Vessel Coronary Artery Disease Research Articles

ANOTHER BRICK IN THE WALL: A STRANGE CASE OF A BIG HUG

Abstract Background Left ventricular pseudoaneurysm (LVP) is a rare complication of myocardial infarction MI (less than 0,1% of all patients with MI) and develops when cardiac rupture is contained by adherent pericardium or scar tissue, thus contains no endocardium or myocardium, unlike a true left ventricular aneurysm (LVA). Clinical Case A 41–year–old man without remote cardiac history was admitted to the Emergency Department with chest pain that had started 7 days before after a referred ‘big hug’ from a friend. Results of the physical examination were unremarkable. Electrocardiogram: T waves negative in the inferior and lateral leads. Blood exams: normal troponins, C–reactive protein and D–dimer values. Chest computed tomography: no sign of pulmonary embolism. Transthoracic echocardiography (TE): ejection fraction 45%, voluminous aneurismal chamber communicating with the infero–posterior wall of the LV, stratified thrombus and mild mitral valve regurgitation. Coronary angiography: three vessel coronary artery disease. The last diagnosis was established by cardiac magnetic resonance imaging (MRI) which revealed a voluminous pseudoaneurysm of the inferior wall (56 mm x 50 mm with a 51 mm neck) and transmural late gadolinium enhancement (LGE) of the wall adjacent to the pseudoaneurysm with fibroadipose replacement and calcific metaplasia. The patient was transferred to the Cardiac Surgery Department. Intraoperatively the LVP was resected and the defect of the LV was repaired with a patch in bovine pericardium. In addition, coronary artery bypass grafting and mitral valve repair were performed. Discussion LVP develops when pericardium, in combination with thrombus and inflammation, surrounds a cardiac rupture. Inferior and posterolateral myocardial infarction (MI), due to occlusion of the Circumflex artery, are responsible for 82% of the LVP. LVP can be also found in the apical region due to anterior MI. In conclusion symptoms, signs, electrocardiographic abnormalities and radiographic findings seen in patients with LVP can be indistinguishable from those in patients with coronary disease alone. TE is the first non–invasive method for early diagnosis of LVA, but MRI is the gold standard for differential diagnosis between true aneurysm vs pseudoaneurysm. LGE of the pericardium is a new specific marker of pseudoaneurysm as opposed to true aneurysm.

SEPTAL COLLATERAL PERFORATION COMPLICATED BY INTRAVENTRICULAR SEPTAL HEMATOMA: RESOLUTION BY COIL EMBOLIZATION

Abstract A 76–year–old man with effort angina was admitted to our cardiology department for an elective coronary angiography (CA). Diagnostic CA revealed severely calcified three–vessel coronary artery disease (CAD) with chronic total occlusions (CTO) of the right dominant coronary artery (RCA) and left circumflex artery (LCX), and severe calcific stenosis of the left descending artery (LAD). An urgent percutaneous coronary intervention (PCI) to treat the LAD was carried out because of ECG modifications and chest pain immediately after CA. During the procedure a septal collateral perforation occurred leading to abrupt development of a large intraventricular septal hematoma (IVSH). Urgent embolization of the culprit vessel with coils was performed using block and deliver (BAD) technique. Rapid hematoma expansion involved another proximal septal collateral. A prompt second coil embolization was carried out arresting the growth of the septal hematoma. The patient was discharged in stable condition and complete resolution of IVSH was confirmed by transthoracic echocardiogram two months later. Timely management of the septal perforation and close echocardiographic monitoring resulted in complete hematoma resolution and a satisfactory outcome.

Early outcome in patients with STEMI undergoing primary PCI and high Zwolle risk score discharged within 72 hours

Abstract Funding Acknowledgements None. Introduction Zwolle risk score has been used to guide decision for early discharge in patients with ST- elevation acute myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). There is limited evidence on the outcome of patients with high score discharged within 72 hours from primary PCI. Our study aim is to evaluate the outcomes via 1 - month follow up in patients with STEMI undergoing primary PCI, with different Zwolle risk who were discharged within 72 hours from the hospital. Purpose To evaluate 1-month outcome of STEMI patients treated with primary PCI discharged within 72 hours according to Zwolle risk score. Methods We studied 187 consecutive STEMI patients from April 2022 to December 2022, presented in hospital within 12 hours of initial of chest pain, treated with primary PCI and discharged within 72 hours from hospital admission based on physician’s clinical judgement and patient’s preference. Patients were divided in two groups according to Zwolle risk score – low risk (≤3) and high risk (>3). The composite of major adverse events (MACE) consisting of: death, non-fatal re-infarction, stroke and repeat intervention at 1-month follow up was the primary endpoint. Follow up rate was 100%. Results There were 131 patients in the low risk and 56 in high risk groups. Males were 90% versus 80.3% in the low vs high risk group; in addition, mean age was 58.64 ± 10.6 vs 67.8± 6.24 years, respectively; mean ischemic time was 4.78± 3.03 vs 6.9 ± 3.6 hours, respectively; anterior localization was present in 32.8% vs 46.4% of the patients, respectively; 3-vessel coronary artery disease was present in 29.0% vs 46.4% of the patients, respectively; final TIMI 3 flow was present in all vs 96.4% of the patients, respectively. MACE occurred in 7 patients (3.8%) in the low risk group versus 3 patients (5.3%) in the high risk group (P = 0.63). Conclusions In our study population at higher Zwolle risk score was not associated with a worse early outcome among STEMI patients discharged within 72 hours.

In between the cracks.

A 65-year-old man with end-stage renal failure, severe aortic stenosis, and triple vessel coronary artery disease was admitted for percutaneous coronary intervention to the left anterior descending artery prior to transcatheter aortic valve replacement.

To determine the frequency of triple vessel coronary artery disease in patients admitted with acute coronary syndrome.

Objective: To determine the frequency of triple vessel coronary artery disease in patients less than 40 years of age undergone diagnostic coronary angiography and were admitted with acute coronary syndrome Study Design: Cross Sectional study. Setting: Department of Cardiology, Punjab Institute of Cardiology, Lahore. Period: 3rd Sep 2018 to 2nd March 2019. Methods: It was consisted of 90 patients Results: Total 90 cases were enrolled in the study. All presented with central or left sided chest pain clinically diagnosed to be having acute coronary syndrome. All patients undergo diagnostic coronary angiography for the first time. 36.7 % of the presenting cases included in the present study were females while 63.3 % were males who had acute coronary syndrome. Average age of patients included in present study was 30.1±5.9 Data was stratified according to age, gender, type of ACS present. Post stratification chi-square test was applied. It showed that 23.29 % patients had triple vessel coronary artery disease whereas 76.71% did not have triple vessel coronary artery disease. Conclusion: TVCAD was observed in 23.29% of patients presented with acute coronary syndrome in patients less than 40 years of age.

Thoracoscopic-assisted, minimally invasive versus off-pump bypass grafting for single vessel coronary artery disease – A propensity matched analysis

ObjectiveThis study compared perioperative outcomes after off-pump revascularization through a thoracoscopic-assisted (non-robotic) minimally invasive approach (Endo-CAB) or sternotomy approach (OPCAB) for patients with single vessel left anterior descending (LAD) disease. MethodsIn this retrospective, propensity matched cohort study, 266 consecutive patients were included in the Endo-CAB group (n = 136) and OPCAB group (n = 130). After propensity score matching 116 Endo-CAB and 116 OPCAB patients were compared. ‘Textbook outcome’ was defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischemia, cardiac tamponade, cerebrovascular events, wound infection, new-onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (> 7 days). Multivariable regression analysis was performed to identify independent predictors for textbook outcome. ResultsTextbook outcome occurred significantly more frequent in the Endo-CAB group compared to the OPCAB group (81.9% vs. 59.5%, p < 0.001). Patients undergoing Endo-CAB surgery had shorter hospital admission (3.0 [3.0–4.0] vs. 5.0 [4.0–6.0] days, p < 0.001), less blood loss (225 [150–355] vs. 450 [350–600] ml, p < 0.001). Other perioperative outcomes were comparable for both groups. Regression analysis demonstrated that Endo-CAB approach was an independent positive predictor for textbook outcome (OR 3.02, 95% CI 1.61–5.66, p < 0.001). ConclusionsOur study suggests that patients undergoing Endo-CAB surgery have improved perioperative outcome resulting in higher rates of textbook outcome for the treatment of single vessel CAD. This technique could be widely available since routine thoracoscopic instruments are used.

A New Frontier for Drug-Coated Balloons: Treatment of "De Novo" Stenosis in Large Vessel Coronary Artery Disease.

Background: Drug-coated balloons (DCB) are a well-established option for treating in-stent restenosis endorsed by European Guidelines on myocardial revascularization. However, in recent years, a strategy of "leaving nothing behind" with DCB in de novo coronary stenosis has emerged as an appealing approach. Methods: We performed a systematic review to evaluate the current literature on the use of drug-coated balloons in the treatment of de novo stenosis in large vessel disease. Results: Observational studies, as well as randomized studies, demonstrated the safety of DCB percutaneous coronary interventions (PCI) in large vessel disease. The rate of major adverse cardiac events is even lower compared to drug-eluting stents in stable coronary artery disease. Conclusions: DCB PCI is feasible in large vessel disease, and future large, randomized studies are ongoing to confirm these results.

Sex differences in surgical site infections following coronary artery bypass grafting: a retrospective observational study

Surgical site infection (SSI) following cardiac surgery poses a significant challenge for healthcare providers. Despite advances in surgical techniques and infection control measures, SSI remains a leading cause of morbidity and mortality, in addition to being a significant economic burden on healthcare services. Current literature suggests there is a reproducible difference in the incidence of SSI following cardiac surgery between sexes. We aim to assess the sex-specific predictive risk factors for sternal SSI following coronary artery bypass grafting (CABG) in addition to identifying any differences in the causative organisms between groups. Adult patients undergoing isolated CABG between January 2012 and December 2022 in one UK hospital organization were included. In this 10-year, retrospective observational study, a total of 10,208 patients met the inclusion criteria. Pre-operative risk factors were identified using univariate analysis. To assess dependence between sex and organism or Gram stain, a Pearson Chi-squared test with Yates correction for continuity was performed. In total there were 8457 males of which 181 developed a sternal SSI (2.14%) and 1751 females, 128 of whom had a sternal SSI (7.31%). Male patients were found to be significantly more likely to develop an SSI secondary to a Gram-positive organism, whereas female patients were more likely to have a Gram-negative causative organism (P<0.00001). Staphylococcus was statistically more likely to be the causative organism genus in male patients. Pseudomonas aeruginosa was found to be twice as common in the female cohort compared with the male group. In our study, we found a statistically significant difference in the causative organisms and Gram stain for post-CABG sternal SSIs between males and females. Male patients predominately have Gram-positive associated SSIs, whereas female SSI pathogens are more likely to be Gram negative. The preoperative risk profiles of both cohorts are similar, including being an insulin-dependent diabetic and triple vessel coronary artery disease. Given these findings, it prompts the question, should we be tailoring our SSI treatment strategies according to sex and associated risk profiles?

Comprehensive clinical outcomes of drug-coated balloon treatment for coronary artery disease. Insights from a single-center experience.

Some clinical trials have verified the efficacy and safety of paclitaxel drug-coated balloon (DCB) for small vessel coronary artery disease. However, nonsmall vessel and calcified lesions received less attention. This study aimed to investigate the efficacy of DCB treatment for various types of coronary artery lesions, including not only small vessel disease but also nonsmall vessel disease and calcified lesions. In this real-world clinical practice study, in-stent restenosis was excluded. This study consecutively included 934 patients with 1751 nonstented lesions who received DCB at a cardiovascular center in Kyoto Katsura Hospital in Japan between 2009 and 2012 and 2014 to 2019. This study enrolled and retrospectively analyzed all of the patients. Eligible patients routinely underwent follow-up angiography at 6-8 months after percutaneous coronary intervention. The primary endpoint includes target lesion revascularization (TLR) during follow-up. Further, this study calculated the predictor of TLR using multivariate analysis. This study included the lesions involving 46.4% of type B2/C, 26.9% with severe calcification, and 6.0% with DCB restenosis. Mean DCB diameter and length were 2.75 ± 0.51 mm and 24.2 ± 9.6 mm, respectively. The median follow-up duration was 18 months. Follow-up angiography revealed a TLR rate of 9% and a restenosis rate of 9%. This study identified hemodialysis and current smoking as independent TLR predictors. In routine clinical practice, the effectiveness of DCB was observed consistently across various types of coronary artery disease.

Severe Refractory Vasoplegic Shock Syndrome after OPCABG Successfully Treated with Hydroxycobalamin: A Case Report and Review of the Literature.

Vasoplegic shock syndrome (VSS) after an off-pump coronary artery bypass graft (OPCABG) is an extremely rare condition. Inotropic support is usually the first-line therapy, though it can precipitate several complications or be ineffective. We report the first case of severe refractory VSS after OPCABG successfully treated with hydroxycobalamin. A 77-year-old gentleman underwent OPCABG for three vessels coronary artery disease. Preoperative LV ejection fraction was 28%, and the patient before surgery started sacubitril/valsartan titrated, then, at the highest dose. Surgery was uneventful and, by the end of the procedure, TEE showed improved biventricular contractility. The patient was transferred to the ICU without inotropic support, but soon developed hypotension. TEE ruled out pericardial tamponade and confirmed fair contractility. Norepinephrine was titrated to a medium-high dose, vasopressin was started and a Swan-Ganz catheter was placed. SVR was 480 dyn·s·cm-5. Despite aggressive pharmacologic treatment (including methylprednisolone and methylene blue), no improvements were noticed. Ten grams of hydroxycobalamin were administered. One hour later, hemodynamic status re-assessment showed SVR > 800 dyn·s·cm-5. Afterward, vasopressors were gradually reduced. Our case demonstrated the importance of adequate early treatment in VSS after OPCABG. This case report shows, for the first time, that hydroxycobalamin was effectively used to restore homeostasis.

Case Report: Multiple atherosclerotic plaques at its extreme in synchrony

Peripheral artery (PAD) disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral artery disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

Systematic Review of the Efficacy of Orbital Atherectomy in Improving the Outcome of Percutaneous Corornary Intervention in People With Diabetes.

The optimal approach to deal with severe coronary artery calcification (CAC) in people with diabetes remains ill-defined. People with diabetes have a significant risk of developing severe vessel calcification and coronary artery disease (CAD). CADis the leading cause of death in people with diabetes. Individuals with diabetes mainly present with severe multivessel stenosis, diffuse coronary calcification, and severe atherosclerosis, which are poor prognostic factors of revascularization procedures. Studies have shown that the revascularization of arteries in people with diabetes often results in worse outcomes than in people without diabetes. Coronary artery bypass grafting (CABG) has been recommended as the standard of care for people with DM and complex anatomic diseases, including left main CAD. However, percutaneous coronary intervention (PCI)is more acceptable to patients in clinical practice because of decreased trauma and rapid recovery. Severe CAC has traditionally been challenging for PCI and a frequent indication for surgical revascularization. This study aims to determine the effectiveness of orbital atherectomy (OA) in improving PCIoutcomes in patients with diabetes and identify possible adverse effects that preclude its use. The study is reported according to PRISMA and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search of EMBASE, Scopus, Web of Science, Cochrane Library, CINAHL, and MEDLINE was conducted for studies that utilized OA before PCI in people with diabetes. A reference list of the eligible articles was also screened. A narrative synthesis was done by representing the data on the effect direction plot, followed by vote counting. Eighteen studies were included in the analysis. Success rate/successful stent delivery was >90%, while freedom from angiographic complication and major adverse cardiovascular and cerebrovascular events (MACCE) were both >80% on the effect direction plot for people with diabetes and those without diabetes. People with diabetes had low event rates similar to those without diabetes. OA appears to be a viable treatment approach for people with diabetes. However, RCTs with a longer duration of follow-up are required to establish the appropriate treatment strategy for severe CAC in people with diabetes.

Comparison of Efficacy and Safety Between Drug-Coated Balloons Versus Drug-Eluting Stents in the Treatment of De Novo Coronary Lesions in Large Vessels: A Study-Level Meta-Analysis of Randomized Control Trials.

Drug-coated balloons (DCB) can be used as an alternative to drug-eluting stents (DES) in patients with de novo small vessel coronary artery disease. This study aims to assess the efficacy and safety of solely using DCB versus DES in percutaneous coronary intervention (PCI) for de novo coronary lesions in large vessels. A database search was conducted using PubMed, EMBASE, Cochrane Library, and http://Clinicaltrials.gov for trials comparing DCB only with DES in treating de novo coronary lesions in large vessels. Efficacy outcomes included coronary angiography (CAG), follow-up minimal lumen diameter (MLD), and late luminal loss (LLL). Safety outcomes included target lesion failure [TLF: cardiac death, myocardial infarction (MI), target lesion revascularization (TLR)] and their individual components. We included seven randomized control trials (RCTs) with 816 patients, of which 422 and 394 patients were in the DCB and DES groups, respectively. MLD measured during the 6-12 months follow-up in the DCB group was statistically significantly smaller than in the DES group (MD -0.21, 95% CI -0.34 to -0.07, P = 0.003, I2 = 52%). LLL measured at 6-12 months follow-up was statistically significantly lower in the DCB group than in the DES group (MD -0.13, 95% CI -0.22 to -0.05, P = 0.003, I2 = 60%). TLF, cardiac death, MI, and TLR, were not statistically significantly different between the two groups. Use of DCB was associated with less LLL at 6-12 months than DES and was not associated with any increase in adverse clinical events. This data suggests DCB are as effective in treating de novo coronary lesions in large vessels as DES.

SYNE1 gene novel variant is associated with myocardial infarction in young people with a family history of premature atherosclerosis

Abstract Introduction Genetic background is thought to be responsible for a family occurred premature atherosclerosis, including myocardial infarction (MI). Purpose The aim of the study was to investigate the role of genetic variants in young patients (aged &amp;lt;50 years) with MI and family history of premature atherosclerosis. Methods The studied group consisted of 70 patients aged 26-49 (mean 43.1, SD ±4.3), 17 women and 53 men, with MI and with family history of premature atherosclerosis, defined as MI or ischaemic stroke in first-degree relatives at age &amp;lt;65 years in women or &amp;lt;55 years in men. The mean BMI in the studied group was 28.8 kg/m2 (SD ±3.5), total cholesterol level 202.3 mg/dl (SD ±3.5), HDL 40.6 mg/dl (SD ±9.6), LDL 124.0 mg/dl (SD ±28.9), triglycerides 164.4 mg/dl (SD ±63.5), glucose 108.3 mg/dl (SD ±19.9) and creatinine 0.9 mg/dl (SD ±0.2). Regarding other risk factors 63 patients (90%) were smokers (mean 24.1 pack-years, SD ±13.0), 44 (62.8%) had hypertension, 11 (15.7%) had diabetes mellitus, and 8 (11.4%) had depression. All patients had diagnosed MI including MI with ST elevation (STEMI) in 18 cases (25.7%) and MI without ST elevation (NSTEMI) in 52 cases (74.3%). All patients, except 2 (no consent), had performed coronary angiography revealing 1-vessel coronary artery disease (VCAD) in 33 patients (47.1%), 2-VCAD in 17 patients (24.3%), and 3-VCAD in 20 patients (28.6%). The mean left ventricular ejection fraction (LVEF) was 51.8% (SD ±8.0). The total DNA has been extracted from whole peripheral blood samples. The targeted enrichment library was prepared and analyzed using New Generation Sequencing method on Hiseq4000, 2x150 cycles. Statistical analyses were performed using the R software package (www.r-project.org/). The results of sequencing were compared to data from the reference control population consisting of 597 healthy people (418 women, 179 men) aged 18-83 (mean 40.5, SD ± 12,4) as a whole and after matching with a studied group by age and gender in a proportion 1:3 (210 people, 51 women and 159 men, aged 18-77, mean 42.1, SD ±10.6) using Propensity Score Matching. Risks associated with detected variants were evaluated using Fisher’s exact test based on the allelic frequencies of variants in both groups. Results SYNE1 gene variant rs36215567 (NM_182961.4: c.20396+22A&amp;gt;G) has been detected in statistically significant higher incidence in the studied group in comparison to the control population (p=0.005) with OR=4,80 (95%CI 1,43-14,45) as well as when compared to the control population matched by age and gender (p=0.004) OR=9,31 (95%CI 1,64-95,41). There were no statistically significant differences in the incidence of familial hypercholesterolemia related gene variants: LDLR c.667G&amp;gt;A, PCSK9 c.658-36G&amp;gt;A, PCSK9 c.996+55C&amp;gt;A and APOB c.12382G&amp;gt;A between both cohorts. Conclusion A novel variant of SYNE1 gene is associated with myocardial infarction in young age patients with a family history of premature atherosclerosis.

ARCANGELO: an observational, prospective study with acute coronary syndrome patients undergoing percutaneous coronary intervention who receive cangrelor transitioning to oral P2Y12 inhibitors

Abstract Background The use of oral platelet P2Y12 receptor inhibitors, to reduce the risk of thrombotic complications related to Percutaneous Coronary Intervention (PCI), have some limitations in the acute phase, e.g., the delayed onset of action and lack of bioavailability in critical patients. Cangrelor is the only intravenous P2Y12 inhibitor, which based on its quick onset and offset of action is a valid alternative option for antiplatelet therapy, particularly for patients who are unable to take oral medications or for whom oral administration is not adequate. Notably, during the clinical development program of cangrelor, ticagrelor and prasugrel were not marketed and, therefore, the pivotal studies were conducted only with transitioning to clopidogrel. The aim of ARCANGELO study was the evaluation of the safety and effectiveness of cangrelor when administered to patients with Acute Coronary Syndrome (ACS) undergoing PCI in a real-world setting, including patients who received cangrelor transitioning to either clopidogrel, prasugrel, or ticagrelor. Methods Adult patients eligible to PCI for ACS who received cangrelor and who consented to take part in the study in 28 Italian centers, were followed in the 30 days after PCI. Bleedings, major adverse cardiac events (MACEs), and adverse events were recorded. The primary outcome was the incidence of any bleedings, according to BARC (Bleeding Academic Research Consortium) criteria, at 30 days post-PCI. Results A total of 1,004 patients were enrolled and 995 (99.2%) patients were eligible for analysis. Median (IQR) age was 65 (56-73) years, and 771 (77.5%) patients were males. 597 (59.9%) patients had ST-segment Elevation Myocardial Infarction; 509 (51.2%) patients had multi-vessel vessel coronary artery disease. A radial artery access was used in 926 (93.1%) patients and drug-eluting stents were implanted in almost all patients (n=972, 97.7%). All 995 patients included in the analysis received 30 micrograms/kg by intravenous bolus and 4 micrograms/kg/min by intravenous infusion. 730 patients (73.4%) were then transitioned to ticagrelor, 127 (12.8%) to prasugrel, and 138 (13.9%) to clopidogrel. 52 (5.2%) (95% CI 3.9% - 6.8%) patients experienced at least one bleeding event up to 30 days post-PCI. Five patients (0.5%) experienced at least one BARC type 3-5 (moderate-severe) bleeding (all type 3). Fourteen (1.4%) patients presented with at least one MACEs during observation (6 [0.6%] death, 7 [0.7%] myocardial infarction, 2 [0.2%] stent thrombosis). Six (0.6%) patients experienced at least one Treatment-Emergent Adverse Events related to cangrelor. Conclusions The results of this large real-world evidence study confirm that the use of cangrelor in patients with ACS undergoing PCI and transition strategy to the currently used P2Y12 oral inhibitors is safe and effective in daily practice.

Optical coherence tomography assessment of dissection following Drug-Coated Balloon treatment in de-novo small vessel disease

Abstract Background/Introduction Several studies have shown either favorable or unfavorable effects of dissection following drug-coated balloon (DCB) angioplasty. However, there is no established method to precisely assess the extent of dissection during DCB treatment and the relationship between dissection and late lumen gain (LLG) remains unclear. Purpose The aim of this study is to develop a new method to quantify the dissection and investigate the impact of dissection volume on angiographic outcomes. Methods The present study consisted of patients enrolled in the randomized TRANSFORM-I trial, comparing novel Magic TouchTM sirolimus coated-balloon with SeQuent Please NeoTM paclitaxel coated balloon (PCB) in patients with de-novo small vessel coronary artery disease. One-hundred lesions in 98 patients were investigated with OCT after pre-dilatation to assess the dissection. A customized software (QCU-CMS, Leiden) precisely quantifies the dissection and lumen volumes separated by a common boundary connecting the two edges of the intimal fracture. Quantitative OCT analysis of dissection volume is derived from cross-sectional slices with a thickness of 200 microns. Tissue composition analysis, using OCT-Deep Learning (DL) (Pulse, Shanghai), at the starting site of the dissection was performed to elucidate the mechanisms triggering the dissection. Results The dissection was found in 96% (96/100) of the treated lesions. The median dissection volume was 1.98 (0.57 – 3.89)mm3. The median maximal dissection arc was 113 degree. The tissue composition analysis showed that the dissection occurs at the thinnest site (320 μm) of fibrous intima (83%) (Figure). The 6-month angiographic outcomes of TRANSFORM-I will be presented at the late breaking session by then the mechanistic determinant of late loss and gain will have been examined in details. Conclusions Quantitative OCT analysis of dissection demonstrated that dissection occurs during DCB treatment. Final results with 6-month outcome, relationship between the dissection volume and late lumen loss (LLL) or LLG will be presented at the time of congress.Figure

Association of lipoprotein(a) with severity of coronary artery atherosclerosis in patients with acute coronary syndromes

Abstract Background Elevated level of lipoprotein (a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease. However, the association of Lp(a) with acute coronary syndromes (ACS) has not been sufficiently studied. Purpose To evaluate the relationship between high serum levels of Lp(a) and (i) factors that play a role in the long-term development of the severity of coronary artery disease (CAD), (ii) extent of CAD amongst patients with ACS. Methods In this study we enrolled 74 consecutive patients hospitalized for ACS in tertiary cardiology center form December 2022 to January 2023. Patients characteristics were compared for patients with Lp(a) &amp;lt;75 nmol/L (53 patients) and ≥75 nmol/L (21 patients). Logistic regression analyses were performed to evaluate the relationship of Lp(a) with severity of CAD. Results In the studied population, the mean age of patients with high Lp(a) levels was 65 years. They were more likely to have arterial hypertension and hypercholesterolemia than those with normal Lp(a) levels (p &amp;lt;0.05). There were no significant differences in distribution of ACS subtype between groups. On univariate analysis, triple vessel CAD [odds ratio (OR) 4.22, 95% confidence interval (CI) 1.34-13.27, p = 0.014), and multivessel CAD (OR 3.05, 95% CI 1.06-8.81, p = 0.040) were significantly associated with abnormal Lp(a) levels. Multivariable determinants of of high Lp(a) levels were also triple vessel CAD (OR 4.19, 95% CI 1.33-13.26, p = 0.013), and multivessel CAD (OR 3.04, 95% CI 1.05-8.80, p = 0.042). Conclusions Lp(a) ≥75 nmol/L was closely associated with the extent and severity of CAD in patients with ACS.

Can Machine Learning Aid the Selectionof Percutaneous vs SurgicalRevascularization?

In patients with 3-vessel coronary artery disease (CAD) and/or left main CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The aim of this study was to assess whether these individualized revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study, ML algorithms (Lasso regression, gradient boosting) were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG) and prespecified effect-modifiers: disease type (3-vessel or left main CAD) and anatomical SYNTAX score. The model's discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n=1,800) and externally validated in the CREDO-Kyoto (Coronary REvascularization Demonstrating Outcome Study in Kyoto) registry (n=7,362), and then compared with the original SYNTAX score II 2020 (SSII-2020). The hybrid gradient boosting model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95%CI: 0.75-0.81) in cross-validation and 0.77 (95%CI: 0.76-0.79) in external validation. The ML models discriminated 5-year mortality better than the SSII-2020 in the external validation cohort and identified heterogeneity in the treatment benefit of CABG vs PCI. An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems-trained to collect large numbers of parameters-may harmonize decision making globally. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries; NCT00114972).

Predictors of Adverse Outcome in High-Risk Percutaneous Coronary Interventions Patients.

Identifying high-risk percutaneous coronary intervention (PCI) patients is challenging. We aimed to evaluate which high-risk patients are prone to adverse events. We performed a retrospective study including consecutive high-risk PCIs from 2005 to 2018 in a large tertiary medical centre. Patients with unprotected left main (LM) disease, last patent coronary vessel, or 3-vessel coronary artery disease with left ventricular ejection fraction < 35% were included. A predictive 30-day major adverse cardiac events (MACE) score consisting of any myocardial infarction, all-cause death, or target-vessel revascularisation was constructed. From 2005 to 2018, a total of 1890 patients who underwent PCI met the predefined high-risk PCI criteria. Mortality rate was 8.8% at 30 days and 20.7% at 1 year, and 30-day MACE rate was 14.2% and 33.5% at 1 year. Predictors of short-term MACE were New York Heart Association functional class (NYHA) 4 (hazard ratio [HR] 6.65; P<0.001), systolic blood pressure (SBP) < 90 mm Hg (HR 4.93; P<0.001), creatinine > 1.3 mg/dL (HR 3.57; P< 0.001), hemoglobin< 11.0 g/dL (HR 3.07; P < 0.001), pulmonary artery systolic pressure> 50 mm Hg (HR 2.06; P<0.001), atrial fibrillation (HR 1.74; P<0.001), and LM disease (HR 2.04; P<0.001) or last patent vessel (HR 1.70; P= 0.002). A score constructed from these parameters reached a sensitivity of 90% and a specificity of 81% with areas under the receiver operating characteristic curve of 0.92 for MACE and 0.94 with 89% sensitivity and 87% specificity for all-cause mortality. Specific features such as LM lesion or last patent conduit, pulmonary hypertension, atrial fibrillation, anemia, and renal failure, along with low SBP and NYHA 4, aid risk stratification and consideration of further treatment measures.

Microscope-assisted coronary artery bypass grafting in diffuse coronary artery disease: immediate and mid-term results

Background: In recent years, a typical candidate for coronary artery bypass grafting (CABG) has become a patient with complex, multivessel coronary artery disease (CAD), often with an unsatisfactory and small distal bed. The prevalence of diffuse CAD is 4.2%-46.0%, and the CABG refusal rate due to this disease accounts for 1.3%-15.0%. Diffuse CAD is an independent predictor of mortality and poor prognosis after CABG. Due to a lack of uniform criteria for diffuse CAD and randomized trials, there is no preferred surgical treatment option for such patients.Objective: To evaluate immediate and mid-term results of microscope-assisted CABG in patients with ischemic heart disease and diffuse CAD.Methods: We calculated a diffuseness score and determined whether the criterion of diffuse lesion by SYNTAX score was met. For our retrospective study we selected 187 ischemic heart disease patients with 3-vessel CAD who underwent microscope-assisted CABG. A coronary lesion with a diffuseness score of &gt;18 was considered diffuse if the SYNTAX score criterion was met for each of the main coronary arteries. The patients were divided into 2 groups: group 1 for patients with diffuse CAD (n = 60) and group 2 for patients with CAD that did not meet the criterion to be considered diffused (n = 127). The propensity score matching was used to reduce differences between the groups. The primary end point was death from any cause; the secondary end points were adverse cardiovascular events (death from cardiac causes, myocardial infarction, repeated revascularization, acute cerebrovascular accident) and angina.Results: No significant differences in the frequency of in-hospital specific and nonspecific complications were found. The frequency of achieved complete revascularization was comparable between the groups. There were no significant differences in the long-term survival, adverse cardiovascular events, and freedom from angina during the median follow-up of 39 months (min 1 month; max 60 months). The univariate analysis after the propensity score matching showed that diffuse CAD was not a significant predictor of death from any cause [hazard ratio (HR), 1.141; 95% CI, 0.348-3.742; P = .83], adverse cardiovascular events [HR, 0.940; 95% CI, 0.425-2.078; P = .88], and angina [HR, 0.817; 95% CI, 0.394-1.696; P = .59]. The multivariate analysis revealed no significant association between diffuse CAD and death from any cause both before [HR, 1.382; 95% CI, 0.396-4.815; P = .61] and after propensity score matching [HR, 2.079; 95% CI, 0.158-27.422; P = .58]. We found that within 60 months after CABG, the risk of death from any cause was increased: by patient’s age [HR, 1.166; 95% CI, 1.043-1.303; P = .007], male sex [HR, 5.583; 95% CI, 1.062-29.344; P = .042], and diabetes mellitus [HR, 3.673; 95% CI, 1.143-11.805; P = .029] before the propensity score matching and by patient’s age [HR, 2.055; 95% CI, 1.028-4.104; P = .041] and cardiopulmonary bypass time [HR, 1.190; 95% CI, 1.014-1.397; P = .033] after the propensity score matching.Conclusion: Microscope-assisted CABG in patients with diffuse CAD can achieve satisfactory immediate and mid-term results. We found no association between diffuse CAD and the risk of adverse events. Received 30 January 2023. Revised 29 June 2023. Accepted 5 July 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.N. Semchenko Data collection and analysis: A.M. Shevchenko, I.V. Zaicev, A.V. Semchenko, T.B. VnukovaStatistical analysis: A.N. SemchenkoDrafting the article: A.N. Semchenko, I.V. ZaicevCritical revision of the article: A.M. Shevchenko, A.V. Semchenko, T.B. VnukovaFinal approval of the version to be published: A.N. Semchenko, A.M. Shevchenko, I.V. Zaicev, A.V. Semchenko, T.B. Vnukova