Percutaneous Coronary Intervention Strategy Research Articles

Bifurcation detection in intravascular optical coherence tomography using vision transformer based deep learning

Objective. Bifurcation detection in intravascular optical coherence tomography (IVOCT) images plays a significant role in guiding optimal revascularization strategies for percutaneous coronary intervention (PCI). We propose a bifurcation detection method using vision transformer (ViT) based deep learning in IVOCT. Approach. Instead of relying on lumen segmentation, the proposed method identifies the bifurcation image using a ViT-based classification model and then estimate bifurcation ostium points by a ViT-based landmark detection model. Main results. By processing 8640 clinical images, the Accuracy and F1-score of bifurcation identification by the proposed ViT-based model are 2.54% and 16.08% higher than that of traditional non-deep learning methods, are similar to the best performance of convolutional neural networks (CNNs) based methods, respectively. The ostium distance error of the ViT-based model is 0.305 mm, which is reduced 68.5% compared with the traditional non-deep learning method and reduced 24.81% compared with the best performance of CNNs based methods. The results also show that the proposed ViT-based method achieves the highest success detection rate are 11.3% and 29.2% higher than the non-deep learning method, and 4.6% and 2.5% higher than the best performance of CNNs based methods when the distance section is 0.1 and 0.2 mm, respectively. Significance. The proposed ViT-based method enhances the performance of bifurcation detection of IVOCT images, which maintains a high correlation and consistency between the automatic detection results and the expert manual results. It is of great significance in guiding the selection of PCI treatment strategies.

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.

The Feasibility, Safety and Middle Term Clinical Outcome Study of Chronic Total Occlusion Percutaneous Coronary Intervention among Elderly Aged &lt;75 Years versus ≥75 Years in a High Intravascular Imaging Usage Centre

Background: Chronic total occlusion (CTO) is common among elderly patients, yet data on their outcomes with CTO percutaneous coronary intervention (PCI) remain limited. Understanding the feasibility, safety and clinical outcomes of CTO-PCI in this population is crucial for optimal care. The present study aimed to evaluate these aspects in elderly patients aged &lt;75 versus ≥75 years. Methods: Two hundred and fifty-eight patients who underwent CTO-PCI at a single Japanese centre, categorised into two groups: &lt;75 and ≥75 years old, were retrospectively analysed. Demographics, clinical factors, angiography and procedure data were collected. Follow-up data were obtained from electronic health records. The primary outcome measure was target lesion failure (TLF) at 1-year follow-up. Kaplan-Meier curve analysis and multivariable Cox-regression analysis were performed to identify predictors of TLF. Results: 68.6% were &lt;75 years old and 31.4% were ≥75 years old. Similar procedural success rates were observed. There were no significant differences in 1-year TLF, death, non-fatal MI or target-lesion revascularisation. The older group had a higher rate of intraprocedural complications. Mechanical circulatory support and emergency PCI negatively impacted target-lesion revascularisation-free survival in older patients, while hypertension appeared protective. Conclusion: The present study demonstrates the feasibility, safety and good mid-term outcomes of CTO-PCI in elderly patients. These findings suggest its potential as a treatment option for appropriate elderly patients. Additionally, possible risk factors for adverse events were identified, potentially guiding future management strategies. Therefore, elderly patients with CTO should not be deprived of invasive PCI strategies when appropriate.

Innovative Strategies for Chronic Total Occlusions

CHRONIC total occlusion percutaneous coronary intervention (CTO PCI) strategies were thoroughly discussed at the EuroPCR 2024 Annual Global Course in Paris, France. Experts in the field gathered to discuss the advantages and limitations of various approaches, including the use of intravascular ultrasound (IVUS) when locating ambiguous proximal caps. Experts discussed several techniques in the context of success rate and patient safety, with a focus on what changes can be made to current guidelines to ultimately improve patient outcomes in high-risk cases.

Standby extracorporeal membrane oxygenation: a better strategy for high-risk percutaneous coronary intervention.

The incidence of cardiac arrest (CA) during percutaneous coronary intervention (PCI) is relatively rare. However, when it does occur, the mortality rate is extremely high. Extracorporeal cardiopulmonary resuscitation (ECPR) has shown promising survival rates for in-hospital cardiac arrests (IHCA), with low-flow time being an independent prognostic factor for CA. However, there is no definitive answer on how to reduce low-flow time. This retrospective study, conducted at a single center, included 39 patients who underwent ECPR during PCI between January 2016 and December 2022. The patients were divided into two cohorts based on whether standby extracorporeal membrane oxygenation (ECMO) was utilized during PCI: standby ECPR (SBE) (n = 13) and extemporaneous ECPR (EE) (n = 26). We compared the 30-day mortality rates between these two cohorts and investigated factors associated with survival. Compared to the EE cohort, the SBE cohort showed significantly lower low-flow time (P < 0.01), ECMO operation time (P < 0.01), and a lower incidence of acute kidney injury (AKI) (P = 0.017), as well as peak lactate (P < 0.01). Stand-by ECMO was associated with improved 30-day survival (p = 0.036), while prolonged low-flow time (p = 0.004) and a higher SYNTAX II score (p = 0.062) predicted death at 30 days. Standby ECMO can provide significant benefits for patients who undergo ECPR for CA during PCI. It is a viable option for high-risk PCI cases and may enhance the overall prognosis. The low-flow time remains a critical determinant of survival.

Optical coherence tomography (OCT) - versus angiography-guided strategy for percutaneous coronary intervention: a meta-analysis of randomized trials

BackgroundOptical coherence tomography (OCT) guidance in percutaneous coronary intervention (PCI) has been shown to improve procedural outcomes. However, evidence supporting its superiority over angiography-guided PCI in terms of clinical outcomes is still emerging and limited. This study aimed to compare the efficacy and safety of OCT-guided PCI versus angiography‐guided PCI in patients with coronary artery disease (CAD).MethodsA systematic search of electronic databases was conducted to identify randomized control trials (RCTs) comparing the clinical outcomes of OCT-guided and angiography‐guided PCI in patients with CAD. Clinical endpoints including all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), stent thrombosis and major adverse cardiac events (MACE) were assessed.ResultsEleven RCTs, comprising 2,699 patients in the OCT-guided group and 2,968 patients in the angiography-guided group met inclusion criteria. OCT-guided PCI was associated with significantly lower rates of cardiovascular death(RR 0.56; 95%CI: 0.32–0.98; p = 0.04; I2 = 0%), stent thrombosis(RR 0.56; 95%CI: 0.33–0.95; p = 0.03; I2 = 0%), and MACE (RR 0.79; 95%CI: 0.66–0.95; p = 0.01; I2 = 5%). The incidence of all-cause death (RR 0.71; 95%CI: 0.49–1.02; p = 0.06; I2 = 0%), myocardial infarction (RR 0.86; 95%CI: 0.67–1.10; p = 0.22; I2 = 0%) and TLR (RR 0.98; 95%CI: 0.73–1.33; p = 0.91; I2 = 0%) was non-significantly lower in the OCT-guided group.ConclusionsAmong patients undergoing PCI, OCT-guided PCI was associated with lower incidences of cardiovascular death, stent thrombosis and MACE compared to angiography-guided PCI.Trial registrationPROSPERO registration number: CRD42023484342.

Timing of Complete Revascularization Stratified by Index Presentation During On- and Off-Hours

Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear.On-hours was defined as an index revascularization performed between 8 AM and 6 PM, Monday to Friday, or else the procedure was defined as performed during off-hours. The primary endpoint consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia driven revascularization and cerebrovascular events at 1 year follow-up. We used Cox regression models to relate randomized treatment with study endpoints. We evaluated multiplicative and additive interactions between on- vs. off-hours and randomized treatment.The BIOVASC trial enrolled 1097 and 428 patients during on- and off-hours respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs. 29.5%, p < 0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR respectively during on-hours (HR 0.80, 95% CI 0.54 to 1.19). During off-hours the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% CI 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes.In conclusion, no differential treatment effect was found when comparing immediate complete revascularization versus staged complete revascularization in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.

COMPLETE VS CULPRIT–LESION–ONLY MYOCARDIAL REVASCULARIZATION IN PATIENTS WITH OUT–OF–HOSPITAL CARDIAC ARREST: INSIGHTS FROM THE MULTICENTRIC LOMBARDIA CARE REGISTRY

Abstract Background Out–of–hospital Cardiac Arrest (OHCA) is an uncommon yet potentially devastating complication of patients with Myocardial Infarction (MI). Multivessel Disease (MVD) is a frequent occurrence in this setting, being present in nearly half patients undergoing Coronary Angiography (CAG). We previously reported that, in case of MI complicated by OHCA and evidence of MVD, a complete myocardial revascularization, as compared to culprit–lesion–only revascularization, was associated with an improved 1–year survival and favorable neurological outcomes. We aimed to validate and confirm these results on a multicentric scale with a larger patient cohort. Methods This is a multicentric, prospective, observational study. We considered all consecutive patients with OHCA and MI enrolled in the Lombardia CARe Registry from January 1st 2015 to December 31st 2022 who underwent CAG in 6 centers in Northen Italy. Results A total of 623 patients were included; of these, 403 underwent CAG. Median age was 64 years, and about 80% had no history of ischemic heart disease. Median ejection fraction (EF) was 40%. MVD was present in 186 patients and was subsequently treated with either complete (32%) or incomplete (67.7%) coronary revascularization. Left anterior descendent (LAD) artery was the culprit lesion in almost 1/3 of patients. The 1–year survival rate was 78.3% in the complete revascularization group and 42.9% in the culprit–lesion–only revascularization group (p–value &amp;lt; 0.001). After correction for EF, hypercholesterolemia, mechanical or pharmacological support, cardiac arrest time and first shockable rhythm, complete revascularization strategy was independently associated with a reduced risk of death [HR: 0.27 (95% CI: 0.01 to 0.739; p = 0.01] and death or unfavorable neurological outcome [HR: 0.23 (95% CI: 0.08 to 0.67); p = 0.007]. Conclusions in patients resuscitated from OHCA, complete revascularization strategy was confirmed to be associated with an improvement of 1–year survival and with a good neurological outcome. These results highlight the independent impact on survival of a complete percutaneous coronary intervention strategy in patients with OHCA plus MVD.

Hybrid total arterial minimally invasive off-pump coronary revascularization and percutaneous coronary intervention strategy for multivessel coronary artery disease: a cohort study with a median 11-year follow-up.

Hybrid coronary revascularization (HCR) is a treatment approach that combines the benefits of coronary artery bypass grafting (CABG) techniques such as minimally invasive direct coronary artery bypass (MIDCAB) or minimally invasive multivessel CABG (MICS-CABG) with percutaneous coronary intervention (PCI) for carefully selected patients with multivessel coronary artery disease (MV CAD). The extant body of research primarily concentrates on the comparison of outcomes between HCR and CABG or PCI. Furthermore, HCR is defined primarily as MIDCAB and PCI. Given the various criteria for HCR identified in the current body of literature, as well as several hybrid revascularization techniques, our primary goal was to analyse the characteristics and track the development of HCR patients operated on in our centre (Robert Bosch Hospital) over both short and long periods of time. Additionally, we sought to validate the practical challenges that arise during the implementation of an HCR methodology. This cohort study included 138 patients with MV CAD who had an HCR approach in conjunction with isolated total arterial off-pump MICS-CABG or MIDCAB between 2007 and 2018 at Robert Bosch Hospital in Stuttgart. Data on major adverse cardiac and cerebral events (MACCE), defined as all-cause mortality, myocardial infarction, repeat revascularization and stroke were gathered through a questionnaire. Long-term follow-up, with a mean duration of 8.7±0.3 years and a median duration of 11 years, was available for a significant majority of the patients (92.8%, n=128). The average age was 69.6±11.2 years, with 79% being male. The mean European System for Cardiac Operative Risk Evaluation score I additive (EuroSCORE I) additive was 7.6±10.2 and the mean SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) Score I was 22.9±9.4. A total of 97 MIDCAB surgeries and 41 MICS-CABG procedures were performed without any instances of conversion to sternotomy or cardiopulmonary bypass (CPB). A total of 70 patients, or 50.7% of the sample, received the planned PCI treatment. This percentage was substantially lower in the subgroup with chronic CAD, with just 27, equivalent to 39.1%. The observed 30-day death rate was 2.1% (3/138). During follow-up, 3 myocardial infarctions, 18 PCI repeats, no CABG, and 4 strokes occurred. From 128 followed-up patients, 28 died (21.9%), 7 of which were heart deaths (5.5%). Total MACCE was 36.7%. The survival rates at 3 and 5 years were 92% and 85% respectively. Patients who didn't get the planned PCI had a mean survival rate of 6.8-9.1 years, while those with completed hybrid treatment had a higher mean survival rate of 8.4-10.2 years. In selected individuals with MVCAD, current evidence suggests that HCR is a safe and effective coronary artery revascularization approach. After coronary bypass surgery, the attention going forward needs to be devoted toward the organization of the PCI step in the treatment process.

Comparative efficacy of interventional therapies and devices for coronary in-stent restenosis: A systematic review and network meta-analysis of randomized controlled trials

BackgroundIn-stent restenosis (ISR) has become a significant obstacle to interventional therapy for atherosclerotic cardiovascular disease. The optimal percutaneous coronary intervention (PCI) strategy for patients with coronary ISR remains controversial. This network meta-analysis (NMA) was aimed to compare and estimate the effectiveness of different PCI strategies and commercial devices for the treatment of patients with coronary ISR. MethodsIn present study, we systematically searched PubMed, Embase, Web of Science, and Cochrane Library from database inception to October 20, 2022, to identify randomized controlled trials. We included studies comparing various PCI strategies for the treatment of any type of coronary ISR. The study was registered with PROSPERO, CRD 42022364308. ResultsWe included 44 eligible trials including 8479 patients, 39 trials comparing the treatment effects of 10 PCIs, and 5 trials comparing the efficacy between different types of drug-eluting stent (DES) or drug-coated balloon (DCB) devices. Among the PCIs, everolimus-eluting stent was the optimal strategy considering target lesion revascularization (TLR), percent diameter stenosis (%DS), and binary restenosis (BR), and sirolimus-coated balloon was the optimal strategy considering late lumen loss (LLL). In the comparison of commercial devices, the combination strategy excimer laser coronary angioplasty plus SeQuent Please paclitaxel-coated balloon showed promising therapeutic prospects. ConclusionsDCB and DES remain the preferred treatment strategies for coronary ISR, considering both the primary clinical outcome (TLR) and the angiographic outcomes (LLL, BR, %DS). Personalized combination interventions including DCB or DES hold promise as a novel potential treatment pattern for coronary ISR.

A Comparison of 2 Paclitaxel-Coated Balloon Systems in Treatment of De Novo Coronary Artery Lesions

BackgroundIn percutaneous coronary intervention (PCI) of de novo lesions, drug-coated balloons (DCB) have been shown to be a promising strategy to improve clinical outcomes of patients with small vessel disease. Evidence of this strategy in PCI of de novo coronary lesions in a real-world setting is limited. The objective of this study was to compare the 12-month outcomes of 2 paclitaxel-coated balloon systems for the treatment of all de novo coronary artery lesions. MethodsAll patients who were treated for de novo coronary artery stenosis with either SeQuent Please or In.Pact Falcon DCB at a single center from January 2014 to December 2018 were included. The primary end point was the composite of cardiac death, nonfatal myocardial infarction, and target vessel revascularization (3-point major adverse cardiovascular events) at 12 months. ResultsA total of 496 patients with 623 lesions, of which 144 were treated with SeQuent Please and 352 were treated with In.Pact Falcon were included in the study. Baseline patient, lesion and procedural characteristics at baseline were similar between groups. At 12-month follow-up, 3-point major adverse cardiovascular event outcomes were similar (4.2% vs 2.3% respectively; P = .272). Deaths due to cardiovascular events were few and similar between groups (2.7% vs 1.1% respectively; P = .20). ConclusionsBoth paclitaxel DCB systems have similar efficacy and safety outcomes, suggesting that both may be an appropriate treatment choice for patients with de novo lesions. However, a larger randomized controlled study is needed to confirm these findings.

Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond.

The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.

Aspirin-free strategy for percutaneous coronary intervention in acute coronary syndrome based on the subtypes of acute coronary syndrome and high bleeding risk: the STOPDAPT-3 trial.

High bleeding risk (HBR) and acute coronary syndrome (ACS) subtypes are critical in determining bleeding and cardiovascular event risk after percutaneous coronary intervention (PCI). In 4476 ACS patients enrolled in the STOPDAPT-3, where the no-aspirin and dual antiplatelet therapy (DAPT) strategies after PCI were randomly compared, the pre-specified subgroup analyses were conducted based on HBR/non-HBR and ST-segment elevation myocardial infarction (STEMI)/non-ST-segment elevation ACS (NSTE-ACS). The co-primary bleeding endpoint was BARC type 3 or 5, and the co-primary cardiovascular endpoint was a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke at 1 month. Irrespective of the subgroups, the effect of no-aspirin compared with DAPT was not significant for the bleeding endpoint (HBR [N=1803]: 7.27% and 7.91%, HR 0.91, 95%CI 0.65-1.28; non-HBR [N=2673]: 3.40% and 3.65%, HR 0.93, 95%CI 0.62-1.39; Pinteraction=0.94; STEMI [N=2553]: 6.58% and 6.56%, HR 1.00, 95% CI 0.74-1.35; NSTE-ACS [N=1923]: 2.94% and 3.64%, HR 0.80, 95%CI 0.49-1.32; Pinteraction=0.45), and for the cardiovascular endpoint (HBR: 7.87% and 5.75%, HR 1.39, 95%CI 0.97-1.99; non-HBR: 2.56% and 2.67%, HR 0.96, 95%CI 0.60-1.53; Pinteraction=0.22; STEMI: 6.07% and 5.46%, HR 1.11, 95%CI 0.81-1.54; NSTE-ACS: 3.03% and 1.71%, HR 1.78, 95%CI 0.97-3.27; Pinteraction=0.18). In patients with ACS undergoing PCI, the no-aspirin strategy compared to the DAPT strategy failed to reduce major bleeding events irrespective of HBR and ACS subtypes. The numerical excess risk of the no-aspirin strategy relative to the DAPT strategy for cardiovascular events was observed in patients with HBR and in patients with NSTE-ACS.

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Complete revascularization by non-infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)-guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective. To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease. In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis >50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023. Fractional flow reserve-guided vs angiography-guided PCI for non-IRA lesions. The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials. The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve-guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was -$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively. This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve-guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients. ClinicalTrials.gov Identifier: NCT02715518.

Comparison of Primary Percutaneous Coronary Intervention (PPCI) vs. Pharmacoinvasive strategy as Reperfusion Strategies in patients with ST-elevation myocardial infarction (STEMI)

Comparison of Primary Percutaneous Coronary Intervention (PPCI) vs. Pharmacoinvasive strategy as Reperfusion Strategies in patients with ST-elevation myocardial infarction (STEMI)

Virtual stenting and coregistration of instantaneous wave-free ratio to predict the physiological effect of percutaneous coronary intervention in patients with multilevel coronary artery disease

Aim. To evaluate the accuracy of virtual stenting in predicting the physiological effect of percutaneous coronary intervention (PCI) for multilevel coronary artery disease (CAD).Material and methods. In order to define PCI strategy, 34 patients with multilevel CAD underwent assessment of instantaneous wave-free ratio (iFR) with mapping. Using the virtual stenting, predicted iFR (priFR) was assessed. After stent implantation, the factual iFR (fiFR) was re-assessed. A discrepancy between the priFR and fiFR by 0,03 was considered the threshold level of a significant difference and "poor agreement" criterion between measurements.Results. Mean iFR before PCI was 0,77±0,11; after PCI, this indicator increased significantly and amounted to 0,94±0,04 (p&lt;0,001). Comparison of the predicted and factual iFR revealed that the difference did not significantly depend on the value (rxy=-0,183; p=0,300), and mean difference between measurements was 0,013 (standard deviation, ±0,019), which indicates no systematic discrepancy and good comparability of the studied methods. In addition, correlation analysis of priFR and fiFR revealed a significant strong (Chaddock scale) direct relationship (r=0,854; p&lt;0,001). Independent predictors of "poor agreement" were heart rate and systolic blood pressure before surgery. Discrepancy in decisions on the choice of stented lesions and the required number of stents based on coronary angiography (CAG) and MRI occurred in 21 patients (62%) and 16 patients (47%), respectively. After iFR measurement, there was a significant decrease in the mean length of affected segment (from 61,82±19,68 mm (CAG) and 49,15±19,19 mm (iFR)), which made it possible to significantly reduce the number of implanted stents from 1,91±0,57 (CAG) to 1,50±0,56 (p=0,001).Conclusion. Mapping the iFR and virtual stenting technology makes it possible to revise the classification of coronary lesions by length, which leads to a significant reduction in the number of implanted stents and the length of stented segment. High correlation between priFR and fiFR achieved in our study indicates the high accuracy of virtual stenting in predicting the physiological effect of stenting.

Cost-effectiveness of intravascular ultrasound-guided percutaneous intervention in patients with acute coronary syndromes: A UK perspective.

Use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes over angiography alone. Despite this, the adoption of IVUS in clinical practice remains low. To examine the cost-effectiveness of IVUS-guided PCI compared to angiography alone in patients with acute coronary syndromes (ACS). A one-year decision tree and lifetime Markov model were constructed to compare the cost-effectiveness of IVUS-guided PCI to angiography alone for two hypothetical adult populations consisting of 1,000 individuals: ST-elevation myocardial infarction (STEMI) and unstable angina/ non-ST-elevation myocardial infarction (UA/NSTEMI) patients undergoing drug-eluting stent (DES) implantation. The UK healthcare system perspective was applied using 2019/20 costs. All-cause death, myocardial infarction (MI), repeat PCI, lifetime costs, life expectancy and quality-adjusted life-years (QALYs) were assessed. Over a lifetime horizon, IVUS-guided PCI was cost-effective compared to angiography alone in both populations, yielding an incremental cost-effectiveness ratio of £3,649 and £5,706 per-patient in STEMI and UA/NSTEMI patients, respectively. In the one-year time horizon, the model suggested that IVUS was associated with reductions in mortality, MI and repeat PCI by 51%, 33% and 52% in STEMI and by 50%, 29% and 57% in UA/NSTEMI patients, respectively. Sensitivity analyses demonstrated the robustness of the model with IVUS being 100% cost-effective at a willingness-to-pay (WTP) threshold of £20,000 per QALY-gained. From a UK healthcare perspective, an IVUS-guided PCI strategy was highly cost-effective over angiography alone amongst ACS patients undergoing DES implantation due to the medium- and long-term reduction in repeat PCI, death, and MI.

Circulating intermediate monocytes CD14++CD16+ are increased after elective percutaneous coronary intervention

Aim Inflammation plays a central role in the pathogenesis of atherosclerosis and in the sequelae of percutaneous coronary intervention (PCI). Previous work demonstrated that intermediate monocytes (CD14++CD16+) are associated with adverse cardiovascular events, yet monocyte subset response following elective PCI has not been described. This article explores the changes in monocyte subset and humoral response after elective PCI. Methods This prospective study included 30 patients without inflammatory diseases being referred for elective PCI. We included patients treated with drug coated balloons or 2nd generation drug eluting stents. Patients underwent blood tests at baseline (prior to PCI), four hours, two weeks and two months later. Analyses were performed in terms of monocyte subsets (classical CD14++CD16-, intermediate CD14++CD16+ and non-classical CD14+CD16++), gene expression of CD14+ leucocytes and humoral biomarkers. Results Intermediate monocytes decreased significantly four hours after PCI, were recovered at two weeks, and increased significantly at two months post elective, uncomplicated PCI. They remain significantly elevated in the DES group but not in the DCB group. Gene expression analysis of CD14+ leucocytes showed IL18 had decreased expression at two weeks, CXCR4 and IL1β decreased at two months, while pentraxin 3 increased at two weeks and two months. In terms of humoral biomarkers, hsTnI remains elevated up to two weeks post PCI while IL6 and TNFα remain elevated till two months post PCI. Conclusion Intermediate monocytes increase significantly two months following elective, uncomplicated PCI. They remain significantly elevated in the DES group but not in the DCB group suggesting that the PCI strategy could be one of the ways to modulate the inflammatory response post PCI.

Comparison of Clinical Outcomes Among Various Percutaneous Coronary Intervention Strategies for Small Coronary Artery Disease

It remains unclear which percutaneous coronary intervention (PCI) strategy is the most preferable in small-vessel coronary artery disease (CAD) patients. We sought to evaluate the clinical efficacy of various PCI strategies for patients with small-vessel CAD through a network meta-analysis of randomized controlled trials (RCTs). We searched multiple databases for RCTs investigating the efficacy of the following PCI strategies for small-vessel CAD (<3 mm in diameter): drug-coated balloons (DCB), early-generation paclitaxel-eluting stents and sirolimus-eluting stents (SES), newer-generation drug-eluting stents (DES), bare-metal stents (BMS), cutting balloon angioplasty, and balloon angioplasty (BA). The primary outcome was the trial-defined major adverse cardiovascular events (MACE), mostly defined as a composite of death, myocardial infarction, and revascularization. The secondary outcomes included each component of MACE and angiographic binary restenosis. We performed a sensitivity analysis for RCTs without BMS or 1st-generation DES. Our search identified 29 eligible RCTs including 8,074 patients among the 8 PCI strategies. SES significantly reduced MACE compared with BA (HR: 0.23; 95% CI [0.10 to 0.54]) with significant heterogeneity (I2 = 55.9%), and the rankogram analysis showed that SES was the best. There were no significant differences between DCB and newer-generation DES in any clinical outcomes, which was consistent in the sensitivity analysis. BMS and BA were ranked as the worst two for most clinical outcomes. In conclusion, SES was ranked as the best for reducing MACE. There were no significant differences in clinical outcomes between DCB and newer-generation DESs. BMS and BA were regarded as the worst strategies for small-vessel CAD.

The impact of primary percutaneous coronary intervention strategies during ST-elevation myocardial infarction on the prevalence of coronary microvascular dysfunction

Coronary microvascular dysfunction (CMD) is a common complication of ST-segment elevation myocardial infarction (STEMI) and can lead to adverse cardiovascular events. This is a non-randomized, observational, prospective study of STEMI patients with multivessel disease who underwent primary PCI, grouped based on whether they underwent balloon pre-dilatation stenting or direct stenting of the culprit lesion. Coronary physiology measurements were performed 3 months post-PCI including coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) measurements at the culprit vessel. The primary endpoint was the prevalence of CMD at 3 months, defined as IMR ≥ 25 or CFR < 2.0 with a normal fractional flow reserve. Secondary endpoints included major adverse cardiovascular events (MACE) at 12 months. Two hundred ten patients were enrolled; most were men, 125 (59.5%), with a median age of 65 years. One hundred twelve (53.2%) underwent balloon pre-dilatation before stenting, and 98 (46.7%) underwent direct stenting. The prevalence of CMD at 3 months was lower in the direct stenting group than in the balloon pre-dilatation stenting group (12.24% vs. 40.18%; p < 0.001). Aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with lower odds of CMD (OR = 0.175, p = 0.001 and OR = 0.113, p = 0.001, respectively). Notably, MACE in patients who underwent direct stenting was lower than in those who underwent balloon pre-dilatation before stenting (14.29% vs. 26.79%; p = 0.040). In STEMI patients with multivessel disease, direct stenting of the culprit lesion, aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with a lower prevalence of CMD at 3 months and lower incidence of MACE at 12 months compared with balloon pre-dilatation stenting.This trial is registered at https://ichgcp.net/clinical-trials-registry/NCT05406297.