Catheterization and Cardiovascular Interventions最新文献

Background: The therapeutic management of patients with multivessel disease and severe left ventricular dysfunction is complex and controversial.

Aims: The aim of this study was to analyze the clinical outcomes and the changes in left ventricular ejection fraction (LVEF) in patients with severe left ventricular dysfunction and at least one chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI) with hemodynamic support provided by Impella.

Methods: Retrospective, multicenter study enrolling patients with severe left ventricular dysfunction and severe coronary artery disease with at least one CTO who required percutaneous mechanical circulatory support with Impella, from January 2019 to December 2023. The primary endpoints were the incidence of MACE (composite of cardiovascular death, acute myocardial infarct, and target lesion revascularization) at 90 days. The secondary endpoint was changes in LVEF and functional class during the same period.

Results: A total of 27 patients (34 CTOs) were included in the study. The mean SYNTAX score was 35 ± 11. The median J-CTO score of 2 (1-3). At 90 day of follow-up, there were three MACE (11%), two cardiovascular deaths and one TLR; three vascular complications were related to access for the Impella device (only one required invasive treatment); and LVEF improved significantly after revascularization (delta LVEF: 10% [CI 95% 6, 15]). A total of 81% of patients improved their angina or dyspnea status at 90 days.

Conclusions: In high-risk patients with severe left ventricular dysfunction with complex coronary disease including CTO, PCI with mechanical circulatory support using the Impella device is associated with favorable safety and efficacy outcomes at short-term follow-up.

Background: Supera interwoven nitinol stents (IWNS) and Eluvia fluoropolymer-based drug-eluting stents (DES) were designed to improve the patency of the femoropopliteal (FP) artery; however, which type of stent yields superior outcomes in calcified FP lesions remains unclear.

Aims: To compare the safety and efficacy of Supera IWNS and Eluvia DES in severely calcified FP lesions.

Methods: This study retrospectively analyzed 257 consecutive patients who underwent endovascular therapy using either IWNS (n = 123) or DES (n = 134) for FP lesions with peripheral arterial calcium scoring system (PACSS) grade 3 or 4 severe calcification between April 2018 and December 2021 at eight cardiovascular centers in Japan.

Results: Propensity score (PS) matching extracted 138 matched patients with no remarkable intergroup difference in patient and lesion characteristics. The 1-year primary patency rates in the matched population were not significantly different between the IWNS and DES groups (85.4% vs. 89.8%, p = 0.320). A significant interaction between the stents used and the number of below-the-knee (BTK) runoff vessels was observed (interaction p = 0.048). The hazard ratio for restenosis was 2.68 (95% confidence interval, 0.51-14.2) in the group with no BTK runoff, favoring DES.

Conclusion: In PS-matched patients with severely calcified FP lesions, 1-year primary patency was not significantly different between treatments using Supera IWNS and Eluvia DES.

Backgrounds: Post-dilatation after stenting with a non-compliant (NC) balloon can be used to improve overall percutaneous coronary intervention (PCI) result. Due to lack of evidence on the effect of post-dilatation on adverse clinical endpoints there is no consensus whether post-dilatation should be used routinely. The aim of the current study was to determine the contemporary practice of post-dilatation.

Methods: This study included patients from the Netherlands Heart Registration who underwent PCI between the 4th quarter of 2020 and the 3rd quarter of 2021. The primary endpoint was the rate of post-dilatation with a NC balloon. Secondary endpoints included differences in baseline and procedural characteristics of patients that received post-dilatation and patients that did not receive post-dilatation.

Results: Out of 12,960 patients from 11 hospitals, 49.9% underwent post-dilatation. There was a variety in post-dilatation between hospitals ranging from 29.3% to 82.7% and among operators ranging from 15.9% to 90.5%. Post-dilatation was used less frequent in patients presenting with ST-elevation myocardial infarction or out of hospital cardiac arrest. Multivessel and left main PCI, long stent length and use of intracoronary imaging and calcium modification were associated with increased use of post-dilatation. When imaging was used, the percentage of post-dilatation was 79.4%.

Conclusions: In the Netherlands, stent optimization with post-dilatation using NC balloon is performed in only half of the patients undergoing PCI, with variations in frequency across centres and operators. Post-dilatation is more often used in cases of complex PCI and when intracoronary imaging or calcium modification techniques are used.

Background: Limited data exist on the impact of polyvascular disease (PolyVD) on clinical outcomes in female patients undergoing transcatheter aortic valve replacement (TAVR). We therefore sought to investigate clinical outcomes in women with versus without PolyVD undergoing TAVR.

Methods: Female participants from the multicentre Women's International Transcatheter Aortic Valve Implantation (WIN-TAVI) registry were categorized based on the presence or absence of PolyVD. The PolyVD population was defined as the presence of atherosclerotic disease affecting ≥ 2 arterial systems from coronary, cerebral, or lower limb peripheral vessels, whilst patients with either no atherosclerosis or atherosclerotic disease in one vascular system were included in the non-PolyVD population. The primary endpoint was the Valve Academic Research Consortium-2 consensus (VARC-2) efficacy endpoint at 1 year, whilst secondary endpoints included VARC-2 safety events, VARC-2 major bleeding and major vascular complications. Cox regression analysis were computed adjusting for various cofounders.

Results: Among 996 participants, 543 (54.5%) had PolyVD, while 453 (45.5%) did not. Across the subgroups no differences in age was noted, whilst patients with PolyVD were more likely to have a history of hypercholesterolemia and a previous cardiac surgery. The incidence of the primary endpoint was higher in the PolyVD group (19.4%) compared to the non-PolyVD group (13.3%, p_log-rank = 0.014), though the difference was attenuated after multivariable adjustments (p = 0.093). Of note, no statistically significant differences concerning incident VARC-2 safety events, VARC-2 major bleeding and major vascular complications were noted according to PolyVD status.

Conclusion: PolyVD is a common comorbidity and is associated with elevated rates of adverse clinical events, but no increase in safety events, vascular complications, or bleeding among women undergoing TAVR.

Background: Evidence regarding drug-coated balloon (DCB)-only angioplasty in de novo lesions of large vessels is still limited and mainly focused on paclitaxel-coated balloon. We aimed to analyze the safety and efficacy of sirolimus-coated balloon (SCB)-only angioplasty in de novo lesions in large vessels compared to drug-eluting stent (DES).

Methods: In this retrospective, dual-center, case-control study, we enrolled all consecutive patients treated between January 2022 and January 2024 with SCB-only angioplasty in de novo lesion in large vessel (> 2.75 mm) compared to a propensity-score matched contemporary population treated with DES. The primary endpoint was the rate of target lesion revascularization (TLR), while secondary endpoints were cardiac death (CD), target vessel revascularization (TVR), myocardial infarction (MI), and target lesion failure (TLF), defined as a composite of them.

Results: The mean age was 70.1 ± 9.8 years in the SCB group (n = 92) and 67.9 ± 9.6 years in the DES group (n = 92) (p = 0.76). The median follow-up was 19.5 ± 12 months in the SCB group and 20.1 ± 13.1 months in the DES group (p = 0.47). TLR occurred in 6.7% of patients in the SCB group and 5.6% in the DES group (p = 0.75). The incidence of MI, TVR, and TLF were similar between the two groups (4.3% vs 3.3%, p = 0.7, 2.2% vs 3.4%, p = 0.65% and 9.8% vs 8.7%, p = 0.79). CD occurred in 4.3% in the SCB group, compared to 3.3% in the DES group (p = 0.70).

Conclusion: Our study suggests that SCB angioplasty is both safe and effective in the treatment of de novo lesions of large vessels compared with DES.

Transcatheter aortic valve replacement (TAVR) is a well-established treatment for severe aortic stenosis, especially in patients over 75 or those at high surgical risk. While these prosthetic valves have a lower thrombogenic profile than mechanical heart valves, leaflet thrombosis in transcatheter aortic valves (TAV) occurs in an estimated 5%-40% of cases. Most TAV thromboses are subclinical and can be detected via cardiac computed tomography (CCT), which reveals hypo-attenuating leaflet thickening and reduced leaflet motion in asymptomatic patients without elevated transprosthetic gradients on echocardiography. The mechanisms behind TAV thrombosis involve local mechanical triggers, patient predisposing factors, and device and procedure-related aspects. The ideal antithrombotic therapy post-TAVR depends on individual patient characteristics, balancing bleeding risks with the need for oral anticoagulants. Data on the optimal management of TAV thrombosis and the routine use of CT post-TAVR are limited. While anticoagulation effectively resolves clinically significant prosthesis thrombosis, its benefit in subclinical cases is unclear. There is an ongoing debate about whether subclinical leaflet thrombosis precedes clinical valve thrombosis, making the ideal follow-up after valve implantation uncertain. This article aims to provide a comprehensive review, summarizing current data on the incidence of TAVR thrombosis, underlying mechanisms, clinical and imaging diagnosis, management strategies, preventive measures, and long-term follow-up.

Introduction: The objective of this study is to determine if cardiac damage based on hospital discharge codes is associated with in-hospital outcomes in patients with aortic stenosis (AS).

Methods: We conducted a retrospective cohort study of hospital admissions between 2016 and 2021 with a diagnosis of AS in the National Inpatient Sample (NIS). The cardiac damage stages 0-4 were determined based on hospital discharge codes. Logistic and linear regressions were used to determine the association between cardiac stage and in-hospital mortality, length of stay (LoS) and cost.

Results: A total of 2,980,150 hospital admissions were included in the analysis (82.5% conservative management, 11.2% transcatheter aortic valve replacement [TAVR], 6.3% surgical aortic valve replacement [SAVR]). The association between cardiac damage stage and in-hospital outcome was most significant for patients who had SAVR treatment (stage 4 vs. stage 0: mortality OR 27.70 95% CI 17.35-35.17, LoS 7.34 95% CI 6.34-8.35, cost 70,710 95% CI 65,110-76,310) compared to TAVR treatment (stage 4 vs. stage 0: mortality OR 9.15 95% CI 5.52-15.15, LoS 6.27 95% CI 5.63-6.90, cost 28,384 25,084 to 31,684) and conservative treatment (stage 4 vs. stage 0: mortality OR 3.55 95% CI 3.13-4.04, LoS 2.09 95% CI 1.87 to 2.31, cost 6362 95% CI 5642-7083).

Conclusions: Cardiac damage can be evaluated using diagnostic codes in patients with AS and it is associated with in-hospital mortality, LoS and cost, and has more impact on these outcomes in patients treated with SAVR versus those treated with TAVR.

Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly with a large spectrum of anatomical variations. Selective engagement of an AAOCA can present challenges during cardiac catheterization. A comprehensive understanding of the characteristics of major AAOCA can effectively assist operators for selecting and maneuvering catheters. This review outlines the recommended catheter manipulations based on the site of ectopic coronary origin. Identifying the initial course (prepulmonic, subpulmonic, interarterial or retroaortic course) is crucial for classifying each AAOCA. Besides invasive coronary angiography, coronary computed tomography angiography is frequently utilized to enhance the diagnostic assessment. Cardiac catheterization enables the use of intracoronary imaging and physiologic tools for accurately assessing the significance of AAOCA identified as at risk, mainly the anomalies associated with an interarterial course. Intravascular ultrasound is recognized as the gold standard for analyzing AAOCA with interarterial course. Optical tomography coherence imaging can be interesting to evaluate the rare AAOCA with a subpulmonic course, which are associated with ischemic symptoms or myocardial ischemia. Invasive physiological indices using pressure wires can be employed, with the caveat that their threshold values remain uncertain. Decision-making can be challenging for patients with AAOCA. Both non-invasive and invasive imaging tools are essential to support the final choice.

Background: Drug-coated balloons present a potentially advantageous therapeutic approach for managing coronary in-stent restenosis (ISR). However, the comparative benefits of paclitaxel-coated balloons (PCBs) over uncoated balloons (UCBs) remain unclear.

Aims: We conducted a systematic review and meta-analysis to evaluate and compare the clinical outcomes of patients treated with PCBs and UCBs.

Methods: We systematically searched PubMed, Embase, and Cochrane for studies comparing PCBs and UCBs in managing coronary ISR. We used a random-effects model to pool risk ratios (RRs) and their 95% confidence intervals (CIs). Statistical analyses were conducted using Review Manager 5.4.1. Heterogeneity was assessed using I² statistics. Quality and risk of bias were evaluated using the Cochrane Collaboration's tool.

Results: We included seven randomized controlled trials with 1349 patients, of whom 840 underwent percutaneous coronary intervention with PCB. In our pooled analysis, patients treated with PCB had lower risks of target lesion revascularization (RR 0.31, 95% CI 0.18-0.52; p < 0.01), target vessel revascularization (0.53, 0.42-0.67; p < 0.01), major adverse cardiac events (MACEs) (0.25, 0.16-0.38; p < 0.01), and myocardial infarction (MI) (0.59, 0.37-0.95; p = 0.03). However, there were no significant differences in all-cause mortality (0.79, 0.37-1.70; p = 0.54), cardiac death (0.46, 0.03-8.12; p = 0.60), while tendencies for a significant difference were found for target lesion failure (0.39, 0.13-1.11; p = 0.08), or stent thrombosis (0.21, 0.03-1.35 p = 0.10).

Conclusion: These findings suggest that PCBs are superior to UCBs regarding the occurrence of target lesion revascularization, target vessel revascularization, MACEs, and MI, but they do not differ in all-cause mortality, and cardiac death, while trends to significant differences favoring PCB were found to stent thrombosis and target lesion failure.

Background: Heavily calcified coronary artery disease presents significant challenges in percutaneous coronary intervention (PCI), often requiring advanced techniques to achieve optimal outcomes. Cutting balloons (CB) have shown potential for plaque modification; however, their effectiveness is limited without standardized protocols.

Aims: This study introduces the RODIN-CUT technique, a novel approach utilizing sequential CB inflations with real-time intravascular ultrasound (IVUS) guidance. The technique aims to enhance calcified plaque modification, improve stent expansion, and achieve consistent procedural success in heavily calcified coronary lesions.

Methodology: A retrospective analysis of three consecutive patients requiring specialized approaches beyond conventional PCI was included at three centers in Belgium. The RODIN-CUT protocol involved multiple CB inflations at precise lesion segments, followed by immediate IVUS imaging after each inflation to assess plaque modification and guide further therapy. Procedural success was defined as residual stenosis < 30% with TIMI 3 distal flow. The study evaluated the dose-dependent effects of repeated CB inflations on plaque fracture depth and distribution.

Conclusion: The RODIN-CUT technique demonstrated promising outcomes, achieving procedural success in all cases with enhanced stent expansion and minimal complications. The technique's simplicity, cost-effectiveness, and reproducibility make it a viable option for treating heavily calcified coronary lesions. Further large-scale studies are required to validate these findings and establish the RODIN-CUT technique as a standard approach for complex calcified lesions.