing after establishing the primary retrograde approach in short CTOs (< 20 mm).

Methods

Registry data from 2014 to 2022 were analyzed. Among patients with CTOs < 20 mm treated by a primary retrograde approach with successful channel crossing, we excluded ostial CTOs, in-stent occlusions, tandem CTOs, unanalyzable caps, and anomalous origins, yielding 334 cases. Because the algorithm's first step states that “if both caps are tapered, either direction is acceptable,” 130 such cases were excluded. The remaining 204 patients were classified as Algorithm-adherent or Algorithm-deviation. All lesion characteristics, exclusion criteria, and outcomes were adjudicated by an independent core laboratory.

Results

Lesion guidewire manipulation time was significantly shorter in the Algorithm-adherent group (76.2 ± 48.9 vs. 123.2 ± 55.5 min; p < 0.0001). Total procedural time was also shorter in the Algorithm-adherent group (153.3 ± 64.2 vs. 205.0 ± 69.5 min, p < 0.0001), while procedural success rates were comparable between the two groups (99.2% vs. 95.9%, p = 0.13). These findings remained consistent after propensity score matching. No significant differences were observed in contrast volume or complication rates.

Conclusions

The proposed algorithm for primary retrograde crossing of short CTOs was associated with shorter lesion guidewire manipulation and total procedural time, without compromising procedural success or safety.

Endomyocardial fibrosis (EMF) is a rare form of restrictive cardiomyopathy associated with eosinophilic disorders, characterized by apical subendocardial fibrosis and thrombus formation. Cardiac magnetic resonance (CMR) provides a comprehensive, noninvasive evaluation, enabling diagnosis, assessment of disease activity, and guidance of therapy. A 73-year-old man with a history of chronic eosinophilia was referred following detection of left ventricular hypertrophy and T-wave inversion on electrocardiogram. Transthoracic echocardiography was inconclusive. CMR revealed a nondilated left ventricle with mildly impaired systolic function, severe left atrial enlargement, and no inducible ischemia. Late gadolinium enhancement demonstrated apical subendocardial fibrosis extending into the right ventricular apex, with an overlying left ventricular thrombus. These findings were diagnostic of EMF. The patient was treated with a direct oral anticoagulant. At 8-month follow-up, repeat CMR showed resolution of the thrombus and persistent fibrotic scarring. Quantitative T2 mapping demonstrated normal values, excluding ongoing myocardial inflammation. Immunosuppression was therefore not initiated, and anticoagulation was continued. The patient remained clinically stable without thromboembolic events. This case highlights the pivotal role of CMR in diagnosing and managing EMF. LGE imaging provided the characteristic pattern of apical fibrosis with thrombus, while T2 mapping enabled discrimination between chronic fibrosis and active inflammation, guiding therapy away from unnecessary immunosuppression. CMR thus represents the gold-standard imaging modality in EMF, offering both diagnostic confirmation and longitudinal monitoring of treatment response.