Myocardial Infarction Flow Grade Research Articles

Prospective investigation of calcium score in optical coherence tomography-guided revascularization to identify lesions with low risk for stent under expansion: the CORAL study.

The optical coherence tomography (OCT)-based calcium scoring system was developed to guide optimal lesion preparation strategies for percutaneous coronary intervention (PCI) of calcified lesions. However, the score was derived retrospectively, and a prospective investigation is lacking. The CORAL (UMIN000053266) study was a single-arm, prospective, multicenter study that included patients with calcified lesions with OCT-calcium score of 1-2 to investigate whether these lesions could be optimally treated with a balloon-only preparation strategy using a non-compliant/scoring/cutting balloon. The primary endpoint was strategy success (successful stent placement with a final percent diameter stenosis [%DS] < 20% and Thrombolysis In Myocardial Infarction flow grade III without crossover to rotational atherectomy/orbital atherectomy/intravascular lithotripsy [RA/OA/IVL]). A superiority analysis for the primary endpoint was performed by comparing the study cohort with a performance goal of 83.3%. One hundred and eighteen patients with 130 lesions were enrolled. The mean age was 79.0 ± 10.3years, and 79 patients (66.9%) were male. The OCT-calcium score was 1 for 81 lesions (62.3%) and 2 for 49 lesions (37.7%). The %DS improved from 47.0 ± 14.8% preprocedure to 11.1 ± 5.6% postprocedure. Stent expansion ≥ 70% was achieved in 90.2%. The strategy success rate was 93.1% (95% confidence interval: 87.3-96.8), and superiority against the performance goal was achieved without any crossover to RA/OA/IVL (P = 0.0027). The OCT-calcium score could identify mild/moderately calcified lesions treatable by PCI with the balloon-first strategy using a non-compliant/scoring/cutting balloon for predilatation, with a high strategy success rate. These results support the intravascular imaging-based treatment algorithm for calcified lesions proposed by CVIT.

Intracoronary Versus Intravenous Low-Dose Tirofiban in Patients With ST-Elevation Myocardial Infarction: A Meta-Analysis of Randomised Controlled Trials

This meta-analysis aimed to evaluate the effects of intracoronary (IC) low-dose tirofiban versus intravenous (IV) administration on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). All published randomised controlled trials (RCTs) comparing the effects of IC low-dose tirofiban (a bolus of ≤10 ug/kg) versus IV administration in patients with STEMI were identified by searching PubMed, EMBASE, Cochrane Library, and ISI Web of Science from inception to June 2023, with no language restriction. The risk ratio (RR) with 95% confidence intervals (CI) and the weighted mean difference (WMD) with 95% CI were calculated. Eleven RCTs involving 1,802 patients were included. Compared with the IV group, IC low-dose tirofiban was associated with improved major adverse cardiac events rate (RR 0.595, 95% CI 0.442-0.802; p=0.001), left ventricular ejection fraction (WMD 1.982, 95% CI 0.565-3.398; p=0.006), thrombolysis in myocardial infarction (TIMI) flow grade (RR 1.065, 95% CI 1.004-1.131; p=0.037), and TIMI myocardial perfusion grade (RR 1.194, 95% CI 1.001-1.425; p=0.049). The two groups had no significant difference in bleeding events (RR 0.952, 95% CI 0.709-1.279; p=0.745). Intracoronary low-dose tirofiban administration may be a safe and effective alternative to IV administration in STEMI patients.

Effect of Early Heparin Anticoagulation on Blood Flow and Cardiac Function in Patients with Acute ST Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Objective: This study aimed to investigate the effect of early administration of heparin anticoagulation on blood flow and cardiac function in patients with acute ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI). Methods: A retrospective analysis was conducted on 730 patients with STEMI who underwent PPCI at the Department of Cardiology of the Chengdu Fifth People's Hospital of Chengdu from December 2017 to May 2023. According to the timing of heparin administration. The patients were divided into two groups based on the timing of heparin administration: the early group (3000 U unfractionated heparin administered immediately after the diagnosis of STEMI) and the delayed group (Intravenous injection of ordinary heparin 3000 U after successful interventional catheterization following the diagnosis of STEMI). The study compared general clinical data, myocardial injury markers (initial troponin, peak troponin, and tmax troponin), interventional related indicators (preprocedural thrombolysis in myocardial infarction (TIMI) flow grade, postprocedural TIMI flow grade, stent length, and thrombus aspiration), and postoperative indexes ST segment resolution (STR), left ventricular ejection fraction (LVEF), n-terminal pro-brain natriuretic peptide (NT-proBNP), major adverse cardiovascular events (MACE), and bleeding events. Results: The early group had a lower proportion of TIMI 0–1 grade and a higher proportion of TIMI 2–3 grade compared to the delayed group (p &lt; 0.05). The early group showed better ST segment resolution (p &lt; 0.05). There was no significant difference in LVEF and NT-proBNP classification between the two groups (p &gt; 0.05). Subgroup analysis suggested an interaction between early heparin anticoagulation and left anterior descending infarct-related artery (IRA) on cardiac function. There was no significant difference in the incidence of MACE and bleeding events between the two groups (p &gt; 0.05). Logistic regression analysis revealed that early heparin anticoagulation was a predictor of immediate TIMI grade 2–3 flow, and TIMI grade 2–3 flow was negatively correlated with early heparin anticoagulation. Conclusions: Early heparin anticoagulation can improve the patency of the IRA and myocardial perfusion in patients with STEMI. Additionally, it can reduce myocardial injury and improve cardiac function without increasing the risk of in-hospital bleeding.

Optical coherence tomography analysis of lesion characteristics and thrombus types in non ST-segment elevation myocardial infarction patients

The precise features of lesions in non-ST-segment elevation myocardial infarction (NSTEMI) patients with total occlusion (TO) of the infarct-related artery (IRA) are still unclear. This study employs optical coherence tomography (OCT) to investigate pathological features in NSTEMI patients with or without IRA TO and explores the relationship between thrombus types and IRA occlusive status. This was a single-center retrospective study. A total of 202 patients diagnosed with NSTEMI were divided into two groups: those with Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 before percutaneous coronary intervention (PCI) (referred to as the TO group, n = 100) and those TIMI flow grade 1–3 (referred to as the Non-TO group, n = 102). Baseline characteristics, coronary angiography findings, and OCT results were collected. Multivariate logistic analysis identified factors influencing TO in NSTEMI. The category of NSTEMI was further subdivided based on the type of electrocardiogram (ECG) into two subgroups: ST segment unoffset myocardial infarction (STUMI) and ST segment depression myocardial infarction (STDMI). This division allows for a more specific classification of NSTEMI cases. The TO group had a younger age, higher male representation, more smokers, lower hypertension and cerebrovascular disease incidence, lower left ventricular ejection fraction (LVEF), and higher creatine kinase myocardial band (CKMB) and creatine kinase (CK) peak levels. In the TO group, LCX served as the main IRA (52.0%), whereas in the Non-TO group, LAD was the predominant IRA (45.1%). Compared to the Non-TO group, OCT findings demonstrated that red thrombus/mixed thrombus was more common in the TO group, along with a lower occurrence of white thrombus (p < 0.001). The TO group exhibited a higher prevalence of STUMI (p = 0.001), whereas STDMI was more commonly observed in the Non-TO group (p = 0.001). NSTEMI presents as STUMI and STDMI distinct entities. Red thrombus/mixed thrombus in IRA often indicates occlusive lesions with STUMI on ECG. White thrombus suggests non-occlusive lesions with STDMI on ECG.

Early unfractionated heparin treatment in patients with STEMI – trial design and rationale

The early unfractionated heparin (UFH) treatment in patients with ST-elevation myocardial infarction (STEMI) is a single-center, open-label, randomized controlled trial. The study population are patients with STEMI that undergo primary percutaneous coronary intervention (PPCI). The trial was designed to investigate whether early administration of unfractionated heparin immediately after diagnosis of STEMI is beneficial in terms of patency of infarct-related coronary artery (IRA) when compared to established UFH administration at the time of coronary intervention. The patients will be randomized in 1:1 fashion in one of the two groups. The primary efficacy endpoint of the study is Thrombolysis in myocardial infarction (TIMI) flow grades 2 and 3 on diagnostic coronary angiography. Secondary outcome measures are: TIMI flow after PPCI, progression to cardiogenic shock, 30-day mortality, ST-segment resolution, highest Troponin I and Troponin I values at 24 hours. The safety outcome is bleeding complications. The study of early heparin administration in patients with STEMI will address whether pretreatment with UFH can increase the rate of spontaneous reperfusion of infarct-related coronary artery.

Comparison of Post PCI TIMI Flow Between Diabetic and Non-Diabetic Individuals

Background: Cardiovascular diseases remain the leading cause of morbidity and mortality globally, with diabetes significantly exacerbating the incidence and severity of coronary artery disease. Diabetic patients experience altered coronary blood flow dynamics, which can impact the efficacy of therapeutic interventions like percutaneous coronary intervention (PCI). Objective: This study aims to compare the post-PCI Thrombolysis in Myocardial Infarction (TIMI) flow grades between diabetic and non-diabetic patients to assess the impact of diabetes on the short-term outcomes of coronary revascularization. Methods: A retrospective observational study was conducted at the National Institute of Cardiovascular Diseases in Karachi, involving 3,000 patients who underwent primary PCI between January 2018 and December 2020. Patients were categorized into diabetic (1,500) and non-diabetic (1,500) groups. Data collected included demographics, coronary artery risk factors, TIMI flow grades before and after PCI, and the use of GPIIb/IIIa inhibitors. Statistical analysis was performed using SPSS version 25, employing chi-square tests, t-tests, and Mann-Whitney U tests for comparative analysis, with a p-value of &lt;0.05 considered statistically significant. Results: The study found significant differences in postoperative TIMI3 flow rates, with non-diabetic patients achieving a higher rate of TIMI3 (59.4%) compared to diabetic patients (58.1%). The use of GPIIb/IIIa inhibitors was higher in diabetic patients (34.7%) than in non-diabetic patients (1.8%). Additionally, diabetic patients showed a higher incidence of multi-vessel disease and more severe lesion profiles, including higher rates of triple branch lesions (45.9% vs. 39.9%) and left main lesions (53% vs. 43.9%). Conclusion: Diabetic patients exhibit worse post-PCI TIMI flow grades and more complex coronary lesions compared to non-diabetic patients, suggesting that diabetes adversely affects the outcomes of coronary revascularization. These findings underscore the need for tailored therapeutic approaches to improve PCI outcomes in diabetic patients.

Risk factors for electrical storms following percutaneous coronary intervention in patients with acute myocardial infarction: A meta-analysis.

Electrical storms (ESs) following percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) patients pose a significant challenge, affecting prognostic outcomes and increasing mortality. This meta-analysis synthesized data from 11 studies involving 9,666 AMI patients to identify risk factors associated with ES following PCI. Our findings revealed an average ES incidence of 7.70%, with identified risk factors including low thrombolysis in myocardial infarction (TIMI) flow grades (0-1), elevated cardiac troponin I levels, persistent hypotension, reperfusion arrhythmias, the right coronary artery being the infarct-related artery, increased diameter of the infarct-related artery, renal dysfunction, elevated creatine kinase-MB, and bradycardia. Notably, the use of β-blockers was found to significantly reduce the risk of ES. The study underscores the importance of early identification and management of these risk factors in AMI patients undergoing PCI to prevent the occurrence of ES, highlighting the protective role of β-blockers. This research provides a foundation for future strategies aimed at reducing the incidence and improving the prognosis of ES in this patient population.

Use of the Indigo CAT RX aspiration system during percutaneous coronary intervention.

The use of the Indigo CAT RX Aspiration System (Penumbra Inc.) during percutaneous coronary intervention has received limited study. We retrospectively examined the clinical, angiographic, and procedural characteristics, outcomes, and follow-up of patients who underwent mechanical aspiration thrombectomy with the Indigo CAT RX system (Penumbra Inc.) at a large tertiary care hospital between January 2019 and April 2023. During the study period, 83 patients (85 lesions) underwent thrombectomy with the Indigo CAT RX. Mean patient age was 64.9 ± 14.48 years and 31.2% were women. The most common presentations were ST-segment elevation myocardial infarction (MI) (66.2%) and non-ST-segment elevation MI (26.5%). A final thrombolysis in MI flow grade of 3 and final myocardial blush grade of 3 were achieved in 76% and 46% of the cases, respectively. Technical success was achieved in 88.9% of the cases that included Indigo CAT RX treatment only, compared with 57.1% of the cases that also included manual aspiration. There were no device-related serious adverse events. At 30-day postprocedure, the incidence of major adverse cardiac events (composite of cardiovascular death, recurrent MI, cardiogenic shock, new or worsening New York Heart Association Class IV heart failure, stroke) was 8.5%: 1.3% stroke (postprocedure, in-hospital), 1.3% MI, 6.1% cardiac death, and 7.5% developed cardiogenic shock. Use of the Indigo CAT RX system is associated with high technical success and acceptable risk of complications, including stroke.

Predictors of No-Reflow Phenomenon in Primary Percutaneous Coronary Intervention among Patients with Acute Myocardial Infarction

Background: The no-reflow phenomenon, characterized by the failure to restore myocardial blood flow after reopening an occluded artery in acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI), has significant implications for patient prognosis. Understanding the predictors of no-reflow is crucial for improving clinical outcomes in this high-risk population. Objective: This study aims to identify the predictors of the no-reflow phenomenon in patients with AMI undergoing PCI and to assess their impact on the efficacy of the intervention. Methods: Conducted at Lady Reading Hospital's Cardiology Department, this descriptive study retrospectively analyzed 120 AMI patients treated with PCI from May 2023 to November 2023. Ethical approval was obtained, and the study conformed to the Declaration of Helsinki. The diagnosis of AMI was based on clinical symptoms and electrocardiographic findings. Experienced cardiologists performed PCI, and no-reflow was defined using Thrombolysis in Myocardial Infarction (TIMI) flow grades and Myocardial Blush Grade (MBG). Data were analyzed using SPSS Version 25, focusing on demographic variables, clinical presentations, and procedural details to identify predictors of no-reflow. Results: Out of 120 patients, 70.8% were male. The incidence of no-reflow was 22.5%. Significant predictors of no-reflow included systolic blood pressure &lt; 100 mmHg (51.9% in no-reflow vs. 28.0% in normal flow, P=0.02), diabetes (59.3% vs. 34.4%, P=0.02), hypertension (77.8% vs. 31.2%, P=0.0001), and history of cardiovascular disease (11.1% vs. 2.2%, P=0.04). Conclusion: The study identified diabetes, hypertension, low systolic blood pressure, and a history of cardiovascular disease as significant predictors of the no-reflow phenomenon in AMI patients undergoing PCI. These findings highlight the importance of identifying and managing these risk factors to enhance the success of PCI and improve patient outcomes.

A New Scoring System Predicting Side-Branch Occlusion in Patients Undergoing Left Main Bifurcation Intervention: The LM V-RESOLVE Score

BackgroundThe risk of side-branch (SB) occlusion is pivotal for decision making of stenting strategies during unprotected left main (LM) bifurcation percutaneous coronary intervention (PCI). Accordingly, this study aimed to develop a scoring system for predicting SB occlusion during unprotected LM bifurcation PCI. MethodsA total of 855 consecutive patients undergoing unprotected LM bifurcation PCI with provisional strategy at Fuwai Hospital from January 2014 to December 2016 were recruited. A prediction model was selected by means of all-subsets logistic regression, and a multivariable risk score (Left Main Visual Estimation for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention [LM V-RESOLVE]) was then established with incremental weights attributed to each component variable based on its estimate coefficients. SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction (TIMI) flow grade or absence of flow in SB after main vessel (MV) stenting. ResultsSB occlusion occurred in 19 LM bifurcation lesions (2.22%). In multivariable model, 3 variables, including MV/SB diameter ratio, MV plaque ipsilateral to SB, and baseline diameter stenosis of SB, were independent predictors for SB occlusion (model C-statistic 0.829, 95% confidence interval [CI] 0.735-0.923, with good calibration). The risk score had a C-statistics of 0.830 (95% CI 0.738-0.923) with good calibration. Satisfactory discriminative ability of the risk score was also preserved in external validation (C-statistic 0.794, 95% CI 0.691-0.896). ConclusionsThe LM bifurcation–specific novel scoring system, LM V-RESOLVE, based on 3 simple baseline angiographic findings, could help to rapidly discriminate lesions at risk of SB occlusion during LM bifurcation PCI.

Association between apelin-12 and creatine kinase-MB, depending on success of reperfusion in STEMI patients.

Acute myocardial infarction is characterised by an imbalance in the supply and demand of oxygen in the heart. It requires urgent reperfusion, and poor outcomes are attributed to myocardial ischaemia-reperfusion injury. We aimed to evaluate the association between apelin-12 levels and creatine kinase-MB activity in predicting the effectiveness of reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) patients. In this study we included 72 patients with the following criteria: chest pain suggestive of myocardial ischaemia for at least 30 minutes, an electrocardiogram with ST-segment elevation (measured at the J-point) ≥ 2 mm in leads V2-V3 and/or ≥ 1 mm in the other leads, rise of specific biomarkers such as cardiac troponin and the MB fraction of creatine kinase (CK-MB), and those who underwent reperfusion therapy. Blood samples for the measurement of apelin-12 and creatine kinase-MB were collected 12 hours after the reperfusion therapy. In patients with thrombolysis in myocardial infarction (TIMI) flow grade ≤ 2, the median of the apelin-12 level was 1.80 ng/ml (0.46-9.20), and with TIMI flow 3, it was 5.76 ng/ml (1.14-15.2). Variability was observed in the apelin values (Mann-Whitney test) based on TIMI flow grade (p < 0.001), while no variability was observed for creatine kinase-MB (p < 0.18). The degree of association between apelin-12 and creatine kinase-MB levels was analysed with Pearson's correlation, enabling us to determine patients with successful reperfusion (determined as TIMI flow 3) (p < 0.004), and those with unsuccessful reperfusion (with TIMI flow ≤ 2) (p = 0.86). In STEMI patients undergoing reperfusion therapy, Apelin-12 level was associated with creatine kinase-MB activity according to the success of the reperfusion.

Association of Total Ischemia Time with No-Reflow Phenomenon in Patients Presenting with STElevation Myocardial Infarction, Undergoing Primary Percutaneous Coronary Intervention

Objective: To find out the association of total ischemic time with no-reflow phenomenon, in terms of Thrombolysis in Myocardial Infarction (TIMI) flow grade, in patients presenting with ST-Elevation Myocardial Infarction and undergoing Primary Percutaneous Coronary Intervention(PPCI). Study Design: Analytical Cross-Sectional study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi Pakistan, from Nov, 2022 to Jan, 2023. Methodology: This analytical cross-sectional study was conducted on n=184 patients, recruited through consecutive sampling technique to collect data prospectively. Patients were divided into no-reflow and normal flow group. Patients’ total ischemic time was documented and pre &amp; post-procedural TIMI flow was noted. SPSS version-24:00 was used to enter and analyze data. Chi-square, Fisher exact test and t-test were applied and p-value≤0.05 was taken as statistically significant. Results: Out of 184 study participants, 17(9.2%) were females as compared to 167(90.8%) males. The mean age was 60.23±10.28 years. No-reflow phenomenon was observed in 20(10.9%) patients. The mean age was higher in the no-reflow group than that of the normal flow group (62.65±11.61 vs 59.94±10.12 years). Total ischemic time, pre &amp; post-procedural TIMI flow were found to be significantly associated with no-reflow phenomenon (p&lt;0.05). Conclusion: There exists a strong association between total ischemic time and the occurrence of no-reflow phenomenon. Patients with delayed reperfusion present with greater frequency of no-reflow and low TIMI grade and vice versa.

Prognostic value of arterial lactate index in ST-elevation myocardial infarction treated with primary percutaneous coronary intervention: a prospective cohort study.

Aim: Limited knowledge exists on the pathophysiological cascade beyond serum lactate's association with myocardial injury. Method: Assessed the prognostic value of lactate index on periprocedural variables and its impact on 30-day major adverse cardiovascular events (MACE)in 300 prospective ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Results: Significant correlations were observed between admission lactate and Killip class, periprocedural time intervals, postprocedure thrombolysis in myocardial infarction (TIMI) flow and myocardial blush grade (MBG;p<0.01). Lactate levels correlated with diminished ST-deviation resolution, cardiac enzymes (CK-MB, troponin;p<0.001; 0.004), and lower ejection fraction (p<0.001). This relationship impacted 30-day MACE (p<0.001). Conclusion: Hyperlactatemia in STEMI patients undergoing pPCI is associated with worse Killip class, unsatisfactory TIMI flow, MBG, larger infarct size and higher 30-day MACE. Serum lactate aids risk stratification in pPCI for STEMI patients.

Development of a simple prediction model for mechanical complication in ST-segment elevation myocardial infarction patients after primary percutaneous coronary intervention.

Mechanical complication (MC) is a rare but serious complication in patients with ST-segment elevation myocardial infarction (STEMI). Although several risk factors for MC have been reported, a prediction model for MC has not been established. This study aimed to develop a simple prediction model for MC after STEMI. We included 1717 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Of 1717 patients, 45 MCs occurred after primary PCI. Prespecified predictors were determined to develop a tentative prediction model for MC using multivariable regression analysis. Then, a simple prediction model for MC was generated. Age ≥ 70, Killip class ≥ 2, white blood cell ≥ 10,000/µl, and onset-to-visit time ≥ 8h were included in a simple prediction model as "point 1" risk score, whereas initial thrombolysis in myocardial infarction (TIMI) flow grade ≤ 1 and final TIMI flow grade ≤ 2 were included as "point 2" risk score. The simple prediction model for MC showed good discrimination with the optimism-corrected area under the receiver-operating characteristic curve of 0.850 (95% CI: 0.798-0.902). The predicted probability for MC was 0-2% in patients with 0-4 points of risk score, whereas that was 6-50% in patients with 5-8 points. In conclusion, we developed a simple prediction model for MC. We may be able to predict the probability for MC by this simple prediction model.

Relation Between Calcium-Phosphorus Product and Total Coronary Artery Occlusion in a Nonchronic Kidney Disease Population: A Cross-Sectional Study

Excessive calcium-phosphorus product (Ca-P product) in patients with chronic kidney disease (CKD) is associated with coronary artery calcification and coronary artery disease, but the relation between Ca-P product and coronary artery disease in non-CKD populations has rarely been reported. Therefore, we designed a cross-sectional study to investigate the role of Ca-P product in total coronary artery occlusion (TCAO) in a non-CKD population. We reviewed 983 patients who underwent coronary angiography at Guangyuan Central Hospital from February 2018 to January 2020. Ca-P product (mg2/dl2) was calculated as Ca (mmol/L)×4×P (mmol/L)×3.1 and was analyzed as a continuous and tertiary variable. TCAO was defined as complete occlusion of any coronary artery by coronary angiography (thrombolysis in myocardial infarction flow grade 0). Statistical analysis was performed using univariate and multivariate logistic regression models and restricted cubic splines. Univariate logistic regression analysis showed a statistically significant association between Ca-P product and TCAO (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95 to 0.99, p <0.001). After stepwise adjustment for covariates, the risk of TCAO was reduced by 40% in the high versus low Ca-P group (OR 0.6, 95% CI 0.38 to 0.95, p=0.031), and the risk of TCAO was predicted to decrease by 4% (OR 0.96, 95% CI 0.94 to 0.99, p=0.006) for each unit increase in Ca-P product. Restricted cubic splines showed a nonlinear relation between Ca-P product and TCAO, with a significant decrease in the risk of TCAO after reaching 27.46 (nonlinear p=0.047). In conclusion, in non-CKD populations, a higher Ca-P product (≥27.46mg2/dl2) may help avoid TCAO.

Same day discharge after large bore vascular access in percutaneous coronary intervention of chronic total coronary occlusions

Abstract Background Same day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) of a chronic total coronary occlusion (CTO) appears feasible, safe, and carries economic advantage. However, SDD may be hampered by the application of large bore dual arterial access, due to its association with vascular complications. Nevertheless, increasing French size augments therapeutic options and is therefore considered fundamental in complex CTO PCI. Purpose The present study investigated the feasibility of SDD in patients undergoing CTO PCI with large bore dual arterial access. Methods Between 2013 and 2018, a total of 683 patients were prospectively enrolled in a single-center CTO registry and underwent single-vessel CTO PCI. Large bore arterial access was defined as the application of 7 and/or 8 French sheaths in at least one access site. Technical success was defined as Thrombolysis in Myocardial Infarction flow grade 3 and residual stenosis &amp;lt;30%. Vascular access complications were defined as a composite of clinically significant bleeding and/or hematoma, urgent transfusion, dissection, pseudoaneurysm, arteriovenous fistula formation, and thrombosis. Results Mean age was 66 ± 11 years; 83% were male. Large bore arterial access was applied in 87%; the most common set-up was radial-femoral (68%) and bifemoral (23%) access. In 432 (62%) patients, SDD was achieved. Patients within the SDD group were younger and had lower rates of prior MI, prior CABG, renal insufficiency, and peripheral artery disease. A high Japanese CTO score (≥2) was less common in patients with versus without SDD (58% vs. 72%, p&amp;lt;0.001). In addition, technical success rate was higher in the SDD group (96% vs. 89%, p&amp;lt;0.001). Vascular access complications were found in 22 (3,2%) cases, with 17 (77,2%) occurring in the non-SDD group. Local access site bleeding was found to be the most common complication (82,4% of total vascular access complications). Finally, multivariable analysis showed that female gender (OR 2.22, 95% CI: 1.30 – 3.78) and local access site bleeding (OR 12.0, 95% CI: 4.37 – 33.21) were significantly associated with a lower probability of SDD. Conclusions Our study demonstrates the feasibility of SDD in the majority of patients undergoing CTO PCI with large bore dual arterial access, with high rates of technical CTO PCI success and acceptable vascular access complication rates. Care should be taken to avoid local access site bleeding since this hinders SDD.

Usefulness of canada acute coronary syndrome risk score for predicting no-/slow-reflow in ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background The no-/slow-reflow phenomenon following primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) patients is associated with a poor prognosis. Early identification of high-risk patients of no-/slow-reflow is critical. This study sought to evaluate the predictive ability of the Canada Acute Coronary Syndrome (C-ACS) risk score for no-/slow-reflow in these patients. Methods STEMI patients who underwent primary PCI were consecutively enrolled and divided into three groups based on the C-ACS score: 0, 1, and ≥2. The C-ACS score was computed using the four clinical variables evaluated at admission (1 point for each): age ≥75 years, heart rate &amp;gt;100 beats/min, systolic blood pressure &amp;lt;100 mmHg, and Killip class &amp;gt;1. No-/slow-reflow was defined as thrombolysis in myocardial infarction flow grade 0 to 2 after primary PCI. The predictive ability of the C-ACS score for no-/slow-reflow was evaluated by the receiver operating characteristic curve. Results Overall, 834 patients were enrolled, with 109 (13.1%) developing no-/slow-reflow. The incidence of no-/slow-reflow increased from the C-ACS 0 group to C-ACS ≥2 group (10.7% vs 17.7% vs 32.2%, respectively, p&amp;lt;0.001). After multivariable adjustment, the C-ACS score was an independent predictor of no-/slow-reflow (odd ratio 2.623, 95% confidence interval 1.948-3.532, p&amp;lt;0.001). Furthermore, the C-ACS score possessed good discrimination for no-/slow-reflow (area under the curve 0.707, 95% CI 0.653-0.762, p&amp;lt;0.001). Further subgroup analyses indicated a significant interaction of C-ACS score with patient sex (p for interaction =0.011). The independent association between C-ACS score and no-/slow-reflow was only observed in male patients (odd ratio 3.061, 95% confidence interval 1.931-4.852, p&amp;lt;0.001). During a median follow-up duration of 4.3 years, the C-ACS score was independently associated with major adverse cardiovascular events independently of the occurrence of no-/slow-reflow (p for interaction =0.212). Conclusion The C-ACS risk score could independently predict the no-/slow-reflow in STEMI patients undergoing primary PCI, particularly in male patients.

Revascularization of coronary chronic total occlusions in the elderly: what results? - The insights of a multicentre national registry

Abstract Lately, the remarkable progress in knowledge and treatment of cardiovascular diseases has been significantly impacting society's morbidity and mortality. However, the burden of coronary artery disease (CAD) remains non-negligible. In addition, as a consequence of demographic changes, age, as a non-modifiable cardiovascular risk factor, makes it increasingly important to focus on the elderly. Up to one-fifth of patients with CAD have a chronic total occlusion (CTO) of a coronary artery, defined as a lesion with 100% stenosis and Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 that exists for more than 3 months. There is current evidence that successful CTO-percutaneous coronary intervention (PCI) is associated with clinical benefits. However, elderly patients are currently underrepresented in CTO-PCI randomized controlled trials and registries, and its clinical impact and safety in this group of patients are still debated. This study aims to characterise patients submitted to CTO-PCI and compare the baseline characteristics, coronary intervention features, intraprocedural complications and in-hospital mortality between patients younger and older than 75. The authors performed a retrospective analysis of adult patients submitted to a CTO-PCI, included in the Portuguese Registry on Interventional Cardiology between January 2019 and December 2022. Comparison tests between groups for parametric and non-parametric variables were performed. A p-value less than 0.05 was considered statistically significant. A total of 353 patients who underwent CTO-PCI were analysed, 271 (76.8%) with 18 to 74 years old (group 1) and 82 (23.2%) with 75 or more years old (group 2). Table 1 shows the most important baseline characteristics, with similar features for both groups except body mass index and smoking habits. Table 2 demonstrates the differences between the groups regarding PCI, with the left main and left anterior descending arteries being more treated among older patients and the right coronary artery in younger patients. Complete coronary revascularization and procedure success rate did not differ significantly between groups (p-value=0.19 and p-value=0.59, respectively). Finally, table 3 presents the main intra-procedural and in-hospital complications, with a significant difference only for occlusion of the side branch, occurring in 2 patients aged over 75 years (p-value=0.01). In conclusion, in our registry, the elderly presents a high success rate in the complete recanalization of CTO lesions, comparable to the group under 75 years of age. However, the presence of side branch occlusion was higher in older patients, without other significant differences in intraprocedural and in-hospital complications, including mortality. Further studies including a large sample and follow-up analysis would be essential to better understand the rate of risks related to PCI-CTO potentially associated with the complexity and comorbidities of the elderly.Table 1Table 2 and 3

Predictive role of intracoronary electrocardiography for procedural success in patients with ST-elevation myocardial infarction developing coronary no-reflow

Abstract Background The no-reflow phenomenon (NRP) is associated with increased mortality and development of heart failure in patients with ST-segment elevation myocardial infarction (STEMI). Although there is no definitive method for NRP treatment in current guidelines, methods to predict the success of procedures with NRP are also limited. There is a need for a practical, real-time method for predicting the outcome of procedures in NRP patients. Intracoronary electrocardiography (ic-ECG) which is simple, cost-effective, and a bedside indicator of myocardial ischemia, is proposed as a potential solution in this study. Purpose The aim of this study was to examine the potential of ic-ECG in predicting the success of primary percutaneous intervention (pPCI) in patients with STEMI and the development of coronary no-reflow. Methods This was a prospective investigation that included 71 patients diagnosed with acute anterior STEMI and underwent pPCI between November 2021 and May 2022. The patients were separated into two groups based on the Thrombolysis in Myocardial Infarction (TIMI) flow grade criteria, with those having a grade of less than 3 defined as NRP. The NRP group was further analyzed to determine the relationship between the percentage of ST-segment resolution (STR) in the ic-ECG records taken during pPCI and short-term major adverse cardiovascular events rates and left ventricular ejection fraction (LVEF) recovery status. Results A total of 71 patients, with a mean age of 56.8 years and 76.1% of them being male, were included in the study. Of these patients, 26 were found to have developed NRP, while TIMI-3 flow was observed in 45 patients. In the NRP group, various parameters were found to be associated with LVEF recovery, such as peak troponin value (6267.8±2488.4 ng/ml vs 3244.6±3183 ng/ml, p=0.013) basal low-density lipoprotein cholesterol (LDL-C) (138.8±29.9 mg/dl vs 104.5±40 mg/dl, p=0.021), total cholesterol value (222.7±69.2 mg/dl vs 167.5±44.5 mg/dl, p=0.024), and ic-ECG STR level (21±22.3% vs 65.5±17%, p&amp;lt;0.001). The results of the multivariate analysis and subsequent ROC analysis showed that an ic-ECG STR ratio greater than 42% (sensitivity 100%, specificity 84.6%) was an independent predictive factor for LVEF improvement (Table 1). Conclusions The results showed that the STR rate measured by ic-ECG was significantly associated with LVEF recovery and was an independent predictive factor for LVEF recovery with a sensitivity of 100% and specificity of 84.6%. The study highlights the usefulness of ic-ECG in predicting pPCI success in NRP patients and supports its integration into clinical practice.

Association between post-procedural and long-term functional outcomes of jailed side branches in stented coronary bifurcation lesions assessed with side-branch murray law-based quantitative flow ratio

Abstract Background In coronary bifurcation lesions treated with percutaneous coronary intervention (PCI) using a 1-stent strategy, the occurrence of side branch (SB) compromise may lead to long-term myocardial ischemia in the SB territory. Murray law-based quantitative flow ratio (μQFR) is a novel angiography-based approach estimating fractional flow reserve from a single angiographic view, and thus more feasible to assess SB compromise in routine practice. However, its association with long-term SB coronary blood flow remained unknown. Aim To explore the association between post-procedural SB μQFR and long term SB coronary blood flow in non-left main (LM) coronary bifurcation lesions receiving 1-stent strategy. Methods A total of 146 patients with 313 non-LM bifurcation lesions receiving 1-stent strategy with drug-eluting stents was included in this retrospective study. These lesions had post-procedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in SBs, and documented angiographic images of index procedure and 6- to 24-month angiographic follow-up. The post-procedural SB μQFR was calculated. Long-term SB coronary blood flow was quantified with the TIMI grading system using angiograms acquired at angiographic follow-up. Results At follow-up, 8 (2.6%), 16 (5.1%), 61 (19.5%), and 228 (72.8%) SBs had a TIMI flow grade of 0, 1, 2, and 3, respectively. The incidences of SB TIMI flow grade &amp;lt;2 and &amp;lt;3 at follow-up both tended to decrease across the tertiles of post-procedural SB μQFR (TIMI flow grade &amp;lt;2: P=0.086; TIMI flow grade &amp;lt;3: P=0.052). In the multivariable logistic regression models, post-procedural SB μQFR was independently associated with SB TIMI flow grade &amp;lt;2 and &amp;lt;3 at follow-up, respectively (all P&amp;lt;0.05). The receiver operating characteristic curve analyses indicated that the area under the curve of post-procedural SB μQFR to identify SB TIMI flow grade &amp;lt;2 at follow-up was 0.6673 (95% CI, 0.5610-0.7737; P=0.0064), and the QFR limits to yield specificity and sensitivity &amp;gt;80% were 0.79 and 0.90, respectively. Conclusions Post-procedural SB μQFR in non-LM bifurcation stenoses was independently associated with impaired long-term SB coronary blood flow. Further investigations should focus on whether PCI optimization based on μQFR may contribute to improve SB flow in the long term.