Revascularization Percutaneous Coronary Intervention Research Articles

Temporal Trend in Revascularization for Patients With Ischemic Cardiomyopathy and Multivessel Coronary Artery Disease.

Current guidelines recommend revascularization in patients with ischemic cardiomyopathy (ICM). However, there is limited information about the trends and outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in ischemic cardiomyopathy patients with multivessel coronary artery disease. Using New Jersey state mandatory registries, 8083 patients with ischemic cardiomyopathy with CABG or PCI revascularization for multivessel coronary artery disease from 2007 to 2018 were included in the analysis. Joinpoint regression and multivariable logistic regression analyses were performed to assess the annual percentage change in trends and predictors of the 30-day mortality rate, respectively. A decline in CABG procedures was observed from 2007 to 2011 (annual percentage change, -11.5%; P=0.003), followed by stabilization. The PCI trend remained unchanged from 2007 to 2010 and then increased significantly (annual percentage change, 3.2%; P=0.02). In the subsample of patients with proximal left anterior descending artery plus circumflex and right coronary artery, CABG was a predominant procedure until 2011, and the proportion of both procedures did not differ thereafter. In the subsample of patients with left anterior descending artery and any other artery stenosis, PCI remained dominant from 2007 to 2018, while in patients with left main and any other artery stenosis, CABG remained dominant from 2007 to 2018 (P<0.001). The 30-day risk-adjusted mortality rate was higher after PCI versus CABG for each year, but after adjustment for completeness of revascularization, there was no difference between groups. The patterns of revascularization procedures for patients with ischemic cardiomyopathy with multivessel coronary artery disease have changed over the years, as evidenced by the changes in CABG and PCI trends. CABG and PCI had comparable 30-day risk-adjusted mortality risks.

Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature.

Contemporary management of spontaneous coronary artery dissection (SCAD) is still controversial. This systematic review of the literature aims to explore outcomes in the patients treated with conservative management vs. invasive strategy. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when we extensively searched three electronic databases: PubMed, ScienceDirect, and Web of Science, for studies that compared conservative vs. invasive revascularization treatment outcomes for patients with SCAD from 2003 to 2023. The outcomes of interest were all-cause death and major adverse cardiovascular events (MACE), including acute coronary syndrome (ACS), heart failure (HF), need for additional revascularization, target vessel revascularization (TVR), SCAD recurrence, and stroke. The systematic review included 13 observational studies evaluating 1,801 patients with SCAD. The overall mean age was 49.12 +/- 3.41, and 88% were females. The overall prevalence of arterial hypertension was 33.2%, hyperlipidemia, 26.9%, smoking, 17.8%, and diabetes, 3.9%. Approximately 48.5% of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. The left anterior descending artery (LAD) was the most common culprit lesion in 51% of the patients. There were initially 65.2% of conservatively treated patients vs. 33.4% that underwent percutaneous coronary intervention (PCI) or 1.28% that underwent coronary artery bypass graft (CABG). SCAD-PCI revascularization was associated with a variable range of PCI failure. The most common complications were hematoma extension and iatrogenic dissection. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. The overall reported in-hospital and follow-up mortality rates were 1.2% and 1.3%, respectively. The follow-up range across studies was 7.3-75.6 months. The authors reported variable prevalence of MACE, recurrent SCAD up to 31%, ACS up to 27.4%, TVR up to 30%, repeat revascularization up to 14.7%, UA up to 13.3%, HF up to 17.4%, and stroke up to 3%. Our results highlight that conservative treatment should be the preferred method of treatment in patients with SCAD. PCI revascularization is associated with a high prevalence of periprocedural complications. SCAD poses a considerable risk of MACE, mainly associated with TVR, ACS, and recurrent SCAD.

Clinical outcomes of percutaneous coronary intervention of chronic total occlusion vs. non-chronic total occlusion: a multicentre registry

Abstract Background Revascularization of Chronic Total Occlusions (CTO) has gained popularity in recent decades. However, there is still debate about the benefits of treating a chronic total occlusion, resulting in a class IIa indication in the ESC Guidelines. Especially data regarding bleedings is scarce which could be expected due to the use of multiple and large-bore access and the use of prolonged and strong dual antiplatelet therapy after percutaneous coronary intervention (PCI). Providing more insight in the benefits and risks of CTO treatment in the context of PCI revascularization could be performed on a more evidence-based assessment. Purpose This study aims to provide additional data about outcomes and complications of patients undergoing revascularization of a CTO. Methods Patients from an ongoing, multicentre registry (‘Zuid-Oost Nederland Hart Registratie’ (ZON-HR)), which has started in November 2020, are included, in which patient- and angiography characteristics and 30-day and 1-year outcomes are collected. MACCE was defined as a composite endpoint of cardiovascular death, myocardial infarction, ischemic cerebrovascular accidents and stent thrombosis. Results A total of 3996 patients with complete 30-day follow-up were included in the registry, of which 185 patients underwent a PCI of a CTO and 3811 patients underwent a PCI of a non-CTO lesion between November 2020 and June 2022. Baseline characteristics are described in Table 1. The mean age of the entire population was 67.9 (± 12.1) years and predominantly male (72.7%). Analysis showed a significantly higher incidence of bleedings in patients treated with CTO (7.6% vs. 3.4%, p &amp;lt; 0.01) and especially access bleedings (5.9% vs. 1.9%, p &amp;lt; 0.01). In patients with access bleedings double access-site punction was more frequently applied for CTO PCI (80% vs. 25%, p &amp;lt; 0.01). Patients with CTO PCI showed more coronary dissection/perforation with the need for covered stent treatment (2.7% vs. 0.6%, p &amp;lt; 0.01) as well. No significant difference for MACCE within 30 days was present. Additionally, multivariate analysis were performed for baseline variables showing no association with the occurrence of access bleedings and peripheral artery vessel disease and the indication of PCI. Ancillary analyses were performed with patients with 1-year follow-up (n = 1356; CTO = 64 vs. non-CTO = 1292), showing no significant differences in MACCE and bleedings. Conclusion(s) This registry shows that CTO PCI results in higher incidence of complications and access bleedings. Access bleedings are possibly related to the frequent use of double access-site punction in patients with CTO PCI which should be investigated further, as well as the role of DAPT after PCI.

Development of a prediction model for exercise tolerance decline in the exercise assessment of patients with acute myocardial infarction undergoing percutaneous coronary intervention revascularization in the acute phase.

Early cardiopulmonary exercise test (CPET) may predict the prognosis of patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). However, data from CPET to assess the exercise capacity of patients with AMI PCI are still scarce. This study aimed to evaluate the safety of the CPET and assess the predictors and clinical influence of exercise capacity measured by CPET in patients with AMI within 1 week after PCI. A total of 275 patients with AMI who underwent PCI in the acute phase were selected. Reduced exercise capacity was defined as peak oxygen uptake (VO2peak) <16 mL/kg/min. According to VO2peak, patients were divided into a normal exercise tolerance group and a reduced exercise tolerance group. The general clinical conditions were compared between the 2 groups to investigate the safety of CPET and the influencing factors of exercise tolerance. A nomogram model for predicting patients' exercise capacity was further developed. Clinical outcomes were recorded. The median time of CPET in all patients was 5 days after PCI. Among the 275 patients, exercise tolerance decreased in 90 cases (32.72%). Multivariate logic analysis showed that E/e', age, glycosylated hemoglobin, and estimated glomerular filtration rate (eGFR) were independent predictors of early exercise capacity reduction in these patients. Utilizing the correlation coefficients from pre-assessment clinical and CPET indicators within the logistic regression framework, we constructed a nomogram model to forecast the diminishing exercise tolerance in AMI patients. The predictive accuracy of this model, as indicated by a C-index of 0.771 and an area under the receiver operating characteristic (ROC) curve of 0.771 (95% CI: 0.710-0.832), demonstrates its potential as a robust tool in clinical settings. During a follow-up of 24 months, the incidence of clinical outcomes in patients with low exercise tolerance was significantly higher than that in patients with normal exercise tolerance, among which all-cause mortality and reinfarction were statistically different (P=0.009 and P=0.043). The reduced exercise capacity in patients with AMI after initial PCI is related to age, diastolic dysfunction, renal function, and blood glucose control, which may lead to poor clinical prognosis. The nomogram prediction model performed well in predicting the declining exercise tolerance of patients with AMI.

Modes of Presentation and Patterns of Coronary Artery Disease in Patients Undergoing Percutaneous Intervention at Birat Medical College Teaching Hospital

Background and Aims: Percutaneous coronary interventions have been provided in various hospitals of Nepal for more than two decades. Hence, we aimed to study the percutaneous coronary intervention revascularization status in patients with coronary artery disease at a tertiary center of eastern Nepal.&#x0D; Methods: A cross sectional study was conducted at Birat Medical College Teaching Hospital from 1st Aug to 30th Feb 2023. Ninety seven coronary artery disease patients (Unstable angina, Non ST elevated Myocardial Infarction ST elevated Myocardial Infarction and Stable Angina) requiring percutaneous coronary interventions were enrolled. Patient socio-demography and findings of percutaneous coronary intervention were recorded, entered in Microsoft Excel and analyzed by SPSS 23.&#x0D; Results: Majority 30(31.3%) had unstable angina. Left main coronary artery was normal in all patients. Severe stenosis was found in 58(59.7%) of left anterior descending artery, 32(32.9%) of right coronary artery and 29(29.8%) of left circumflex artery. Total occlusion was found in 10(10.3%) of left anterior descending artery, 8(8.2%) of right coronary artery and 6(6.2%) of left circumflex artery. Majority 68(70.1%) of patients had elective percutaneous coronary intervention.&#x0D; Conclusion: The most common mode of presentation of coronary artery disease was unstable angina and majority have severe stenosis. The preferred intervention was elective percutaneous coronary intervention.

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Intracoronary Imaging in left main stent percutaneous coronary intervention has a clear survival benefit particularly in more complex patients

Abstract Background Left Main Stem Disease (LMS) is prognostically important coronary artery disease that is managed either with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI). Use of intracoronary imaging (ICI) modalities such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve outcomes with PCI revascularization. The primary objective of this study was to evaluate the impact of ICI on outcomes following LMS PCI. Methods Retrospective observation study of 498 (5.1% of all PCI cases) patients who had undergone LMS PCI at our tertiary primary PCI centre hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records. Follow-up was also obtained through linkage with the Office of National Statistics. Results The mean age at the time of enrolment was 70.7±11.5 years. Majority of the patients were male 351 (70.5%). 353 (70.9%) of cases had acute coronary syndrome (ACS) presentation while the remainder were elective procedures. Mean follow-up duration was 3.75±3.06 years. Survival calculated by Kaplan-Meier was 70%. 87 patients (17.5%) deceased during first year of enrolment. 344 (69.1%) patients had ICI, with IVUS in 316 (63.5%) and OCT in 28 (5.6%) patients. IVUS comprised 91.9% of ICI procedures. Protected LMS (OR 0.175, 95% CI: 0.037–0.833, P-value=0.029) and the use of left ventricular mechanical support device (OR 0.324, 95% CI: 0.122–0.859, P-value=0.024) were associated with decreased odds of undergoing an ICI. Patients undergoing ICI had significantly better survival compared to those without ICI (HR: 0.54, P&amp;lt;0.001). Moreover, OCT showed significantly better survival compared with IVUS (HR: 0.181, P=0.017). Use of ICI was associated with better survival in patients who had Rotablation (HR: 0.455, 95% CI: 0.232–0.892, P=0.022), ACS (HR: 0.523, 95% CI: 0.383–0.714, P&amp;lt;0.001) or comorbidities of diabetes and stroke (HR: 0.551, 95% CI: 0.337–0.807, P=0.002). Conclusion ICI in LMS PCI has a significant survival benefit in our dataset. This is especially the case in patients presenting with ACS, those with comorbidities of Diabetes mellitus and stroke and those undergoing rotablation. Funding Acknowledgement Type of funding sources: None.

Coronary Artery Bypass Graft Surgery Brings Better Benefits to Heart Failure Hospitalization for Patients with Severe Coronary Artery Disease and Reduced Ejection Fraction.

Objectives: We compared the outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) for revascularization in patients with reduced ejection fraction (EF) and severe coronary artery disease (CAD). Methods: Between February 2006 and February 2020, a total of 797 patients received coronary angiograms due to left ventricular EF ≤ 40% at our hospital. After excluding diagnoses of dilated cardiomyopathy, valvular heart disease, prior CABG, acute ST-segment myocardial infarction, and CAD with low Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score (≤22), 181 patients with severe coronary artery disease (CAD) with SYNTAX score >22 underwent CABG or PCI for revascularization. Vascular characteristics as well as echocardiographic data were compared between CABG (n = 58) and PCI (n = 123) groups. Results: A younger age (62 ± 9.0 vs. 66 ± 12.1; p = 0.016), higher new EuroSCORE II (8.6 ± 7.3 vs. 3.2 ± 2.0; p < 0.001), and higher SYNTAX score (40.5 ± 9.8 vs. 35.4 ± 8.3; p < 0.001) were noted in the CABG group compared to those in the PCI group. The CABG group had a significantly higher cardiovascular mortality rate at 1-year (19.6% vs. 5.0%, p = 0.005) and 3-year (25.0% vs. 11.4%, p = 0.027) follow-ups but a lower incidence of heart failure (HF) hospitalization at 1-year (11.1% vs. 28.2%, p = 0.023) and 3-year (3.6% vs. 42.5%, p = 0.001) follow-ups compared to those of the PCI group. Conclusions: Compared with PCI, revascularization with CABG was related to a lower incidence of HF hospitalization but a worse survival outcome in patients with severe CAD and reduced EF. CABG-associated reduction in HF hospitalization was more notable when SYNTAX score ≥33.

Effect and benefit of percutaneous coronary intervention in chronic total occlusion on ventricular repolarization: QT correction and dispersion.

ST segment, T wave changes, QT interval changes, and QTc dispersion are among the parameters used to diagnose ischemic heart disease. The increase in the QT dispersion can be caused by myocardial ischemia, among other heart diseases, whereas cardiac diseases such as coronary artery disease (CAD) can be diagnosed by observing an abnormally high QTc dispersion. This study aimed to evaluate the variations in the QTc dispersion (depolarization and repolarization) of surface electrocardiography as a result of percutaneous coronary intervention (PCI) in patients with chronic total occlusion. This study took place in the Iraqi Center for Heart Disease from October 2020 to February 2021. 110 patients who suffered from chronic occlusion of the coronary artery and underwent PCI revascularization were examined. Twelve-lead electrocardiograms were recorded at the time of admission (12 hours before intervention) and more than one hour after the intervention. The measured ECG parameters included corrected QT interval durations and corrected QT dispersion in both pre and post-PCI electrocardiograms, and their values were compared. The average corrected QT interval and QTC dispersion changed significantly before and after the percutaneous coronary intervention. Performing percutaneous coronary intervention on patients who suffer from coronary artery total occlusion shows a major reduction in the corrected QT dispersion.

MO464: Long-Term Renal Outcomes After ST-Elevation Myocardial Infarction Treated by Percutaneaous Coronary Intervention

Abstract BACKGROUND AND AIMS Among patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), short- and long-term renal function evaluations are of prime importance. Most studies have focused on short-term renal dysfunction and acute kidney injury (AKI) occurrence after STEMI treated by PCI, which is associated with major adverse cardiovascular events (MACE) and especially the occurrence of heart failure. However, few studies have focused on long-term renal outcomes. We aimed to describe renal function evolution and to determine predictors of estimated glomerular filtration rate (eGFR) decline one year after STEMI is treated by PCI. METHOD From May 2016 to July 2020, 322 consecutive patients with STEMI who underwent PCI revascularization were enrolled prospectively. Serum creatinine (SCr) concentration was routinely measured at patient admission, after 48 h or hospital discharge, then during systematic 1-month and 1-year clinical check-ups, AKI was determined according to the Acute Kidney Injury Network (AKIN) definition. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) formula. The evolution of renal function was evaluated by the difference between admission and 1-month or 1-year eGFR. Rapid progression was defined as a decline in eGFR of more than 5 mL/min/1.73m² per year. Determinants of eGFR decline ≥ 10 mL/min/1.73m² per year were analyzed with multivariate logistic regressions. RESULTS The mean age was 59.6 years, 29.5% of patients had a medical history of hypertension, 13.8% had diabetes and 52.8% presented with anterior myocardial infarction. Median admission SCr concentration was 71 µmol/L, with an eGFR of 96.5 mL/min/1.73m² [inter quartile range (IQR): 84.4–105.1]. A total of 38 patients (11.8%) developed AKI. In the whole population median eGFR decline was 7.7 mL/min/1.73 m² (1.2–14.4) and 8 mL/min/1.73 m² [1.3–15.9] 1-month and 1-year after STEMI respectively (Figure 1). Rapid eGFR decline was found in 59.7% of the total population and 44.6% of patients presented a 1-year eGFR decline of at least 10 mL/min/1.73 m². AKI patients had significant lower eGFR at 1-month and 1-year follow up (median 1-year eGFR of 74.5 mL/min/1.73m² (52.4–96.4) versus 88.1 mL/min/1.73m² (74.0–100.3) in non-AKI patients, P = 0.01). There was no significant difference between AKI and non-AKI patients regarding rates of eGFR decline at both 1-month and 1-year after inclusion. Multivariate analysis (Table 1) showed that age and 1-month eGFR decline was significantly associated with 1-year eGFR decline ≥ 10 mL/min/1.73m². Especially, 1-month eGFR decline greater than 10 mL/min/1.73m² was an independent and stratified predictor of 1-year eGFR decline with an odds ratio (OR) of 7.45 [95% confidence interval (CI): 2.76–22.81, P &amp;lt; 0.01). AKI occurrence and peak hs-I troponin were not found as predictors of 1-year eGFR decline. CONCLUSION Among STEMI patients treated by PCI, a large majority of patients present a significant decline in renal function 1-year after STEMI, regardless of AKI occurrence or infarct size. One-month eGFR decline is a strong predictor of 1-year eGFR evolution and could help identify high-risk patients and adjust nephrological care. Our findings bear important clinical implications and underline the need for longitudinal follow-up of renal function after STEMI is treated by PCI.

A novel use of small ballons to reduce the risk of subintimal hematoma formation during recanalization of chronic total occlusion: two case reports

BackgroundSubintimal hematoma remains a major challenge associated with unnecessary technical complexity, failure of the antegrade approach or imperfection of revascularization in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Some techniques and devices release the hematoma after its formation. Here, we describe a novel use of small ballons to prevent the hematoma formation during antegrade approach in two cases.Case presentationWe report two cases of CTO-PCI in which balloon occlusion was successfully applied to prevent haematoma formation. The first case, a 72-year-old female with diabetes, was hospitalized because of unstable angina. Angiography showed right coronary artery (RCA) CTO, which initiated from the proximal part to the trifurcation at the distal part of the RCA. Considering the high likelihood and serious consequences of subintimal haematoma, a small balloon is employed to prevent subintimal hematoma formation. A balloon and microcatheter or double-lumen microcatheter are placed in the proximal coronary CTO lesion; then the balloon was dilated beside the catheter, most of the antegrade blood flow was sealed which reduced the likelihood of haematoma formation. The procedure was successfully completed without subintimal hematoma formation. The second case a 62-year-old male with unstable angina, was hospitalized for PCI. Angiography showed left anterior descending coronary artery CTO. Similar to case 1, we also used a small balloon to prevent hematoma formation. Both patients underwent PCI, which employed a small balloon to prevent hematoma formation and both procedures were successful without complications.ConclusionIn patients who underwent CTO-PCI, balloon occlusion offers an alternative for reducing the incidence of subintimal haematomas.

Surviving a Decade or More after Coronary Revascularization in a Middle Eastern Population: The Impact of Diabetes Mellitus.

Introduction:Studies that evaluate Middle Eastern patients who have long-term survival after coronary artery revascularization are scarce. The prevalence of diabetes mellitus (DM) is high and rapidly increasing in our region.Methods:The study enrolled consecutive ambulatory or in-patients who had percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery at least 10 years earlier. Collected data included cardiovascular risk factors at the time of the index revascularization and evolution of risk factors since then, the occurrence of cardiovascular events, and the need for coronary revascularization after the index procedure. Events were compared between patients with DM and no DM at baseline.Results:The study population consisted of 891 consecutive patients with 351 patients (39.4%) had DM and 540 patients (60.6%) had no DM. The mean age at baseline was 53.9 ± 8.8 years for DM patients and 53.0 ± 9.8 years for no DM patients (P = 0.16). At baseline, the DM group had more hypertension (70.9% vs. 27.6%, P < 0.0001), more dyslipidemias (12% vs. 5.2%, P = 0.001) but less smokers compared to no DM group (44.4% vs. 58.3%, P < 0.001). DM and no DM groups had similar proportion of PCI (65.5% vs. 68.3%, P = 0.42) and CABG (34.5% vs. 31.7%, P = 0.43) at baseline. Following the index revascularization procedure, acute coronary events, heart failure, and stroke developed in similar proportions in the two groups. Repeat revascularization after the index procedure showed that the DM group had more PCI compared to no DM group (52.7% vs. 45.4%, P = 0.04) but similar proportions of CABG (7.1% vs. 9.8%, P = 0.20).Conclusions:In this retrospective observation of Middle Eastern patients who survived at least a decade after coronary revascularization, the DM group had more hypertension and dyslipidemias but fewer smokers compared to no DM at baseline. During follow-up, the DM group required more PCI revascularization compared with no DM group.

Abstract 14477: Meta-Analysis of Studies Comparing Multivessel Percutaneous Coronary Intervention and Culprit Vessel Only Intervention Among Patients With Acute Myocardial Infarction and Cardiogenic Shock

Background: Studies investigating mortality and adverse event outcomes in patients presenting with acute myocardial infarction (MI) in cardiogenic shock (CS) have reported conflicting results, and have primarily included patients with ST elevation MI. This meta-analysis investigates appropriate revascularization strategy in these patients. Methods: PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing multivessel (MV) percutaneous coronary intervention (PCI) and culprit vessel (CV) PCI in patients with MI in CS. Data on outcomes from the selected studies were extracted and analyzed by means of random effects model. Two tailed p-value less than 0.05 was considered significant. Heterogeneity was assessed using I 2 test. Results: Twelve studies were included in the final analysis. There was no significant difference in short-term (OR 0.95, 95% CI [0.90-1.01]; p=0.09) or long-term (1.16 [0.95-1.41]; p=0.14) mortality between MV PCI and CV PCI ( Figure) . Similarly, the odds of reinfarction (1.04 [0.58-1.85]; p=0.90) and stroke (1.08 [0.88-1.33]; p=0.46) were similar between the two groups. Although patients with MV PCI had lower odds of revascularization (0.46 [0.34-0.62]; p&lt;0.01), they carried higher odds of new renal replacement therapy (1.30 [1.14-1.48]; p&lt;0.01) and bleeding (1.25 [1.14-1.36]; p&lt;0.01). Interestingly, on exclusion of study exclusively containing patients with non-ST elevation MI, odds of short-term mortality were higher (1.44 [1.28-1.62]; p&lt;0.01) in the MV PCI group. Conclusions: Among patients with AMI and cardiogenic shock, there was no difference observed in short-term or long-term all-cause mortality, between MV PCI and CV PCI revascularization strategies. However, adopting the MV PCI strategy may lead to higher odds of bleeding and renal replacement therapy.

Serum Soluble Tumor Necrosis Factor Receptors 1 and 2 Are Early Prognosis Markers After ST-Segment Elevation Myocardial Infarction.

Background: As inflammation following ST-segment elevation myocardial infarction (STEMI) is both beneficial and deleterious, there is a need to find new biomarkers of STEMI severity.Objective: We hypothesized that the circulating concentration of the soluble tumor necrosis factor α receptors 1 and 2 (sTNFR1 and sTNFR2) might predict clinical outcomes in STEMI patients.Methods: We enrolled into a prospective cohort 251 consecutive STEMI patients referred to our hospital for percutaneous coronary intervention revascularization. Blood samples were collected at five time points: admission and 4, 24, 48 h, and 1 month after admission to assess sTNFR1 and sTNFR2 serum concentrations. Patients underwent cardiac magnetic resonance imaging at 1 month.Results: sTNFR1 concentration increased at 24 h with a median of 580.5 pg/ml [95% confidence interval (CI): 534.4–645.6]. sTNFR2 increased at 48 h with a median of 2,244.0 pg/ml [95% CI: 2090.0–2,399.0]. Both sTNFR1 and sTNFR2 peak levels were correlated with infarct size and left ventricular end-diastolic volume and inversely correlated with left ventricular ejection fraction. Patients with sTNFR1 or sTNFR2 concentration above the median value were more likely to experience an adverse clinical event within 24 months after STEMI [hazards ratio (HR): 8.8, 95% CI: 4.2–18.6, p < 0.0001 for sTNFR1; HR: 6.1, 95% CI: 2.5 –10.5, p = 0.0003 for sTNFR2]. Soluble TNFR1 was an independent predictor of major adverse cardiovascular events and was more powerful than troponin I (p = 0.04 as compared to the troponin AUC).Conclusion: The circulating sTNFR1 and sTNFR2 are inflammatory markers of morphological and functional injury after STEMI. sTNFR1 appears as an early independent predictor of clinical outcomes in STEMI patients.

Two-year left ventricular systolic function of percutaneous coronary intervention vs optimal medical therapy for patients with single coronary chronic total occlusion.

In this study, two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (RT-3DE) were applied to compare the changes of left ventricular systolic function associated with percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with single chronic total occlusion (CTO). 63 single CTO patients (age 61.88±8.86years) were examined by echocardiography and were divided into the PCI group (n=27) and OMT group (n=36) according to the initial treatment strategy. Two-dimensional left ventricular ejection fraction (2D-LVEF), two-dimensional indexed left ventricular end-systolic volume (2D-LVESVI), and two-dimensional indexed left ventricular end-diastolic volume (2D-LVEDVI) were measured using two-dimensional echocardiography (2DE). Three-dimensional left ventricular ejection fraction (3D-LVEF), three-dimensional indexed left ventricular end-systolic volume (3D-LVESVI), and three-dimensional indexed left ventricular end-diastolic volume (3D-LVEDVI) were measured using RT-3DE. Global circumferential strain (GCS) and global longitudinal strain (GLS) were measured using 2D-STE. After 2years of follow-up, there were no significant differences in the 2D-LVEF, 2D-LVESVI, 3D-LVEF, 3D-LVESVI, 3D-LVEDVI, and GCS, except for GLS (P=.001) between the CTO-PCI and CTO-OMT groups. GLS decreased significantly in OMT group (P=.016) in contrast with PCI group in which GLS increased significantly (P=.007). Left ventricular systolic function assessment using 2D-STE showed a significant difference in GLS between CTO-PCI and CTO-OMT. And the patients who chose PCI revascularization at the 2-year follow-up had better left ventricular systolic function improvement than those who were conservatively treated with OMT.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Outcomes With Deferred Versus Performed Revascularization of Coronary Lesions With Gray-Zone Fractional Flow Reserve Values.

Management of coronary lesions with fractional flow reserve values in the gray zone (0.75-0.80) remains controversial due to conflicting data on the performance versus deferral of revascularization. We performed a systematic review and meta-analysis of 7 observational studies including 2683 patients that compared the outcomes of deferred versus performed revascularization of coronary lesions with gray-zone fractional flow reserve values. During a mean follow-up of 31±9 months, the incidence of major adverse cardiovascular events (12.54 % versus 11.25%; odds ratio [OR], 1.64 [95% CI, 0.78-3.44]; P=0.19, I2=84%), cardiac mortality (1.25% versus 0.72%; OR, 1.78 [95% CI, 0.58-5.46]; P=0.31, I2=18%), and myocardial infarction (1.28% versus 2.66%; OR, 0.79 [95% CI, 0.22-2.79]; P=0.71, I2=65%) was similar with deferral versus performance of revascularization in coronary lesions with gray-zone fractional flow reserve. Deferral of revascularization was associated with a higher incidence of target vessel revascularization (9.12% versus 5.78%; OR, 1.85 [95% CI, 1.03-3.33]; P=0.04, I2=62%). When the analysis was limited only to studies that used percutaneous coronary intervention for revascularization, deferred revascularization remained associated with a higher risk of target vessel revascularization (18% versus 7.3%; OR, 3.04 [95% CI, 1.53-6.02]; P<0.001) and was associated with a higher risk of major adverse cardiovascular event (23.2% versus 13.4%; OR, 3.38 [95% CI, 1.92-5.95]; P<0.001). In lesions with gray-zone fractional flow reserve, revascularization was associated with a similar incidence of major adverse cardiovascular event but a lower incidence of target vessel revascularization over a mean follow-up of approximately 2.5 years. URL: https://www.crd.york.ac.uk/prospero/. Unique identifier: CRD42019128076.

Influencing factors of exercise tolerance in patients with myocardial infarction undergoing percutaneous coronary intervention revascularization in acute phase

Objective: The aim of the study was to explore the influencing factors of exercise tolerance in patients with myocardial infarction (MI) after percutaneous coronary intervention (PCI) revascularization in acute state. Methods: A total of 112 patients with first MI undergoing PCI revascularization in acute state and completing cardiopulmonary exercise testing (CPET) were enrolled. Exercise capacity was evaluated by peak oxygen consumption percentage (VO(2 peak)%) in CPET. Patients were divided into normal exercise capacity (NEC) group (n=40) and abnormal (AEC) group (n=72) according to VO(2 peak)% value. Clinical manifestations, histories of hypertension and diabetes, medications, coronary arterial angiography and echocardiography findings of patients were compared. The onsets of diabetes and blood glucose levels during the period of CPET were evaluated in the MI patients with diabetes. The patients were followed up for major adverse cardiovascular events (MACE) (admission due to chest pain, re-revascularization, re-infarction and all-cause death) within 24 months after PCI. Multivariate logistic regression analyses were conducted to examine influencing factors for exercise tolerance. Results: The ratio of diabetes, type C lesions in the AEC group were higher than those in the NEC group (diabetes: 37.5% vs. 17.5%; type C lesions: 69.4% vs. 42.5%, respectively, all P<0.05). The left ventricular ejection fraction (LVEF) in patients in the AEC group was lower than that in the NEC group [(60.6±10.0)% vs. (65.0±8.2)%, P=0.019]. Multivariate logistic regression analyses showed that history of diabetes and history of type C lesions were the independent risk factors for the declined exercise capacity in the MI patients after PCI revascularization (OR=3.14, 95%CI 1.167-8.362, P=0.023; OR=3.32, 95%CI 1.444-7.621, P<0.01). Among the MI patients with diabetes, the duration of diabetes in the AEC group was significantly longer than that in the NEC group[(7.7±3.6)years vs. (5.0±2.4)years] and the proportions of subjects reaching target levels of fasting plasma glucose (40.7% vs. 57.1%) and glycosylated hemoglobin A1c(HbA1c) (55.6% vs. 71.4%) in this group were significantly lower than those in the NEC group (all P<0.05). A multivariate logistic regression analysis showed that reaching HbA1c target was an independent predictor of improved exercise tolerance in MI patients with diabetes who received PCI (OR=2.518, 95%CI 1.395-7.022, P=0.021). No significant differences were observed in incidence of admission due to chest pain, re-revascularization and re-infarction between the two groups within 24 months after PCI between the groups. Conclusions: Diabetes and type C lesions are independent risk factors of declined exercise capacity in patients with first myocardial infarction who received revascularization in acute state. Reaching target HbA1c is independent factor of improved exercise capacity in patients with myocardial infarction and diabetes.

Impact of percutaneous coronary intervention extent, complexity and platelet reactivity on outcomes after drug-eluting stent implantation

BackgroundRisk stratification after percutaneous coronary intervention (PCI) is mainly based on demographics and clinical presentation (stable coronary artery disease [CAD] vs. acute coronary syndromes [ACS]). We investigated the impact of PCI extent and complexity on 2-year clinical outcomes after successful implantation of drug-eluting stents (DES) and whether this effect is influenced by clinical presentation and/or high platelet reactivity (HPR) on clopidogrel. Methods and resultsPatients from the prospective, multicenter Assessment of Dual Antiplatelet Therapy with Drug-Eluting Stents study were stratified according to PCI complexity, with complex PCI (C-PCI) defined as ≥3 stents implanted, bifurcation PCI with 2 stents, rotational atherectomy use for severely calcified lesions, or left main or saphenous vein graft (SVG) PCI. Major adverse cardiac events (MACE; cardiac death, myocardial infarction, and stent thrombosis) were compared at 2-year follow-up in patients with and without C-PCI. Successful DES PCI was performed in 8582 patients—2255 (26.3%) with C-PCI. C-PCI was independently associated with higher 2-year risk of MACE (adjusted HR [adjHR]: 1.56; 95%CI: 1.29–1.89; p<0.0001), MI (adjHR: 1.71; 95%CI: 1.37–2.14; p<0.0001), and ST (adjHR: 2.26; 95%CI: 1.42–3.59; p=0.0006). The association between C-PCI vs. non–C-PCI and the risk of MI and ST was greater in stable CAD than in ACS (Pinteraction=0.04 and 0.03, respectively). SVG PCI, 2-stent bifurcation treatment, and implantation of ≥3 stents were independently associated with MACE. ConclusionsPatients undergoing extensive and more complex PCI experienced worse outcomes after successful PCI. Considering the extent and complexity of PCI revascularization may improve risk stratification.

THE ROLE OF PULSE REDUCTION THERAPY IN ADDITIONAL IMPROVEMENT OF CLINICAL EFFECTS OF MYOCARDIAL REVASCULARIZATION IN CORONARY HEART DISEASE STABLE ANGINA PATIENTS

The review is focused on the role of ivabradine in percutaneous coronary intervention (PCI) and coronary bypass grafting (CBG) in coronary heart disease patients (CHD) with stable angina. The data provided, on insufficient clinical effect of PCI revascularization with modern medication therapy. Authors argue for improvement of the clinical effect of PCI and CBG by addition of ivabradine together with sufficient (up to maximal) dosages of beta-adrenoblockers (BAB). Inhibition of I f -channels of cardiomyocytes with ivabradine makes positive influence on the main clinical endpoints. The role of multiple effect of ivabradine is highlighted, that increase efficacy of the drug.