Percutaneous Coronary Intervention For Lesions Research Articles

Imaging in Percutaneous Coronary Intervention

Intracoronary imaging (ICI) use during percutaneous coronary intervention (PCI) has been shown to effectively improve cardiovascular outcomes, particularly for high-risk subgroups. However, data from randomized controlled trials are limited and the overall utilization rate of ICI remains variable between different countries and centers. Potential benefits of ICI include identification of appropriate lesions for PCI, improved characterization of lesions, and optimization of stent placement. Currently available modalities of ICI include intravascular ultrasound, optical coherence tomography and near infrared spectroscopy. Within this review, we summarize the contemporary evidence surrounding ICI and discuss its application in clinical practice.

P58 IMMEDIATE CORONARY ANGIOGRAPHY AND SYSTEMATIC TARGETED TEMPERATURE MANAGEMENT ARE ASSOCIATED WITH IMPROVED OUTCOME IN COMATOSE SURVIVORS OF CARDIAC ARREST

Abstract Background Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short– and long–term outcome of our retrospective cohort of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. Methods All consecutive comatose CA survivors with no obvious extracardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST–elevation on electrocardiogram, and good neurological recovery. Results We enrolled 107 patients with a median age of 64.9 (57.7–73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty–six (61.7%) patients underwent PCI. In–hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in–hospital survival. Long–term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log–rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non–shockable) and ST–deviation (elevation vs no–elevation), and improved the long–term survival of patients discharged with good neurological recovery. Conclusion Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST–deviation in the post–ROSC electrocardiogram. The benefit was sustained at long–term particularly in those with neurological recovery.

Comparison of long-term clinical outcomes in diabetic and non-diabetic patients of the mini-crush two-stent technique for percutaneous treatment of complex coronary artery bifurcation lesions

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Diabetic patients present more aggressive coronary artery disease and worse outcomes after percutaneous coronary intervention (PCI), especially in complex coronary bifurcation lesions. Currently, the benefit of "double stenting" techniques in the treatment of complex bifurcations in diabetics with coronary artery disease, is controversial. Purpose The aim of this study was to compare the outcomes of PCI with "mini-crush" two-stent technique in diabetic and non-diabetic patients, in terms of MACE: cardiovascular mortality, non-fatal myocardial infarction, target lesion revascularization (TLR) and stent thrombosis after long follow-up (median 32 months). Methods Observational study in which were included 152 consecutive patients (mean age 69.5 years, 38.3% diabetics) with 152 complex bifurcated coronary severe lesions that underwent PCI from April 2014 to April 2020. Results No significant differences were observed in the baseline characteristics, clinical presentation and antiplatelet pretreatment between both groups. Clopidogrel was the P2Y12-receptor inhibitor most commonly used. There were no differences in mean complexity according to the Syntax score (29.7 ± 11.3 in diabetics vs 30.4 ± 14.4 in non-diabetics, p=0.293). Left main bifurcation was the most frequently coronary artery affected in both groups and circumflex was the most common side vessel. The characteristics of the procedure was similar in both groups: no differences observed in pre-dilation rate either in final kissing balloon post-dilation rate. Similar length and diameter of the stents implanted in both groups. Angiographic follow-up clinically guided was 15.8% in diabetics and 16.9% in non-diabetics. We found no significant differences in the incidence of MACE or in any of its components separately. TLR rate was similar in diabetics and non-diabetics patients. Conclusions Comparable to non-diabetic patients, PCI in complex coronary bifurcation lesions with "mini-crush" two-stent technique in diabetic patients shows favorable results with low event rates and need for revascularization at long-term follow-up.

Clinical results at a long-term follow-up of percutaneous coronary intervention in ostial left main coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left main coronary ostial lesions are notable for being found more commonly among middle-aged women with fewer conventional coronary artery risk factors and for lower long-term patency of internal thoracic grafts. Isolated ostial left main coronary artery (LMCA) disease is involved in the 18% of lesions and have a management approach do well either with percutaneous coronary intervention (PCI) or cardiac surgery. Continuous improvement in the devices and the emergence of better drug-eluting stents (DES) has improved the results of PCI in these high-risk lesions. Purpose The main objective of this study was to evaluate the efficacy and safety of PCI in ostial LMCA disease at a 14-year follow-up. Methods We prospectively included 109 consecutive patients (72± 12 years, 72.5% male) with ostial LMCA disease treated with PCI between June 2006 and June 2020. We evaluated the presence of major adverse cardiovascular events (MACE) defined as cardiac death, non-fatal myocardial infarction, target lesion revascularization (TLR) and stent thrombosis after a 14-year clinical follow-up (median 63.6 months). Results 55.9% had stable coronary disease and 44.1% had acute coronary syndrome (35.9% Non-STEMI and 8.2% STEMI). 45% were diabetic patients and 36.6% presented moderate-severe left ventricular systolic dysfunction. The mean logistic EuroSCORE was 8.1 % and SYNTAX score was ≥ 23 in 72.5% of the patients. We implanted second-generation DES in the 83.5% of patients (76% zotarolimus-eluting stent) and post-dilatation was performed in the 68.8%. The angiographic success rate was 99%. Complication rate in the procedure was 5.5% without intra-procedure deaths. During follow-up, MACE rate at 14 years was 18.3% (13.7% of cardiac death, 4.6% of nonfatal myocardial infarction, 7.3% of TLR and thrombosis rate of 0.9%). 24.2% of patients had an angiographic follow-up. Conclusions In spite of high surgical risk, complex coronary anatomy and older aged patients, PCI in ostial LMCA disease is safe and effective with a low rate of major cardiovascular events at long-term follow-up.

Outcome of ST-segment elevation myocardial infarction (STEMI) patients with significant non-infarct related artery (IRA) lesions

Abstract Funding Acknowledgements Type of funding sources: None. Background Multivessel disease is common (50%) in patients presenting with ST-segment elevation myocardial infarction (STEMI), and this is associated with a higher mortality compared to single-vessel disease. The optimal timing for revascularisation of significant non-infarct related artery (IRA) (non-culprit) lesions in STEMI patients remains controversial. The two main approaches include immediate revascularisation during the primary percutaneous coronary intervention (PPCI) or deferred (48 hours after the index procedure) percutaneous coronary intervention (PCI). The European Society of Cardiology guidelines recommend consideration of immediate non-IRA PCI in STEMI patients with cardiogenic shock, while revascularisation of other patients with non-IRA significant lesions should be considered prior to hospital discharge. Purpose To determine the optimal timing of intervention of significant non-IRA lesions in patients presenting with STEMI. Methods Coronary angiograms of nationwide STEMI patients who underwent a PPCI between 2013 and 2017 were reviewed to determine whether a significant non-IRA lesion was present (defined as >70% stenosis, or >50% of left main stem). The patients were divided into Group 1: immediate PCI of the non-IRA lesion during the PPCI, and Group 2: deferred PCI of non-IRA lesion prior to hospital discharge. Patients were followed up till end 2020 to determine whether a major adverse cardiovascular event occurred (death, myocardial infarction [MI], hospitalization due to pulmonary oedema and revascularization with repeat PCI and coronary artery bypass [CABG]). Chi-square and Fisher’s exact test were used for statistical analysis. Results 1080 patients underwent a PPCI between 2013 and 2017. 578 patients were excluded as they had no bystander disease, and a further 340 were excluded as they underwent CABG or medical treatment for the non-IRA lesions. From the remaining cohort, 55 patients were stratified to group 1 and 107 patients in group 2. There were no significant differences in baseline characteristics (Picture 1). Picture 2 demonstrates the distribution of non-IRAs which required PCI. Patients who had immediate non-IRA lesion PCI had a significantly higher mortality (Group 1, 21.8% vs Group 2, 8.4%, p=0.016) and more admissions with pulmonary oedema (Group 1, 10.9% vs Group 2, 0.9%, p=0.006). Group 1 patients were found to have a higher occurrence of cardiac arrest during the PPCI (10.9% vs 0.9%, p=0.006) and cardiogenic shock (12.7% vs 3.7%, p=0.046). There were no differences with regards to angina (p=0.386), MI (p=0.426) or re-vascularisation with repeat PCI (p= 0.090) or CABG (p=0.114). Conclusion STEMI patients who underwent immediate PCI to non-IRA lesions had a poorer outcome with higher rates of mortality and pulmonary oedema admissions compared to the deferred PCI cohort. Large randomised controlled trials are required to determine the optimal timing for intervention of significant non-IRA lesions.

C-2 | Comparing the Peri-procedural and Long-term Outcome between Minimally Invasive Hybrid Coronary Revascularization versus Percutaneous Coronary Intervention of Multivessel Coronary Artery Disease: A Meta Analysis

Hybrid Coronary Revascularization (HCR) involves harvesting Left Internal Mammary Artery (LIMA) and grafting it to Left Anterior Descending artery (LAD) with minimally invasive bypass surgery as well as percutaneous coronary intervention (PCI) of non- LAD arteries. The study aims to assess if there are any benefits of HCR when compared to PCI for both LAD and non-LAD lesions.

Percutaneous Coronary Intervention of Bifurcation Lesion

Bifurcation lesion whether it is left main (LM) stem disease with left main to left anterior descending artery (LM-LAD) or left main to left circumflex (LM-LCX), LAD-Diagonal or LCX-Obtuse marginal or right coronary artery- posterior descending artery (RCA-PDA); are not uncommon lesion type that needs to be revascularized either by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) to establish the coronary flow and relieved patient anginal symptoms. Even though, many of the literature maintained non-inferiority of bifurcation lesion PCI over CABG and is Class IIb indication for PCI by coronary stent. In literature, bifurcation lesions commonly encountered in PCI and are regarded as most technically challenging lesions to treat, in up to 20% of PCI cases. With the advent of interventional procedures and the availability of cardiac catheterization laboratory facilities, skilled interventionist, many of the Bangladeshi patients are being treated for coronary artery diseases (CAD). With the advent of drug eluting stents, availability of IVUS (Intravascular Ultrasound), FFR (Fractional Flow Reserve) and individual expertise, treating bifurcation lesion may not be difficult task. Interventionist must be expert enough in doing PCI, before to proceed for bifurcation lesion PCI. We need to work together to develop common consensus in developing updated skill in treating bifurcation lesion which will prove bifurcation PCI in our population. Cardiovasc j 2022; 14(2): 168-175

Outcomes of Patients Undergoing PCI of Ostial Coronary Lesions: A Single-Center Study

Introduction: Ostial coronary lesions are a subset of proximal coronary lesions, which are relatively more difficult to treat and were associated with worse clinical outcomes in the early percutaneous coronary intervention (PCI) era. Data regarding the outcomes of ostial lesions’ PCI in the contemporary era are lacking. Methods: We conducted a single-center, all-comer, prospective registry study, enrolling patients undergoing PCI with the use of contemporary drug-eluting stents (DES) between July 2016 and February 2018. Included in the present analysis were only patients treated for proximal lesions. Clinical outcomes were compared between patients undergoing PCI of ostial versus proximal nonostial lesions. The primary endpoint was target vessel revascularization (TVR). Secondary endpoints included target lesion revascularization (TLR) and major cardiovascular adverse events (MACE) at 12 months. Results: A total of 334 (84.7% male, 67.3 ± 10.7 years) patients were included, of which 91 patients were treated for ostial lesions and 243 were treated for proximal nonostial lesions. Baseline and procedural characteristics were similar between the two groups. At 12 months, TVR and TLR were numerically higher among patients undergoing PCI of ostial versus nonostial lesions without reaching statistical significance (5.5% vs. 3.3%; p = 0.35 and 4.4% vs. 2.5%; p = 0.47, respectively). The rate of MACE was similar between the two groups. Conclusion: In patients undergoing PCI with the use of contemporary DES, clinical outcomes were similar among patients treated for ostial compared to proximal nonostial lesions. Larger studies are required to further evaluate the performance of contemporary DES in this subset of lesions.

Effect of Asymptomatic Hyperuricemia on Mortality of Elderly Patients After Elective Percutaneous Coronary Intervention.

PurposeThe purpose of this study is to investigate the effect of asymptomatic hyperuricemia on mortality of elderly patients with coronary artery disease (CAD) after elective percutaneous coronary intervention (PCI).MethodsOne thousand two hundred ninety-six patients with coronary heart disease ≥65 years old who had increased uric acid records and without gout history underwent elective PCI from January 2015 to January 2016 were enrolled. The hyperuricemia is defined as serum uric acid level >420 μ mol/l (7 mg/dl) for males and >357 μ mol/l (6 mg/dl) for females. Patients were divided into hyperuricemia group and non-hyperuricemia group. After an average of 519 days follow-up, the differences in mortality between the two groups were compared.ResultsThere were 236 patients in hyperuricemia group and 1060 patients in non-hyperuricemia group. In hyperuricemia group, BMI was higher (P = 0.036); the proportions of patients with hypertension (P < 0.001) and myocardial infarction history (P = 0.046) were higher; white blood cells (P = 0.015) and triglyceride levels were higher (P < 0.001); and estimated glomerular filtration rate (P < 0.001) and high-density lipoprotein cholesterol level were lower (P = 0.007). In addition, in hyperuricemia group, during hospitalization, the ratios of patients treated with diuretics (P < 0.001) and the number of PCI lesions were higher (P = 0.030), and the complete revascularization rate was lower (P = 0.017). The mortality rate (2.2 vs. 7.6%, P < 0.001) of hyperuricemia group was significantly higher than that of non-hyperuricemia group. Multivariate Cox regression analysis showed that after adjusting for other factors, hyperuricemia was an independent risk factor for increased mortality after PCI (HR 2.786, 95% CI 1.233–6.297, P = 0.014).ConclusionAsymptomatic hyperuricemia is an independent risk factor for increased mortality of elderly patients with coronary heart disease undergoing elective PCI.

Four-Year Outcomes of Unprotected Left Main Lesion PCI with Self-Apposing Stents versus Balloon-Expandable Stents

Abstract Background Left main percutaneous coronary intervention (PCI) has been established as an effective and safe treatment option for left main coronary artery disease. There are data suggesting that different stent platforms can impact the outcomes after left main PCI. The aim of current study was to compare the four-year outcomes of patients with left main stenosis treated by PCI with a balloon-expandable stent or a self-apposing stent. Methods and Results A total of 146 patients with left main stenosis treated by PCI were included, of which 84 (57.5%) had balloon-expandable stents (Group A) and 62 (42.5%) had self-apposing stents (Group B). Baseline SYNTAX scores were higher in Group A than in Group B. Proximal optimization technique was used more often in Group A (45.2% in Group B vs 81.4% in Group A, p&lt;0.001). The same observations were made for kissing balloon postdilation (30.6% Group B vs 62.7% in Group A, p&lt;0.001). Procedural success with TIMI 3 flow was achieved in similar proportions in both groups. Mortality rate and MACE rates at 4-year follow-up were higher in Group B compared to Group A but have not reached statistical significance in univariable or multivariable analysis. Implantation of a self-apposing stent has been an independent predictor for target lesion revascularization rate (TLR) in multivariable analysis (HR 0.06, CI − 1.11–11.7, =0.03). Conclusions In our study, TLR rate was significantly higher in patients with left main lesion treated by PCI with self-apposing stents.

Intravascular Lithotripsy in Calcified Coronary Lesions: A Single-Center Experience in "Real-World" Patients.

ObjectivesThis study aims to describe the outcome of intravascular lithotripsy (IVL) when used with different indications and to assess the short- and long-term outcomes of IVL-facilitated percutaneous coronary intervention (PCI).BackgroundIntravascular lithotripsy can improve the results of PCI of calcified coronary lesions with a low rate of periprocedural complications.MethodsA total of 105 consecutive patients with 110 calcified lesions underwent IVL. A total of 87 de novo lesions were treated by IVL with the following indications: 25 before attempting other balloon-based devices (primary IVL), 51 after the failure of non-compliant balloon dilatation (secondary IVL), and 11 after stent implantation because of stent under expansion (bailout IVL). In 23 lesions, IVL was used for the treatment of in-stent restenosis (ISR). Effectiveness (angiographic success) and safety [major adverse cardiovascular events (MACEs) and IVL-related procedural complications] endpoints were assessed.ResultsAngiographic success was achieved in 84.6% of lesions. Early MACEs were periprocedural MI only, ranging from 6.7 to 20% depending on MI definition. The flow-limiting dissections rate was 2.7%. A total of five (4.5%) IVL balloons ruptured during treatment with subsequent vessel perforation in 1 case. MACEs at 12 months were 13.3%, with TLR occurring in 8 lesions (12% primary IVL, 0% secondary IVL, 0% bailout IVL, and 21.7% IVL for ISR, p = 0.002).ConclusionTreatment of calcified coronary lesions with IVL in a “real-world” setting can be performed with high success, low rate of procedural complications, and an acceptable MACEs rate. Target lesion failure may be more frequent when IVL is performed for the treatment of ISR due to calcium-mediated stent under expansion.

Prognostic Value of Coronary Sinus Flow Quantification by Cardiac Magnetic Resonance Imaging in Patients With Acute Myocardial Infarction.

BackgroundThis study aimed to evaluate the prognostic value of hyperemic coronary sinus flow (h‐CSF) and global coronary flow reserve (g‐CFR) obtained by phase‐contrast cine‐magnetic resonance imaging in patients with acute myocardial infarction (MI).Methods and ResultsThis retrospective study analyzed patients with acute MI (n=523) who underwent primary (ST‐segment–elevation MI) or urgent (non–ST‐segment–elevation MI) percutaneous coronary intervention. Absolute coronary sinus blood flow (CSF) at rest and during vasodilator stress hyperemia was quantified at 30 days (24–36 days) after the index infarct‐related lesion percutaneous coronary intervention and revascularization of functionally significant non–infarct‐related lesions. We used Cox proportional hazards regression modeling to examine the association between h‐CSF, g‐CFR, and major adverse cardiac events defined as all‐cause death, nonfatal MI, hospitalization for congestive heart failure, and stroke. Finally, 325 patients with ST‐segment–elevation MI (62.1%) and 198 patients with non–ST‐segment–elevation MI (37.9%) were studied over a median follow‐up of 2.5 years. The rest CSF, h‐CSF, and g‐CFR were 0.94 (0.68–1.26) mL/min per g, 2.05 (1.42–2.73) mL/min per g, and 2.17 (1.54–3.03), respectively. Major adverse cardiac events occurred in 62 patients, and Cox proportional hazards analysis showed that h‐CSF and g‐CFR were independent predictors of major adverse cardiac events (h‐CSF: hazard ratio [HR], 0.64; 95% CI, 0.47–0.88; P=0.005; g‐CFR: HR, 0.62; 95% CI, 0.47–0.82; P=0.001). When stratified by h‐CSF and g‐CFR, cardiac event‐free survival was the worst in patients with concordantly impaired h‐CSF (<1.6 mL/min per g) and g‐CFR (<1.7) (P<0.001).ConclusionsGlobal coronary sinus flow quantification using phase‐contrast cine‐magnetic resonance imaging provided significant prognostic information independent of infarction size and conventional risk factors in patients with acute MI undergoing revascularization.

Impact of directional coronary atherectomy followed by drug-coated balloon strategy to avoid the complex stenting for bifurcation lesions.

Although the simple single stenting rather than complex double stenting is recommended on percutaneous coronary intervention (PCI) for bifurcation lesions, double stenting cannot always be avoided. We investigated the impact of directional coronary atherectomy (DCA), followed by drug-coated balloon (DCB) treatment to reduce the number of stents and avoid complex stenting in PCI for bifurcation lesions and short-term patency. DCA treatment without stents was attempted for 27 bifurcation lesions in 25 patients, of those, 26 bifurcation lesions in 24 patients were successfully treated and 3-month follow-up angiography and optical coherence tomography (OCT) were performed. Sixteen lesions (59.3%) were related to left main trunk distal bifurcations, and 7 (25.9%) were true bifurcation lesions. Among the true bifurcation lesions, 4 lesions (57.1%) needed 1 stent, and the other 3 lesions (42.9%) needed no stents. Among the non-true bifurcation lesions, 1 lesion (5.0%) needed bailout stent and other lesions (95.0%) needed no stents. According to DCA followed by DCB treatment, the angiographic mean diameter stenosis improved from 65.5 ± 15.0% to 7.8 ± 9.8%, and the mean plaque area in intravascular ultrasound improved from 80.4 ± 10.5% to 39.0 ± 11.5%, respectively. Angiographic and OCT late lumen loss values were 0.2 ± 0.6mm and 1.4 ± 1.9mm, respectively. No patient had in-hospital major adverse cardiac events (MACE) and 3-month MACE. In conclusion, compared with standard provisional side branch stenting strategy, DCA followed by DCB treatment might reduce the number of stents, avoid complex stenting for major bifurcation lesions and provide good short-term outcomes.

Research Progress of Percutaneous Interventional Therapy For Bifurcation Lesions of Coronary Heart Disease

Compared with non-bifurcation lesions, even if the new generation of percutaneous coronary intervention (PCI) technology is used to treat coronary bifurcation lesions, the incidence of adverse cardiovascular events is still higher. The evaluation of related clinical data and computer virtual modeling before surgery can guide the implementation of bifurcation PCI in a more precise manner. The new understanding of bifurcation PCI may further improve the clinical prognosis and outcome of patients with bifurcation disease. This review aims to summarize the assessment methods of PCI for coronary heart disease non-left main bifurcation disease and the treatment plan supported by clinical evidence. The treatment plan depends on three parameters: the diameter of the three parts of the bifurcation lesion; the length of the lesion and plaque distribution; and the angle of the bifurcation. To this day, the best technique for PCI for bifurcation lesions is still controversial, and a personalized approach using temporary collateral stent implantation schemes seems to be suitable for 75% to 95% of patients. For more complex bifurcation lesions, it may be necessary to use two stents at the same time. More and more evidence supports the practicability of the DK-crush technique.

Impact of COVID-19 pandemic on the management of nonculprit lesions in patients presenting with ST-elevation myocardial infarction: Outcomes from the pan-London heart attack centers.

BackgroundThe impact of COVID‐19 on the diagnosis and management of nonculprit lesions remains unclear.ObjectivesThis study sought to evaluate the management and outcomes of patients with nonculprit lesions during the COVID‐19 pandemic.MethodsWe conducted a retrospective observational analysis of consecutive primary percutaneous coronary intervention (PPCI) pathway activations across the heart attack center network in London, UK. Data from the study period in 2020 were compared with prepandemic data in 2019. The primary outcome was the rate of nonculprit lesion percutaneous coronary intervention (PCI) and secondary outcomes included major adverse cardiovascular events.ResultsA total of 788 patients undergoing PPCI were identified, 209 (60%) in 2020 cohort and 263 (60%) in 2019 cohort had nonculprit lesions (p = .89). There was less functional assessment of the significance of nonculprit lesions in the 2020 cohort compared to 2019 cohort; in 8% 2020 cohort versus 15% 2019 cohort (p = .01). There was no difference in rates of PCI for nonculprit disease in the 2019 and 2020 cohorts (31% vs 30%, p = .11). Patients in 2020 cohort underwent nonculprit lesion PCI sooner than the 2019 cohort (p < .001). At 6 months there was higher rates of unplanned revascularization (4% vs. 2%, p = .05) and repeat myocardial infarction (4% vs. 1%, p = .02) in the 2019 cohort compared to 2020 cohort.ConclusionChanges to clinical practice during the COVID‐19 pandemic were associated with reduced rates of unplanned revascularization and myocardial infarction at 6‐months follow‐up, and despite the pandemic, there was no difference in mortality, suggesting that it is not only safe but maybe more efficacious.

Real-Life Outcomes of Coronary Bifurcation Stenting in Acute Myocardial Infarction (Zabrze-Opole Registry).

Percutaneous coronary intervention (PCI) of bifurcation lesions is a technical challenge associated with high risk of adverse events, especially in primary PCI. The aim of the study is to analyze long-term outcomes after PCI for coronary bifurcation in acute myocardial infarction (AMI). The outcome was defined as the rate of major adverse cardiac event related to target lesion failure (MACE-TLF) (death-TLF, nonfatal myocardial infarction-TLF and target lesion revascularization (TLR)) and the rate of stent thrombosis (ST). From 306 patients enrolled to the registry, 113 were diagnosed with AMI. In the long term, AMI was not a risk factor for MACE-TLF. The risk of MACE-TLF was dependent on the culprit lesion, especially in the right coronary artery (RCA) and side branch (SB) with a diameter >3 mm. When PCI was performed in the SB, the inflation pressure in SB remained the single risk factor of poor prognosis. The rate of cumulative ST driven by late ST in AMI was dependent on the inflation pressure in the main branch (MB). In conclusion, PCI of bifurcation culprit lesions should be performed carefully in case of RCA and large SB diameter and attention should be paid to high inflation pressure in the SB. On the contrary, the lower the inflation pressure in the MB, the higher the risk of ST.

FLOWER-MI and the root of the problem with non-culprit revascularisation

How do we reduce cardiac death and myocardial infarction by percutaneous coronary intervention (PCI) in coronary heart disease? Although the interventional community continues to grapple with this question in stable...

Baseline troponin-T is powerful predictor of mortality after coronary bifurcation stenting

Abstract Introduction Considerable progress has been made in the treatment of coronary bifurcation stenosis. Anatomical characteristics of the lesion, however, fail to give information about the functional significance of the bifurcation stenosis. There is no study that systematically establishes the baseline functional significance of coronary stenosis and its effect on procedural and clinical outcomes. Methods Patients with significant angiographically bifurcation lesions defined as diameter stenosis &amp;gt;50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). If FFR was ≤0.80 the lesion was considered functionally significant, and patients underwent PCI. For the group with FFR &amp;gt;0.80 – intervention was deferred. All patients were followed-up for vital status every 3 months. Cox regression analysis was performed to identify independent predictors of all-cause and cardiovascular death. The local ethics committee approved the study and patients signed informed consent for participation into registry. Results For mean follow-up of 38±18 months (median 40, IQR 23–55 months) all-cause mortality was numerically lower: 8.5% (n=7/82) in deferred group and 12.6% in stented group (n=11/76, p=0.387). The cardiac mortality was also numerically lower, but statistically not significant (9.8%, n=8/82 vs. 11.5%, n=10/88, p=0.714). On multivariate model, independent predictors were mitral regurgitation &amp;gt;1st degree – HR=1.778 (CI 1.100–2.874, p=0.019); dyslipidemia HR=0.765 (CI 0.594–0.985, p=0.038); hemoglobin concentration – HR=0.976 (CI 0.964–0.988, p&amp;lt;0.001); pre-PCI serum troponin ≥0.010 ng/ml – HR=2.702 (CI 1.451–5.032, p=0.002). On multivariate analysis, the following factors were identified as independent predictors of cardiac mortality: age – HR=1.035 (CI 1.009–1.062, p=0.009); diabetes – HR=1.789 (CI 1.089–2.962, p=0.024); dyslipidemia treated with statin – HR=0.667 (CI 0.515–0.863, p=0.002); LV posterior wall thickness – HR=1.230 (CI 1.062–1.424, p=0.006); mitral regurgitation more than 1st degree – HR=1.763 (CI 1.065–2.917, p=0.027); troponin pre-PCI ≥0.010 ng/ml – HR=2.498 (CI 1.228–5.081, p=0.011); true bifurcation lesion – HR=1.820 (CI 1.026–3.229, p=0.040); SBBARI score &amp;lt;10% – HR=1.715 (CI 1.049–2.804, p-0.031). Conclusion Baseline high-sensitive troponin T value is a strong predictor for both all cause and cardiac mortality in patients undergoing coronary bifurcation lesion PCI. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Alexandrovska University Hospital

The use of floating wire technique and intravascular ultrasound for precise aorto-ostial stenting

Abstract Background Aorto-ostial interventions often lead to imprecise ostial demarcation, suboptimal stent implantation, and worse clinical outcomes when compared to non-ostial interventions. The floating wire technique (bumper or sepal wire technique) employs a second guidewire placed in the aortic root to both mark the ostium and prevent prolapse of the guide catheter past the target ostial lesion. Its use has been described in the literature and is used often in daily practice however, procedural and long-term clinical endpoints have not been assessed using the gold standard of post-implant IVUS to determine technical success. The aim of the study is therefore to objectively assess the rate of geographic miss using the floating wire technique as well as long-term clinical outcomes. Methods A single center retrospective study was conducted. Patients who underwent ostial lesion percutaneous coronary intervention (PCI) with the floating wire technique between January 2019 and September 2020 were identified. Procedural and clinical outcomes at 6 months follow up were investigated. The co-primary endpoints include 1) Geographic miss defined as inadequate ostial coverage by IVUS or excess stent protrusion on angiography and 2) Target lesion failure (TLF) at 6 months after PCI, defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and target lesion revascularization. Results In total, 48 patients were identified. The average age was 71.7 years old, and 85.4% were male. Indication for PCI was acute coronary syndrome in about a third of patients. Twenty-six patients had left main ostial lesion, and 22 patients had right coronary artery ostial lesions. The average syntax score was 24.2. IVUS assessment was performed in 45 patients. Four (8.3%) patients had more than 2mm of excess stent proximal protrusion. Ostial miss occurred in 1 (2.2%) patient. Seven patients had loss to follow up. TLF, stroke, or major bleeding were not observed in any patients. One non-cardiovascular death, three type 2 MIs, and 1 type 4 MI were observed, which occurred in non-target vessels. Conclusions The floating wire technique was safe and efficient with low rates of geographic miss or adverse clinical outcomes. This is the first study to confirm precise aorto-ostial stent implantation using the floating wire technique with IVUS assessment. Funding Acknowledgement Type of funding sources: None. Floating Wire Technique for LM Stenting

Glycaemic status and reperfusion injury in patients with ST-segment elevation myocardial infarction

Abstract Background Failed myocardial tissue reperfusion due to microvascular injury despite successful culprit lesion percutaneous coronary intervention (PCI) is associated with poor clinical outcome in patients with ST-elevation myocardial infarction (STEMI). A possible influence of dysglycaemia on myocardial reperfusion injury is unclear. Objectives To investigate the association between glycaemic status and microvascular injury determined by magnetic resonance imaging in STEMI patients. Methods This prospective observational cohort study included 260 consecutive STEMI patients undergoing primary PCI between 2016 and 2019. Peripheral venous blood samples for glucose and HbA1c measurements were drawn on admission. Primary microvascular injury endpoint was defined as presence of intramyocardial haemorrhage (IMH) assessed by cardiac magnetic resonance T2* mapping at 4 (interquartile range [IQR]:2–5) days after PCI. Results HbA1c (odds ratio [OR]: 1.73 [95% CI: 1.24–2.40]; p=0.001), pre-diagnosis of diabetes (OR: 2.63 [95% CI: 1.18–5.90]; p=0.02) and glucose concentration (OR: 1.01 [95% CI: 1.00–1.01]; p=0.01) significantly predicted IMH, which was present in 90 (35%) patients. Of these three parameters, only HbA1c remained significantly associated with IMH (OR: 2.12 [95% CI: 1.12–3.99]; p=0.02) after adjusting for total ischemic time, culprit lesion location, pre- and post-interventional TIMI flow and peak biomarker concentrations (troponin, N-terminal pro-B-type natriuretic peptide and C-reactive protein). The rate of IMH was 24% in patients with HbA1c &amp;lt;5.7%, 43% in patients with HbA1c ≥5.7 to 6.4% and 59% in patients with HbA1c ≥6.5% (p&amp;lt;0.001). Conclusions In STEMI patients undergoing primary PCI, admission HbA1c was independently associated with reperfusion injury as determined by IMH. These findings suggest that IMH could represent the underlying pathophysiological link between dysglycaemia and adverse outcomes following STEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FWF - Austrian Science Fund; ÖKG - Austrian Society of Cardiology Figure 1. This figure illustrates the relation between HbA1c and IMH by two patient examples successfully treated with PCI (intervention with stent implantation schematically shown on the very left side). The first patient (upper line), representing the patient group with HbA1c &amp;lt;5.7% (associated IMH risk 24%), showed an anterior wall STEMI without IMH (T2* mapping on the very right, corresponding schematic picture of the infarct area without IMH next on the left). The second patient (lower line), representing the patients with HbA1c ≥5.7% (associated IMH risk 47%), showed an anterior wall STEMI with large IMH (arrows point to the hypo-intense core on the T2* mapping image and to the corresponding dark-red area in the schematic illustration). The zoomed view of one microvessel indicates the complex pathophysiology of IMH (including endothelial destruction, embolisation of thrombotic material and inflammation). (Created with BioRender)