Direct Percutaneous Coronary Intervention Research Articles

FACTORS INFLUENCING LATE PROGNOSIS IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION TREATED WITH DIRECT PERCUTANEOUS CORONARY INTERVENTION.

Objective: To investigate factors influencing the late prognosis of patients with acute ST-segment elevation myocardial infarction treated by direct percutaneous coronary intervention. Methods: We retrospectively analyzed 349 ST-segment elevation myocardial infarction patients treated with direct percutaneous coronary intervention. Patients were categorized based on catheter laboratory activation time (CLAT) (≤15 or >15 min), time of arrival (working hours or out-of-hours), and mode of arrival (emergency medical services transportation or self-presentation). The primary endpoint was the 2-year major adverse cardiovascular events (MACEs), defined as all-cause death, nonfatal myocardial infarction, and target vessel revascularization. Results: Patients with CLAT ≤15 min showed significant differences in oxygen saturation, FMC-to-device time, symptom-to-device time, symptom-to-FMC time, presentation mode, presentation duration, and MACEs (all P < 0.005). Self-presentation (odds ratio = 0.593, 95% confidence interval = 0.413-0.759) and out-of-hours presentation (odds ratio = 0.612, 95% confidence interval = 0.433-0.813) were risk factors for CLAT >15 min. The working-hours group showed significant differences in FMC-to-device time, activation-to-arrival time at the catheter laboratory, and the number of cases with activation time ≤15 min (all P < 0.005). The emergency medical services and self-presentation groups differed significantly in age, blood pressure, FMC-to-device time, and electrocardiography-to-CLAT (all P < 0.005). Conclusion: Reducing CLAT to 15 min significantly lowers the 2-year MACE rate. Self-presentation and out-of-hours presentation are risk factors for delayed catheter laboratory activation.

Development and validation of a machine learning-based readmission risk prediction model for non-ST elevation myocardial infarction patients after percutaneous coronary intervention

To investigate the factors that influence readmissions in patients with acute non-ST elevation myocardial infarction (NSTEMI) after percutaneous coronary intervention (PCI) by using multiple machine learning (ML) methods to establish a predictive model. In this study, 1576 NSTEMI patients who were hospitalized at the Affiliated Hospital of North Sichuan Medical College were selected as the research subjects. They were divided into two groups: the readmitted group and the non-readmitted group. The division was based on whether the patients experienced complications or another incident of myocardial infarction within one year after undergoing PCI. Common variables selected by univariate and multivariate logistic regression, LASSO regression, and random forest were used as independent influencing factors for NSTEMI patients’ readmissions after PCI. Six different ML models were constructed using these common variables. The area under the ROC curve, accuracy, sensitivity, and specificity were used to evaluate the performance of the six ML models. Finally, the optimal model was selected, and a nomogram was created to visually represent its clinical effectiveness. Three different methods were used to select seven representative common variables. These variables were then utilized to construct six different ML models, which were subsequently compared. The findings indicated that the LR model exhibited the most optimal performance in terms of AUC, accuracy, sensitivity, and specificity. The outcome, admission mode (walking and non-walking), communication ability, CRP, TC, HDL, and LDL were identified as independent predicators of readmissions in NSTEMI patients after PCI. The prediction model constructed by the LR algorithm was the best. The established column graph model established proved to be effective in identifying high-risk groups with high accuracy and differentiation. It holds a specific predictive value for the occurrence of readmissions after direct PCI in NSTEMI patients.

Frequency of No-Reflow Phenomenon in Patients Treated with Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Background: The no-reflow phenomenon is a critical complication following percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI), which can significantly affect morbidity and mortality. Despite advancements in interventional cardiology, no-reflow remains a challenge, with various factors contributing to its occurrence. Objective: This study aims to identify independent risk factors for the no-reflow phenomenon in STEMI patients undergoing direct PCI and to develop a practical scoring system for predicting the likelihood of its occurrence. Methods: In a retrospective cohort analysis, 1,345 patients who underwent direct PCI at a single center were evaluated. Baseline characteristics, clinical manifestations, and angiographic findings were meticulously recorded. Multivariate logistic regression was employed to ascertain independent predictors for no-reflow. The derived scoring system was based on statistically significant variables, including age, collateral circulation, thrombus burden, lesion diameter, and ACEI/ARB therapy. Results: The mean age of the development cohort (n=1011) was 61.2±11.2 years, with the validation cohort (n=334) averaging 62.1±10.8 years. No-reflow was present in 80.1% of the development group with TIMI blood flow grade 1. Independent predictors of no-reflow included age ≥55 years (OR 2.100, p=0.001), collateral circulation &lt;grade 2 (OR 2.907, p=0.002), thrombus burden ≥4 points (OR 1.920, p&lt;0.001), and lack of ACEI/ARB therapy (OR 1.678, p=0.017). The scoring system demonstrated a sensitivity of 42.0% and a specificity of 78.4%, with PPV and NPV of 45.8% and 78.5%, respectively. Conclusion: The study identified several key predictors for no-reflow and established a scoring system that may aid clinicians in the early identification of patients at risk for no-reflow post-PCI. This scoring system, given its simplicity and reliance on readily available clinical data, has the potential to be incorporated into routine clinical practice, subject to validation in future prospective studies.

Preserving flow, saving lives: Successful treatment of aortic valve failure in acute myocardial infarction without flow down-regulation using ECMO - a case report and mini review.

Direct percutaneous coronary intervention (PPCI) has significantly reduced cardiac mortality in patients with acute myocardial infarction (AMI), but the mortality rate remains high for those who develop cardiogenic shock (CS), reaching 40% to 50%. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) provides robust hemodynamic support and oxygen delivery for AMI patients with refractory CS, ensuring adequate organ perfusion and oxygen supply. However, there is currently no standardized optimal Mean Arterial Pressure (MAP) range during V-A ECMO support. Achieving the proper MAP is crucial for adequate myocardial perfusion, cardiac function recovery, successful weaning off of V-A ECMO, and improving long-term outcomes. In this case study, we successfully treated a 55-year-old man with AMI and refractory cardiogenic shock using V-A ECMO. By adjusting ECMO blood flow and employing hemodynamic strategies, including vasoactive drugs, we optimized the MAP, leading to improved cardiac function and successful weaning off of V-A ECMO. This presents a potential opportunity for MAP optimization under ECMO support in patients with acute myocardial infarction and cardiogenic shock.

Minimally invasive direct coronary artery bypass and percutaneous coronary intervention followed by transcatheter aortic valve implantation: A promising concept in high-risk octogenarians.

In this article, we present our initial clinical experience with staged minimally invasive direct coronary bypass (MIDCAB), percutaneous coronary intervention (PCI), and transcatheter aortic valve implantation (TAVI) in high-risk octogenarians (Hybrid). The use of percutaneous techniques for managing structural heart diseases, especially in elderly high-risk patients, has revolutionized the treatment of structural heart diseases. These procedures are present predominantly being offered as isolated interventions. The feasibility, clinical benefit, and outcomes of combining these techniques with MIDCAB have not been sufficiently explored and have subsequently been underreported in the contemporary literature. Four consecutive octogenarians with severe aortic stenosis (AS) and complex coronary artery disease (CAD) that were at high risk for conventional surgery with extracorporeal circulation (ECC) were discussed in our Multidisciplinary Heart Team (MDH). Our MDH consisted of an interventional cardiologist, cardiac surgeon, and cardiac anesthesiologist. A hybrid approach with the alternative strategy comprising of MIDCAB, PCI, and TAVI in a staged fashion was agreed on. All 4 patients had both PCI/stenting and MIDCAB prior to deployment of the TAVI-prosthesis. From January 2019 to December 2020, 4 consecutive patients aged between 83 and 85 (3 male/1 female) years were scheduled for MIDCAB/PCI followed by percutaneous treatment of severe symptomatic AS. Intraoperatively, one patient was converted to full sternotomy, and surgery was performed by off-pump coronary artery bypass grafting. The overall procedural success rate was 100% in all 4 patients with resolution of their initial presenting cardiopulmonary symptoms. There were no severe complications associated with all hybrid procedures. There was no 30-day mortality in all patients. All patients were discharged home with a median hospital stay ranging between 9 and 25 days. All patients have since then been followed-up regularly. There was one noncardiac-related mortality at 6-months postsurgery. All other patients were well at 1-year follow-up with improved New York Heart Association Class II. In a selected group of elderly, high prohibitive risk patients with CAD and severe symptomatic AS, a staged approach with MIDCAB and PCI followed by TAVI can be safely performed with excellent outcomes. We advocate a MDH-based preliminary evaluation of this patient cohort in selecting suitable patients and appropriate timing of each stage of the hybrid procedure.

Minimally Invasive Direct Coronary Artery Bypass Versus Percutaneous Coronary Intervention for Isolated Left Anterior Descending Artery Stenosis: An Updated Meta-Analysis.

The optimal revascularization strategy for isolated left anterior descending (LAD) coronary artery lesion between minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) remains controversial. This updated meta-analysis aims to compare the long- and short-term outcomes of MIDCAB versus PCI for patients with isolated LAD coronary artery lesions. The Pubmed, Web of Science, and Cochrane databases were searched for retrieving potential publications from 2002 to 2022. The primary outcome was long-term survival. Secondary outcomes were long-term target vessel revascularization (TVR), long-term major adverse cardiovascular events (MACEs), and short-term outcomes, including postoperative mortality, myocardial infarction (MI), TVR, and MACEs of any cause in-hospital or 30 days after the revascularization. Six randomized controlled trials (RCTs) and eight observational studies were included in this updated meta-analysis. In total, 1757 patients underwent MIDCAB and 15245 patients underwent PCI. No statistically significant difference was found between the two groups in the rates of long-term survival. MIDCAB had a lower long-term MACE rate compared with PCI. Besides, PCI resulted in an augmented risk of TVR. Postoperative mortality, MI, TVR, and MACEs were similar between the two groups. The updated meta-analysis presents the evidence that MIDCAB has a reduced risk of long-term TVR and MACEs, with no benefit in terms of long-term mortality and short-term results, in comparison with PCI. Large multicenter RCTs, including patients treated with newer techniques, are warranted in the future.

Prognosis Analysis of Delayed Call Time for Chest Pain in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Direct Percutaneous Coronary Intervention.

To describe the impact of delayed call time for chest pain in the salvage of ST-segment elevation myocardial infarction (STEMI) patients and its associated independent risk factors, and to identify risk factors associated with cumulative morbidity and mortality in STEMI patients at 4 years after percutaneous coronary intervention (PCI). Retrospective analysis of 398 patients diagnosed with STEMI and treated with emergency PCI within 24 hours of symptom onset in Fuyang People's Hospital from April 2018 to April 2021. The enrolled patients were divided into ≤60 minutes group (193 cases), and > 60 minutes group (205 cases), according to the delayed call time of patients with chest pain. Analysis of basic clinical data, rescue time, and major cardiovascular adverse events in the 2 groups. Multifactorial logistic regression analysis of independent correlates of delayed chest pain calls and Cox proportional risk regression modeling of risk factors for cumulative morbidity and mortality at 4 years after surgery. Compared to the delayed call time ≤ 60 minutes group, the > 60 minutes group had a higher proportion of females, a history of diabetes, rural remote areas, and farmer occupation (P < .05). Binary logistic regression analysis shows the history of diabetes and female as independent risk factors for delayed call time >60 minutes for chest pain. In the delayed call time ≤60 minutes group, the time from symptom onset-to-balloon (S0-to-B) and from symptom onset-to-first medical contact (SO-to-FMC) were smaller than in the delayed call time >60 minutes group (P < .05). The sum of postinfarction angina and major cardiovascular adverse events was lower in the group with delayed call time ≤60 minutes than in the group with delayed call time >60 minutes (P < .05). The Kaplan-Meier survival curve and the survival curve without the occurrence of major adverse cardiovascular events were statistically significant in both groups (P < .05). Multifactorial Cox regression analysis showed that delayed call time for chest pain >60 minutes, left main + 3 branch lesions, and cardiac function Killip ≥ III were all risk factors for cumulative morbidity and mortality at 4 years after PCI in patients with STEMI. Delayed call time for chest pain >60 minutes, left main + 3 branch lesions, and cardiac function Killip ≥ III are all risk factors for cumulative morbidity and mortality in STEMI patients at 4 years after PCI. Reducing the delayed call time for chest pain can improve the long-term prognosis of patients.

The Systemic Immune Inflammatory Index Predicts No-Reflow Phenomenon after Primary Percutaneous Coronary Intervention in Older Patients with STEMI

Purpose: Coronary no-reflow phenomenon (NRP), a common adverse complication in patients with ST-segment elevation myocardial infarction (STEMI) treated by percutaneous coronary intervention (PCI), is associated with poor patient prognosis. In this study, the correlation between the systemic immune-inflammation index (SII) and NRP in older patients with STEMI was studied, to provide a basis for early identification of high-risk patients and improve their prognosis. Materials and methods: Between January 2017 and June 2020, 578 older patients with acute STEMI admitted to the Department of Cardiology of Hebei General Hospital for direct PCI treatment were selected for this retrospective study. Patients were divided into an NRP group and normal-flow group according to whether NRP occurred during the operation. Clinical data and the examination indexes of the two groups were collected. Logistic regression was used to analyze the independent predictors of NRP, and the receiver operating characteristic curve was used to further analyze the ability of SII to predict NRP in older patients with STEMI. Results: Multivariate logistic analysis indicated that hypertension (OR=2.048, 95% CI:1.252–3.352, P=0.004), lymphocyte count (OR=0.571, 95% CI:0.368–0.885, P=0.012), platelet count (OR=1.009, 95% CI:1.005–1.013, P&lt;0.001), hemoglobin (OR=1.015, 95% CI:1.003–1.028, P=0.018), multivessel disease (OR=2.237, 95% CI:1.407–3.558, P=0.001), and SII≥1814 (OR=3.799, 95% CI:2.190–6.593, P&lt;0.001) were independent predictors of NRP after primary PCI in older patients with STEMI. Receiver operating characteristic curve analysis demonstrated that SII had a high predictive value for NRP (AUC=0.738; 95% CI:0.686–0.790), with the best cut-off value of 1814, a sensitivity of 52.85% and a specificity of 85.71%. Conclusion: For older patients with STEMI undergoing primary PCI, SII is a valid predictor of NRP.

Culprit vessel revascularization first with primary use of a dedicated transradial guiding catheter to reduce door to balloon time in primary percutaneous coronary intervention.

The effect of a single transradial guiding catheter (STGC) for culprit vessel percutaneous coronary intervention (PCI) first on door-to-balloon (D2B) time remains unclear. Between February 2017 and July 2019, 560 patients with ST-elevation myocardial infarction (STEMI) were randomized into either the STGC group (n = 280) or the control group (n = 280) according to direct culprit vessel PCI with a STGC. In the STGC group, a dedicated transraidal guiding catheter (6F either MAC3.5 or JL3.5) was used for the treatment of electrocardiogram (ECG)-guided culprit vessel first and later contralateral angiography. In the control group, a universal diagnostic catheter (5F Tiger II) was used for complete coronary angiography, followed by guiding catheter selection for culprit vessel PCI. The primary endpoint was D2B time, and the secondary endpoint included catheterization laboratory door-to-balloon (C2B), procedural, fluoroscopy times, and major adverse cardiac events (MACE) at 30 days. The median D2B time was significantly shorter in the STGC group compared to the control group (53.9 vs. 58.4 min; p = 0.003). The C2B, procedural, and fluoroscopy times were also shorter in the STGC group (C2B: 17.3 vs. 24.5 min, p < 0.001; procedural: 45.2 vs. 49.0 min, p = 0.012; and fluoroscopy: 9.7 vs. 11.3 min, p = 0.025). More patients achieved the goal of D2B time within 90 min (93.9% vs. 87.1%, p = 0.006) and 60 min (61.4% vs. 51.1%, p = 0.013) in the STGC group. Radial artery perforation (RAP) was significantly reduced in the STGC group compared with the control group (0.7% vs. 3.2%, P = 0.033). MACE at 30 days was similar (2.5% vs. 4.6%, P = 0.172) between the two groups. ECG-guided immediate intervention on culprit vessel with a STGC can reduce D2B, C2B, procedural, and fluoroscopy times (ECG-guided Immediate Primary PCI for Culprit Vessel to Reduce Door to Device Time; NCT03272451).

Minimally invasive surgery or stenting for left anterior descending artery disease - meta-analysis.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years’ experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.

A nomogram for predicting the risk of no-reflow after primary percutaneous coronary intervention in elderly patients with ST-segment elevation myocardial infarction

BackgroundThe purpose of this study was to screen the predictive factors of no-reflow after a percutaneous coronary intervention (PCI) in elderly patients with ST-segment elevation myocardial infarction (STEMI), and to construct a nomogram model, to guide clinical treatment.MethodsA total of 551 elderly STEMI patients (age >65) underwent direct PCI were randomly classified into training group (n=386, 70%) and validation group (n=165, 30%). All patients in the two groups were divided into a no-reflow group and a normal blood flow group according to whether there was a no-reflow phenomenon. Univariable and multivariable logistic regression analysis was used to analyze the relevant data, including demographic characteristics, clinical characteristics, coronary angiography results, electrocardiogram (ECG) results, and biochemical indicators. Then, a nomogram model was constructed on the screened risk factors. The performance of the nomogram was evaluated in terms of discrimination and calibration. The nomogram was further confirmed in the internal validation group. Additionally, decision curve analysis (DCA) was applied to assess the clinical usefulness of the nomogram.ResultsFive remarkable risk factors were determined: preoperative TIMI blood flow, the diameter of the target lesion, collateral circulation, pulse pressure, and the number of leads for ST-segment elevation. The nomogram involving these five risk factors showed full calibration and discrimination in the training group, with an AUC of 0.71 (95% CI: 0.66–0.77). It was confirmed in the validation group, and the entire cohort and the AUC were 0.64 (95% CI: 0.56–0.73) and 0.69 (95% CI: 0.65–0.74), respectively. Whether in the training group or the verification group, the calibration curve for the probability of no-reflow phenomenon all showed considerable consistency between prediction by nomogram and actual observation. The decision curve revealed a specific role in our nomogram in clinical practice.ConclusionsWe set up a nomogram that showed absolute accuracy for the prediction of the risk of no-reflow after primary PCI in elderly STEMI patients.

Survival in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction

Background Field identification and treatment of ST-segment elevation myocardial infarction (STEMI) by paramedics is an important component of care for these patients. There is a paucity of studies in the setting of paramedic-identified STEMI. This study investigated mortality and factors associated with mortality in a large state-wide prehospital STEMI sample. Methods: Included were adult STEMI patients identified and treated with reperfusion therapy by paramedics in the field between January 2016 and December 2018 in Queensland, Australia. 30-day and one-year all-cause mortality was compared between two prehospital reperfusion pathways: prehospital fibrinolysis versus direct referral to a hospital for primary percutaneous coronary intervention (direct percutaneous coronary intervention [PCI] referral). For prehospital fibrinolysis patients, factors associated with failed fibrinolysis were investigated. For direct PCI referral patients, factors associated with mortality were examined. Results: The 30-day mortality was 2.2% for prehospital fibrinolysis group and 1.8% for direct PCI referral group (p = 0.661). One-year mortality for the two groups was 2.7% and 3.2%, respectively (p = 0.732). Failed prehospital fibrinolysis was observed in 20.1% of patients receiving this therapy, with male gender and history of heart failure being predictors. For direct PCI referral group, low left ventricular ejection fraction (LVEF) on admission and cardiogenic shock prior to PCI were predictors of both 30-day and one-year mortality. Aboriginal and Torres Strait Islander status, and impaired kidney function on admission, were associated with one-year but not 30-day mortality. Being overweight was associated with lower 30-day mortality. Conclusions: Mortality in STEMI patients identified and treated by paramedics was low, and the prehospital fibrinolysis treatment pathway was effective with a mortality rate comparable to that of patients undergoing primary PCI. Key words: prehospital; Queensland; cardiac reperfusion; STEMI

Prediction of no-reflow phenomenon in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

No-reflow is an important complication among patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).A retrospective study of 1658 STEMI patients undergoing direct PCI was performed. Patients were randomly assigned at a 7:3 ratio into development cohort and validation cohort and into no-reflow and normal blood flow groups. Clinical data and laboratory examinations were compared to identify independent risk factors and establish a no-reflow risk scoring system.In the development cohort (n = 1122), 331 (29.5%) had no-reflow. Multivariate analysis showed age ≥ 65 years (OR = 1.766, 95% confidence interval (CI): 1.313–2.376, P < .001), not using angiotonase inhibitor/angiotensin receptor antagonists (OR = 1.454, 95%CI: 1.084–1.951, P = .013), collateral circulation <grade 2 (OR = 3.056, 95%CI: 1.566–5.961, P = .001), thrombosis burden ≥4 points (OR = 2.033, 95%CI: 1.370–3.018, P < .001), diameter of target lesion ≥3.5 mm (OR = 1.511, 95%CI: 1.087–2.100, P = .014), thrombosis aspiration (OR = 1.422, 95%CI: 1.042–1.941, P = .026), and blood glucose >8 mmol/L (OR = 1.386, 95%CI: 1.007–1.908, P = .045) were related to no-reflow. Receiver operating characteristic (ROC) area under the curve was 0.648 (95%CI: 0.609–0.86). At 0.349 cutoff sensitivity was 42.0%, specificity was 79.3%, positive predictive value (PPV) was 44.7%, negative predictive value (NPV) was 77.4%, P < .001. The resulting risk scoring system was tested in the validation cohort (n = 536), with 30.1% incidence of no-reflow. The area under the ROC curve was 0.637 (95%CI: 0.582–0.692). At a cutoff of 0.349 sensitivity was 53.2% and specificity was 66.7%, PPV was 41.2%, NPV was 76.4%, P < .001.The no-reflow risk scoring system was effective in identifying high-risk patients.

Minimally invasive coronary bypass versus percutaneous coronary intervention for isolated complex stenosis of the left anterior descending coronary artery

ObjectiveDebate continues as to the optimal minimally invasive treatment modality for complex disease of the left anterior descending coronary artery, with advocates for both robotic-assisted minimally invasive direct coronary artery bypass and percutaneous coronary intervention with a drug-eluting stent. We analyzed the midterm outcomes of patients with isolated left anterior descending disease, revascularized by minimally invasive direct coronary artery bypass or drug-eluting stent percutaneous coronary intervention, focusing on those with complex lesion anatomy. MethodsA retrospective review was undertaken of all patients who underwent coronary revascularization between January 2008 and December 2016. From this population, 158 propensity-matched pairs of patients were generated from 158 individuals who underwent minimally invasive direct coronary artery bypass for isolated complex left anterior descending disease and from 373 patients who underwent percutaneous coronary intervention using a second-generation drug-eluting stent. Midterm survival and incidence of repeat left anterior descending intervention were analyzed for both patient groups. ResultsOverall 9-year survival was not significantly different between patient groups both before and after propensity matching. Midterm mortality in the matched minimally invasive direct coronary artery bypass group was low, irrespective of patient risk profile. By contrast, advanced age (hazard ratio, 1.10; P = .012) and obesity (hazard ratio, 1.09; P = .044) predicted increased late death after drug-eluting stent percutaneous coronary intervention among matched patients. Patients who underwent minimally invasive direct coronary artery bypass were significantly less likely to require repeat left anterior descending revascularization than those who had percutaneous coronary intervention, both before and after propensity matching. Smaller stent diameter in drug-eluting stent percutaneous coronary intervention was associated with increased left anterior descending reintervention (hazard ratio, 3.53; P = .005). ConclusionsIn patients with complex disease of the left anterior descending artery, both minimally invasive direct coronary artery bypass and percutaneous coronary intervention are associated with similar excellent intermediate-term survival, although reintervention requirements are lower after surgery.

Correlation between intracoronary thrombus components and coronary blood flow after percutaneous coronary intervention for acute myocardial infarction at different onset time.

BACKGROUNDAcute myocardial infarction (AMI) is a leading cause of mortality. Early reperfusion to restore blood flow is crucial to successful treatment. In the current reperfusion regimen, an increasing number of patients have benefited from direct percutaneous coronary intervention (PCI). In order to understand whether there is a correlation between the components of coronary thrombosis and the absence of reflow or slow blood flow after coronary stent implantation in direct PCI, we collected data on direct PCI cases in our hospital between January 2016 and November 2018.AIMTo investigate the correlation between intracoronary thrombus components and coronary blood flow after stent implantation in direct PCI in AMI.METHODSWe enrolled 154 patients (85 male and 69 female, aged 36–81 years) with direct PCI who underwent thrombus catheter aspiration within < 3, 3–6 or 6–12 h of onset of AMI between January 2016 and November 2018. The thrombus was removed for pathological examination under a microscope. The patients of the three groups according to the onset time of AMI were further divided into those with a white or red thrombus. The thrombolysis in myocardial infarction (TIMI) blood flow after stent implantation was recorded based on digital subtraction angiography during PCI. The number of patients with no-reflow and slow blood flow in each group was counted. Statistical analysis was performed based on data such as onset time, TIMI blood flow.RESULTSThere were significant differences in thrombus components between the patients with acute ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction (P < 0.01). In the group with PCI < 3 h after onset of AMI, there was no significant difference in the incidence of no-reflow and slow-flow between the white and red thrombus groups. In the groups with PCI 3-6 and 6-12 h after onset of AMI, there was a significant difference in the incidence of no-reflow and slow-flow between the white and red thrombus groups (P < 0.01). There was a significant correlation between the onset time of AMI and the occurrences of no-reflow and slow blood flow during PCI (P < 0.01).CONCLUSIONIn direct PCI, the onset time of AMI and color of coronary thrombus are often used to predict whether there will be no reflow or slow blood flow after stent implantation.

Corrigendum to "Minimally invasive direct coronary artery bypass graft surgery versus percutaneous coronary intervention of the LAD: costs and long-term outcome".

Corrigendum to "Minimally invasive direct coronary artery bypass graft surgery versus percutaneous coronary intervention of the LAD: costs and long-term outcome".

Minimally invasive direct coronary artery bypass graft surgery versus percutaneous coronary intervention of the LAD: costs and long-term outcome.

Outcomes and treatment costs for coronary artery disease involving the left anterior descending coronary artery (LAD) are influenced by the type of treatment, which can be either isolated minimally invasive revascularization of the LAD using the internal thoracic artery (ITA) (MIDCAB) or percutaneous coronary intervention (PCI) on the LAD. This retrospective study sought to evaluate long-term survival, freedom from re-intervention and cost analysis after MIDCAB compared to PCI on the LAD. Between 2006 and 2012, from a total of 561 patients, 106 consecutive patients with LAD stenosis underwent a MIDCAB procedure whereas 100 patients underwent elective PCI. Urgent and emergent cases were excluded from the present study (n = 355). Detailed analysis of the outcome data was performed for both groups. A Kaplan-Meier survival estimation with up to 10-year follow-up was applied for both groups for survival analysis and freedom from re-intervention. There were no statistically significant differences in terms of clinically relevant baseline characteristics. The outcome in the MIDCAB group was superior regarding long-term overall survival, accounting for 100% versus 92.8% at 1 year, 98.5% versus 82.1% at 6 years and 79.6% versus 61.5% at 10 years (Log Rank (Mantel-Cox) p = 0.011) and freedom from re-intervention at 10 years (97.2% vs. 86.7%, Log Rank (Mantel-Cox) p = 0.001). Intensive care unit (ICU) stay (p = 0.020) and total hospital stay (p<0.001) were significantly longer in the MIDCAB group, which was also associated with higher in-hospital costs (10,879 € vs. 4009 €, p<0.001). Whereas patients undergoing MIDCAB remained longer on ICU and in hospital, causing higher costs, this procedure was associated with a significantly lower incidence of repeat revascularization and significantly lower mortality compared to PCI on the LAD.

Referral of patients for fractional flow reserve using quantitative flow ratio.

Quantitative flow ratio (QFR) is a recently developed technique to calculate fractional flow reserve (FFR) based on 3D quantitative coronary angiography and computational fluid dynamics, obviating the need for a pressure-wire and hyperaemia induction. QFR might be used to guide patient selection for FFR and subsequent percutaneous coronary intervention (PCI) referral in hospitals not capable to perform FFR and PCI. We aimed to investigate the feasibility to use QFR to appropriately select patients for FFR referral. Patients who underwent invasive coronary angiography in a hospital where FFR and PCI could not be performed and were referred to our hospital for invasive FFR measurement, were included. Angiogram images from the referring hospitals were retrospectively collected for QFR analysis. Based on QFR cut-off values of 0.77 and 0.86, our patient cohort was reclassified to 'no referral' (QFR ≥0.86), referral for 'FFR' (QFR 0.78-0.85), or 'direct PCI' (QFR ≤0.77). In total, 290 patients were included. Overall accuracy of QFR to detect an invasive FFR of ≤0.80 was 86%. Based on a QFR cut-off value of 0.86, a 50% reduction in patient referral for FFR could be obtained, while only 5% of these patients had an invasive FFR of ≤0.80 (thus, these patients were incorrectly reclassified to the 'no referral' group). Furthermore, 22% of the patients that still need to be referred could undergo direct PCI, based on a QFR cut-off value of 0.77. QFR is feasible to use for the selection of patients for FFR referral.

Evaluation of related factors, prediction and treatment drugs of no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction after direct PCI.

This study determined the related factors of no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction (STEMI) after direct percutaneous coronary intervention (PCI), and evaluated related factor scores in predicting the occurrence of no-reflow phenomenon and drug treatments. A total of 203 patients with acute STEMI receiving PCI who were admitted to the Department of Cardiovascularology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine (Xiangyang, China) from January 2015 to December 2016 were selected. The clinical and image data were analyzed to determine the related factors of no-reflow phenomenon after operation, and related factor scores were quantified to predict the occurrence of no-reflow phenomenon. Three drugs (diltiazem, nitroglycerin and tirofiban needles) were continuously injected in coronary arteries of patients with no-reflow phenomenon, and the effects of these drugs were analyzed. There were 38 patients (18.7%) with no-reflow phenomenon. The correlation analysis showed that 10 factors were associated with no-reflow phenomenon, in which five factors were identified as risk factors, including IRA open-up time ≥8 h, SBP <100 mmHg, Hs-CRP >18 mg/l, thrombus loads, length of the culprit vessel ≥20 mm. The score analysis of related factors of 38 patients with no-reflow phenomenon was conducted. Three points were set for five risk factors each, and 1 point was set for the other five factors each. It was found that the score was approximately normally distributed. The average was 11.5±1.57 points and the lower limit of 95% confidence interval was >8.93 points. The effective rates of three drugs were different (P<0.05), and the pairwise comparison showed their effective rates were not fully identical (P<0.05). The results showed that: i) Τhere are 10 related factors, including five risk factors; ii) related factors with the score ≥9 points can be used for clinical prediction of STEMI after direct PCI; and iii) it is obviously effective to use diltiazem needle and tirofiban needle to treat no-reflow phenomenon, but this conclusion lacks statistical support.

Evaluation on the impact of spontaneous reperfusion on cardiac muscle of acute myocardial infarction by three-dimensional speckle tracking imaging.

To explore the effect of spontaneous reperfusion (SR) on three-dimensional myocardial strain in patients with acute anterior myocardial infarction by three-dimensional speckle tracking imaging (3D-STI) technology. Patients diagnosed with acute anterior myocardial infarction during 2013 to 2016 were consecutively selected and divided into SR group and non-spontaneous reperfusion (Non-SR) group based on whether there was SR. Patients in both groups received direct percutaneous coronary intervention (PCI) in time window. Baseline information, patency rates of culprit vessel, durations of operation, intraoperative non-reflow phenomenon ratios, and thrombolysis in myocardial infarction (TIMI) blood flows after reperfusion of patients in each group were recorded. Hospital stays of patients were compared between the two groups. Before discharge, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDd) were measured. Global longitudinal strain (GLS), global radial strain (GRS), and global circumferential strain (GCS) of left ventricular (LV) were also detected by 3D-STI, so as to assess movement situations of ventricular wall and cardiac muscle in occlusive blood vessel distribution area. LVEF, LVEDd and various 3D-STI parameters were reexamined and compared one year after discharge. There were no significant differences between the Non-SR group and the SR group regarding the patency rate of culprit vessel, duration of operation, intraoperative non-reflow phenomenon ratio, TIMI blood flow after reperfusion, and LVEDd (p>0.05). Both LVEF before discharge and LV three-dimensional strain indexes of the SR group, were clearly higher than those of the Non-SR group (p<0.05). After one-year follow-up, the SR group had a remarkably lower LVEDd than the Non-SR group (p<0.05). LVEF of the SR group was overtly higher than that of the Non-SR group (p<0.05). LV three-dimensional strain indexes were also distinctly higher in the SR group than in the Non-SR group (p<0.05). There were good correlations between GLS, GRS, GCS and LVEF (r values were -0.620, -0.674 and 0.723, respectively). SR can improve nosocomial and long-term LV remodeling in patients with acute anterior myocardial infarction, and 3D-STI is able to assess ventricular remodeling after myocardial infarction.