Percutaneous Coronary Intervention Procedures Research Articles

Impact of percutaneous coronary intervention in right coronary artery on right ventricular function in patients with acute myocardial infarction.

Background: Right ventricular (RV) dysfunction is a potent predictor of mortality and morbidity following acute myocardial infarction (AMI). Despite the fact that elective percutaneous coronary intervention (PCI) has significantly decreased myocardial damage to the left ventricle, there is a lack of information regarding the effect of PCI on RV function. Aim: This study aimed to examine the effect of right coronary artery (RCA) revascularization on the systolic and diastolic functions of the right ventricle following acute inferior wall myocardial infarction. Methods: Fifty-nine patients diagnosed with acute inferior wall myocardial infarction after RCA revascularization were prospectively investigated between April 2018 and January 2020. The patients underwent 2D echocardiography. RV systolic and diastolic functions were reported before and after the PCI procedure and compared using echocardiographic RV systolic and diastolic parameters. Results: After PCI, echocardiographic RV systolic and diastolic functions significantly improved in the proximal and mid RCA in terms of TAPSE, RVFAC, and E/A. Significant improvement was found in the mid RCA in terms of S' velocity (p=0.008) and in the proximal RCA in terms of E/e' (p=0.021). Overall echocardiographic systolic and diastolic parameters in patients with RV dysfunction following PCI were improved [TAPSE (37.29% vs. 81.82%), S' velocity (37.29% vs. 68.18%), RVFAC (33.90% vs. 90.00%), and E/A (33.90% vs. 75.00%)]. Conclusion: Our findings revealed that patients with RV dysfunction showed remarkable improvement after RCA revascularization. Hence, in future cases, RCA revascularization may become an appropriate treatment alternative for the recovery of patients with RV dysfunction.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography.

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calciumscore and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

EE81 The Budget Impact of Cangrelor for the Treatment of Patients Undergoing Percutaneous Coronary Intervention When Oral P2Y12 Inhibitors Are Not Feasible or Desirable in the UK

Cangrelor is an intravenous, direct-acting, reversible P2Y12 inhibitor indicated for the reduction of thrombotic cardiovascular events in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) who have not received an oral P2Y12 inhibitor prior to the PCI procedure, and in whom oral therapy with P2Y12 inhibitors is not feasible or desirable. The objective of this analysis is to estimate the UK budget impact of introducing cangrelor, for the ST-elevation myocardial infarction (STEMI) population in whom oral P2Y12 inhibitors are not feasible or desirable.

Trends and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in New South Wales from 2008 to 2019

Risk profiles are changing for patients who undergo percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In Australia, little is known of the nature of these changes in contemporary practice and of the impact on patient outcomes. We identified all CABG (n=40,805) and PCI (n=142,399) procedures in patients aged ≥18 years in New South Wales, Australia, during 2008 to 2019. Between 2008 and 2019, the age- and gender-standardized revascularization rate increased by 20% (from 267/100,000 to 320/100,000 population) for all revascularizations. The increase in revascularization was particularly driven by a 35% increase (from 194/100,000 to 261/100,000) in PCI, whereas the rate of CABG decreased by 20% (from 73/100,000 to 59/100,000). Mean age and the prevalence of co-morbidities (especially diabetes and atrial fibrillation) increased for patients with PCI in more recent years but remained consistently lower than for patients with CABG. CABGs performed in patients presenting with a non-ST-segment-elevation acute coronary syndrome halved from 34.3% to 18.7% during the study period, whereas PCIs in this group decreased from 36.5% to 29.6%. Risk-adjusted in-hospital mortality decreased by 7.5 deaths/1,000 procedures per month for CABG but remained unchanged for PCI. Risk-adjusted readmission rates were consistently higher for CABG than for PCI and did not change significantly over time. In conclusion, we observed a dramatic shift over time from CABG to PCI as the revascularization procedure of choice, with the patient base for PCI extending to older and sicker patients. There was a large decrease in mortality after CABG, whereas mortality after PCI remained unchanged.

Treatment of Refractory No-Reflow in Cardiac Catheterization Laboratory; Role of Intracoronary Verapamil (A Case Report)

The no reflow phenomenon is a feared complication in Percutaneous Coronary Intervention (PCI) procedures including elective as well as primary PCI (Percutaneous Coronary Intervention), and results in worse prognosis. A number of etiological factors are involved in pathogenesis of no reflow phenomenon. These include distal athero embolization, ischemic and reperfusion injury, microvascular spasm and endothelial dysfunction. The treatment of no reflow depends on underlying mechanism and includes pharmacological as well as non-pharmacological interventions. Pharmacological agents include vasodilators like adenosine, sodium nitroprusside, verapamil, in addition to adrenaline (intracoronary) and, GpIIa/IIIb inhibitors. Non pharmacological measures include mechanical thrombus aspiration. Among pharmacological agents, Verapamil is usually the least preferred agent because of its negative ionotropic effect. Here, we describe a case of refractory no reflow in a patient undergoing primary PCI to right coronary artery (RCA), which was treated with a no. of pharmacological agents as well as aspiration thrombectomy but without much success and finally responded to intracoronary verapamil.

Prevalence of Acute Gastro Intestinal Tract Bleeding in Patients Undergoing Primary Percutaneous Coronary Intervention After Acute Myocardial Infarction

Objective: To determine the prevalence of acute gastro-intestinal tract bleeding and the factors associated with it in patients undergoing Primary PCI after acute myocardial infarction.
 Study Design: Analytical Cross sectional study.
 Place and Duration of Study: Department of Interventional Cardiology, Tertiary Cardiac Care Center, Rawalpindi Pakistan, from May 2021 to April 2022.
 Methodology: Five hundred patients (n =500) between 30-80 years of age, presented at the emergency of Tertiary cardiac care center, Rawalpindi and diagnosed with Acute Myocardial Infarction were planned to undergo the Primary Percutaneous Coronary Intervention (PCI) procedure. After the procedure, patients were evaluated for acute gastro-intestinal tract bleeding within first 48 hrs. Blood samples were taken before and after 24 hrs and 72 hrs of primary PCI. The blood hemoglobin level was assessed and fall in its level was noted. SPSS 26 was used to enter and analyze the collected data.
 Results: Out of n=500 patients enrolled in the study, 440(88%) were males and 60(12%) were females. The mean age of patients was 64.27 ± 6.47 years. The mean time from symptoms onset to primary PCI was 9.74±5.15 hrs. The mean duration of the procedure was 34.99 ± 6.01 mins. After the procedure, 23(4.60%) patients had developed the acute gastro-intestinal tract bleeding. In patients who developed acute gastro-intestinal bleeding, mean blood hemoglobin level before the procedure was 11.95 ± 1.05 g/dl, which was reduced to 8.46 ± 0.51 g/dl after the procedure. In patients who did not develop it, the mean blood hemoglobin level before the procedure was 11.94±1.03 g/dl, which was reduced to 11.80 ± 1.04 g/dl after the procedure. The blood hemoglobin level after the procedure was significantly less in patients who suffered from acute gastro-intestinal tract bleeding.
 Conclusion: The research study concluded that the frequency of acute gastro-intestinal tract bleeding in patients after primary PCI for acute myocardial infarction was very low but on the other hand marked reduction in blood hemoglobin level was observed, which can lead to many adverse sequelae.

Abstract 12825: Merging Machine Learning and Patient Preference: A Contemporary, Comprehensive, Patient-Centered Tool for Risk Prediction Prior to Percutaneous Coronary Intervention

Introduction Predicting personalized risk for adverse events following percutaneous coronary intervention (PCI) remains critical in weighing treatment options, employing risk-mitigation strategies, and enhancing shared decision-making. Hypothesis We hypothesized that by employing machine learning models, we would be able to use pre-procedural factors to predict common post-PCI complications. Methods A patient panel ranked the importance of common PCI complications. A separate group of 66 adults underwent a semiquantitative survey assessing for a preferred list of outcomes and model display. Our cohort included 71,963 PCI procedures performed at 48 hospitals in Michigan between 4/1/2018 and 9/30/2020 in the BMC2 registry divided into two groups for training (75%) and validation (25%). XGBoost and random forest models were created to predict the risk of in-hospital outcomes. Results The overall rate of mortality was 1.76% (n=1,264), AKI 2.64% (n=1,712), new need for dialysis 0.41% (n=295), major bleeding 0.89% (n=631), and transfusion 2.43% (n=1,746). The XGBoost model was selected as the final model and demonstrated excellent discrimination and calibration for all outcomes including mortality (AUC: 0.950 [95%CI 0.939-0.962]), AKI (AUC: 0.889 [95%CI 0.874-0.904]), dialysis (AUC: 0.949 [95%CI 0.928-0.969]), transfusion (AUC: 0.918 [95%CI 0.905-0.931]), and major bleeding (AUC: 0.892 [95%CI 0.861-0.922]). Survey subjects preferred a comprehensive list of individually reported post-procedure outcomes. Conclusion Using common pre-procedural risk factors, we designed an XGBoost machine learning model that accurately predicts individualized post-PCI outcomes. Utilizing patient feedback, we created a patient-centered tool to clearly display risks to patients and providers (Figure, shiny.bmc2.org/pci-prediction/). Enhanced risk prediction prior to PCI could help inform treatment selection and shared decision-making discussions.

Effect of glomerular filtration rate in patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis.

Through meta-analysis of the relationship between glomerular filtration rate and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI), we studied the impact of glomerular filtration rate on the prognosis of PCI. We collected literature on the incidence of MACE in patients with chronic kidney disease (CKD; estimated glomerular filtration rate < 60 mL/minute/1.73 m2) and patients with nonchronic kidney disease undergoing PCI. The search period was from January 1, 2000, to November 1, 2021. The searched databases included CNKI, Chinese Wanfang Data, China Biology Medicine disc, Web of Science, PubMed, and Cochrane Library. We used subgroup analysis and meta-regression to assess heterogeneity. Twenty-one eligible studies were included, with 46,255 samples included, 4903 cases of MACE (10.6%), and patients with CKD had a higher risk of MACE after PCI (Risk ratios = 1.67; 95% confidence interval: 1.51-1.85). Multivariate meta regression results show that heterogeneity is related to region. The risk of MACEs in patients with CKD is different in different regions, and North America has the lowest risk, with an risk ratios value of 1.21 (95% confidence interval: 1.08-1.35). Chronic kidney disease will increase the probability of MACE in patients with myocardial infarction after PCI and affect the prognosis of PCI. Therefore, clinical attention should be given to assessing glomerular filtration rate effects while treating patients with myocardial infarction with the PCI procedure.

Main stem intervention-Is one stent better than two after all?

The current European Society of Cardiology (ESC) guideline recommendations give equal consideration to percutaneous coronary interventions (PCI) and bypass surgery for the treatment of main stem stenosis. Because of the anatomical setting, interventional treatment of main stem stenosis represents acomplex PCI procedure. For this reason, extensive planning of the PCI with the use of intravascular imaging is necessary to assess the extent of calcification in the main stem itself and also in the proximal vascular segment of the anterior interventricular branch (left anterior descending, LAD) and the circumflex branch (RCX). Furthermore, an assessment of the vessel diameter is necessary for planning the PCI as well as for stent selection. Especially in the case of severely calcified lesions, careful and routine dissection of the lesion to be treated is essential. For this purpose, so-called cutting balloons, scoring balloons or debulking devices (rotational atherectomy, orbital atherectomy) can be used. In the case of amain stem stenosis involving the bifurcation, the choice of stent strategy depends on the extent of calcification of the daughter vessels (LAD and RCX), as well as the complexity of the bifurcation stenosis. The superiority of the so-called double kissing (DK) crush technique over asingle stent strategy could be confirmed in arandomized trial and should be used in main stem bifurcation stenoses with pronounced calcification of the proximal segments of the LAD and RCX (stenosis length > 10 mm, and > 70% diameter stenosis). The already established 2‑stent strategies for the treatment of bifurcation stenosis could be modified or further developed. In preliminary studies the advantage of the so-called DK nano-crush technique and the DK culotte technique could be shown, whereby these initial results still have to be confirmed by larger randomized studies.

Utilization of Non–Drug-Eluting Devices for Inpatient Percutaneous Coronary Intervention in the United States

There is a paucity of data on the contemporary use of non-drug-eluting devices (balloon angioplasty or bare-metal stents) in contemporary percutaneous coronary intervention (PCI) in the United States. We utilized the Nationwide Readmissions Database to identify patients hospitalized to undergo PCI with non-drug-eluting devices from 2016 to 2019. The main outcome of interest was the trends in utilization over the study years. Among 1,870,262 PCI procedures, 127,810 (6.8%) were performed with non-drug-eluting devices; 72% of these were in the setting of acute myocardial infarction (MI). The use of non-drug-eluting devices decreased throughout the study period from 12.9% of all PCI in the first quarter of 2016 to 3.4% in the last quarter of 2019 (p <0.001). Factors associated with their use included advanced age and high bleeding risk. Only a small percentage were used as a bridge to coronary artery bypass graft surgery (2%) and for treatment of in-stent restenosis (3%). The in-hospital mortality was 5.8% for the entire cohort and 6.6% when the indication for use was an acute MI. In patients presenting with an acute MI, reinfarction within 30 days was common and occurred in 18% of the patients. In conclusion, the use of non-drug-eluting devices in PCI in the United States decreased from 2016 to 2019. Factors associated with their use included old age and high bleeding risk. Due to suboptimal outcomes in patients currently being treated with non-drug-eluting devices, there remains an unmet clinical need for alternative treatment options.

Quality of healthcare and admission rates for acute cardiac events during COVID-19 pandemic: a retrospective cohort study on ST-segment-elevation myocardial infarction in China

ObjectiveTo evaluate changes in admission rates for and quality of healthcare of ST-segment-elevation myocardial infarction (STEMI) during the period of the COVID-19 outbreak and postoutbreak.MethodsWe conducted a retrospective study among...

Learning Curve of Robotic Percutaneous Coronary Intervention: A Single-Center Experience.

Robotic percutaneous coronary intervention (R-PCI) has been shown to provide benefits to operators and patients when compared with traditional percutaneous coronary intervention. Despite being available for 16 years in the United States, utilization of R-PCI remains low. This may be because of an expected learning curve with this technology. We sought to describe the characteristics and magnitude of the learning curve with R-PCI. Consecutive patients undergoing R-PCI (Corpath GRX-2) at a tertiary care center by a single operator were studied prospectively. Demographic, angiographic, and procedural variables were collected. The primary study endpoints included fluoroscopy time, procedure time, and contrast volume. The distributions of each of these variables were plotted against the case numbers in chronological sequence, and the best curve fits were identified. Using the best model, the slope of the relationships was analyzed. Flattening of the slope of these plots were considered suggestive of a learning effect. A total of 546 R-PCI and 1654 traditional percutaneous coronary intervention procedures were studied; 22 crossovers to traditional percutaneous coronary intervention occurred. Most of the crossovers occurred in the first quartile of procedures; no crossovers occurred in the latter half of the cohort. Procedure time decreased as the procedure number increased, with the slope flattening at procedure number 50. Contrast volume decreased as experience increased, with a slope flattening at procedure number 30. Both parameters continued to decrease as experience increased. Fluoroscopy time demonstrated a flattening slope after procedure number 15. This likely is driven by the lower complexity by Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score remained stable over the procedure sequence, with no significant complexity change over the study period. The "learning effect" of R-PCI is observed with steep improvement in study metrics up to 50 procedures and a continuing improvement of lesser magnitude afterward.

Outcomes of Left Main Coronary Artery Revascularization after Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting Surgery

Background: Our study's major goal is to examine how several existing ULMCAD Currently, percutaneous coronary intervention (PCI) and coronary artery bypass grafting are the most common non-invasive methods of treating (unprotected left predominant) CAD in the United States (CABG). Place of study and duration: Conducted at the department of Cardiology, Hayatabad Medical Complex, Peshawar for the Duration from July 1 -2016 to Jun 30 -2017. Methods and Results: The effects of PCI and CABG have been analyzed in 558 patients with ULMCAD in a row (suggest age 71.9 years, eighty-one percent male). The most important end results were a total prevalence of mortality, nonfatal MI, and stroke. Diabetes prevalence increased to 29 percent, whereas acute coronary syndrome increased to 56 percent and 11 became the standard Euro SCORE. An extremely complicated form of coronary disease affected 50% of the patients (SYNTAX score &gt;32). Up to four years after PCI and CABG, the primary composite outcomes were equivalent (15, 53, 1 percent vs. 17,126.6 percent; p=0.585). Additionally, the impacts on the top findings were equivalent for the 2 cohorts with similar propensity ratings. Revascularization was required in 5.5 percent of PCI patients and 1.5 percent of CABG patients, respectively, due to ischemia (p=0.010). Conclusions: According to our local network of ULMCAD patients, the long-term scientific outcomes of the present PCI or CABG revascularization procedures were equivalent. No matter the intricacy of the coronary artery.

Patient Characteristics, Procedural Details, and Outcomes of Contemporary Percutaneous Coronary Interventions

Background: The prevalence and success of percutaneous coronary intervention (PCI) varies widely between regions, with South Asia displaying some of the greatest regional differences. Objectives: Examining PCI procedures and their outcomes in Pakistan over time and comparing this information to that from other countries is the goal of this study. Methods: Throughout the course of a year, information was collected from several cardiac catheterization laboratories in Pakistan. An in-depth history of each patient was recorded, along with data on their procedures, the tools and drugs they required, their outcomes, and any complications that may have arisen. Results: The study contained information from 22,741 patients. Their average age was 64.2 years (11.7) and they were predominantly male (70%). Acute coronary syndrome was the most prevalent symptom (57%), while ST-elevation myocardial infarction was the most common type of heart attack (28%). Multivessel disease was present in nearly two-thirds of patients, and 11% of those patients also had substantial left main stenosis. Almost half of these procedures (44.2%) opted for the transradial route. In spite of the high complexity of the lesions (56.9% class C lesion), the operative success rate was quite good at 95.2%. There was a 5.3% rate of procedure-related complications and a 2.8% rate of in-hospital deaths. Conclusion: The collected data shed light on the state of PCI in the United States, both in terms of its implementation and its results. Despite the complexity of the lesions being treated, the success rate was high, and problems were minimal.

Is It Safe to Do Percutaneous Coronary Intervention in Moderate to Severe Chronic Kidney Disease Patients? A Prospective Cohort Study.

Contrast-induced acute kidney injury (CI-AKI) is a common and potentially serious complication of percutaneous coronary intervention (PCI) procedures, as it induces acute kidney injury (AKI), especially in previously diagnosed chronic kidney disease (CKD) patients, particularly in those who also have diabetes. Adequate hydration and using a minimal volume of contrast media are the recommended measures to decrease CI-AKI in CKD patients. A combination of sodium bicarbonate and N-acetylcysteine (NAC) may be a superior strategy for preventing CI-AKI. This study is aimed to evaluate the safety of PCI in moderate to severe CKD patients. This was a prospective, single-center study, from 2019 to 2021. We included all chronic kidney disease who undergo PCI procedures. The kidney level was measured on admission and 24 hours after the PCI procedure. The patients received 75 meq/500 mL of sodium bicarbonate one to six hours before procedures, oral acetylcysteine 600 mg bid for three days, and rehydration with 1000 ml of normal saline infusion for eight hours in patients without congestive heart failure. SPSS Version 23.0 (IBM SPSS Statistics for Windows, Version 23.0., IBM Corp., Armonk, NY) was used to input and process the data. This study included 118 subjects, with baseline characteristics of age 58.77 ± 9.08 years, 80.5% male, 47.5% diabetic, 50% hypertension, and 59.5% congestive heart failure. From the coronary angiogram, we found most of our subjects (57.6%) had three-vessel disease, 28.8% had two-vessel disease, and 15.6% had one-vessel disease. About 67.8% of subjects used <50 ml of low molecular contrast. The baseline creatinine level was 2.46 ± 1.04 mg/dL and the estimated glomerular filtration rate (eGFR) was 30 ± 12.65 mL/min. There were 19 (16.1%) patients with stage 3A CKD, 45 (38.1%) stage 3B, 41 (34.7%) stage 4, and 41 (34.7%) stage 5. The kidney function test after 24 hours of contrast admission showed a creatinine level of 2.37 ± 1.20 mg/dL (P<0.05) and the eGFR of 34.74 ± 16.10 mL/min. There was no significant difference in creatinine levels between stage 3A and stage 5 CKD. There was a significant reduction in creatinine in stage 3B CKD, from 1.917 ± 0.22 to 1.71 ± 0.37 mg/dL (P = 0.001); and stage 4 CKD, from 2.77 ± 0.55 to 2.72 ± 0.94 mg/dL (P = 0.013). CKD is a risk factor for developing CI-AKI after PCI, which is a marker of poor long-term outcomes. The development of CI-AKI is a strong predictor of post-PCI bleeding, which aggravates hemodynamic instability. The combination of NAC and NaHCO3 exerts a better antioxidative effect, which reduces the harmful short-term and long-term consequences of contrast media. Previous studies revealed the use of low-to-zero contrast media was safer in CKD patients who had undergone PCI. By applying these measures, our study showed a good outcome of PCI with no worsening renal function in CKD patients. With good prophylaxis measures, such as using minimal volume contrast media, adequate rehydration, and the combination of sodium bicarbonate and acetylcysteine, it is safe to do PCI in moderate to severe CKD patients.

Establishment of a Risk Scoring Model for Perioperative Unex-Plained Shock during Percutaneous Coronary Intervention for the Treatment of Chronic Total Occlusion.

Several complications can contribute to the risk of shock during the chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedure. However, some patients that develop shock do not exhibit any apparent complications, and few studies to date have discussed the risk of unexplained perioperative shock in patients undergoing CTO PCI. Accordingly, this study was designed with the goal of defining perioperative risk factors linked to the odds of unexplained shock during CTO PCI. In total, this study analyzed data from 924 patients that underwent CTO PCI without any in-hospital complications from January 2016-August 2021. Cardiologists collected data pertaining to patient clinical characteristics, laboratory findings, angiographic findings, and procedural characteristics. Patients were separated into two groups based upon whether or not they experienced perioperative shock. The relationship between specific variables and perioperative shock incidence was assessed via a multivariable stepwise logistic regression approach. A risk-scoring nomogram was then designed for use as a tool to guide patient risk assessment efforts during PCI procedural planning. Overall, 4.8% of these patients (44/924) experienced unexplained perioperative shock. Independent predictors associated with unexplained shock during CTO PCI included baseline systolic pressure (odds ratio (OR) 0.968, 95% confidence interval (CI): 0.945-0.991), baseline heart rate (OR 1.055, 95% CI: 1.020-1.091), baseline hemoglobin (OR 0.970, 95% CI: 0.947-0.994), procedure duration (OR 1.008, 95% CI: 1.002-1.015), J-CTO score (OR 1.521, 95% CI: 1.021-2.267), and use of a retrograde approach (OR 3.252, 95% CI: 1.426-7.415). The unbiased C-index estimate was 0.859, and this model exhibited excellent calibration. The risk of unexplained shock is an important consideration for clinicians performing the CTO PCI procedure. These analyses revealed unexplained shock risk to be independently related to lower baseline systolic pressure, higher baseline heart rate, lower baseline hemoglobin, more procedure time, higher J-CTO score, and more use of a retrograde approach.

Biomarkers associated with vulnerable plaques

Abstract Background Cardiovascular heart disease is the leading cause of mortality worldwide, with the rupture or thrombosis of an atherosclerotic plaque being the main reason behind an acute coronary syndrome. It has already been established that the morphology of atherosclerotic plaques determine their stability. A lipid rich lesion with a thin fibrous cap is more prone to rupture compared to solid fibrous lesions. In the PROSPECTII study we used Near infrared spectroscopy (NIRS) and Intravascular ultrasound (IVUS) to identify atherosclerotic plaques in the coronary arteries; NIRS-derived lipid core burden index (LCBI) and IVUS-derived plaque burden (PB) identified plaques that caused adverse cardiovascular events. Purpose Our aim is to find biomarkers associated with LCBI or PB, to understand the development of vulnerable plaques. Methods 902 patients were enrolled in this study after successful percutaneous coronary intervention (PCI). A combined NIRS-IVUS catheter was then used to analyze approximately 200m of coronary arteries. Blood samples for biomarker analysis were taken before the PCI procedure and plasma levels of 182 proteins associated with cardiovascular disease were assessed using a novel method for measuring proximity extension assay. Adjusted linear regression models were calculated between the biomarkers and the outcomes of interest, followed by a false discovery rate (FDR) correction. Results We found 24 proteins associated with plaque burden and 28 proteins associated with LCBI after using a cut off of two tailed P value &amp;lt;0.05. An overlap of 8 biomarkers could be seen between the two groups. After adjusting the P values with FDR, Angiopoeitin like 3 (ANGPTL3) retained its association to LCBI, and Interleukin 18 receptor 1 (IL18R1) and colony stimulating factor 1 (CSF-1) to plaque burden. Conclusion We were able to identify different biomarker patterns associated with plaque burden compared to lipid rich vulnerable plaques. ANGPTL3 was shown to only have an association with lipid rich plaques and not with solid fibrous lesions which further supports its role in vulnerable plaques. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott Vascular, Infraredx, and The Medicines Company

Procedural outcomes and annual operator volume among patients treated with percutaneous coronary intervention of chronic total occlusions – analysis based on a large national registry

Abstract Background It has been demonstrated that low operator and institutional volume is associated with poorer procedural and long-term clinical outcomes in general population of patients treated with percutaneous coronary interventions (PCI). Purpose The aim of the current study was to assess the relationship between operator volume and procedural outcomes of patients treated with PCI within chronic total occlusion (CTO). Methods Data for conducting the current analysis were obtained from the national registry of percutaneous coronary interventions (ORPKI) maintained in cooperation with the Association of Cardiovascular Interventions (AISN) of the Polish Cardiac Society. The study covered data obtained from the registry from January 2014 to December 2020. To investigate the association between operator and all periprocedural complications, coronary artery perforation (CAP) and TIMI flow grade 2/3 after PCI in the presence of confounding and clustering effects, we used multivariable, mixed effects logistic regression modelling. Results During the investigated period, there were 162 active CathLabs, at which 747,033 PCI procedures were performed during the time of observation. Of those 14,924 were CTO-PCI procedures. Considering the number of CTO-PCIs performed annually by individual operators during the analyzed 7 years we assessed differences between four groups (≤10; &amp;gt;10≤20; &amp;gt;20≤30 and &amp;gt;30 procedures). We demonstrated by nonlinear relationship with annualised CTO-PCI operator volume that operators performing more than 40 PCI with CTO per year have lower number of the overall periprocedural complications (Fig. 1) including CAP, as well greater procedural success rates (Fig. 2) compared to operators performing less procedures (p&amp;lt;0.0001). Conclusions High-volume CTO operators achieve a greater procedural success with a lower frequency of periprocedural complications. This study suggests that the cut-off of 50 CTO-PCIs per year recommended in the EuroCTO Consensus remains a reasonable compromise to optimize outcome and maintain local availability. Special CTO training programs and a higher annual case load might increase the overall quality of CTO PCI. Funding Acknowledgement Type of funding sources: None.

Clinical and angiographic outcomes following percutaneous treatment of non-occlusive vs. chronically total occluded coronary lesions

Abstract Background Recent advancements in recanalization techniques, introduction of dedicated equipment and elaboration of systematic algorithmic approaches have significantly improved procedural success of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures. However, despite their undisputable merits in terms of procedural success, direct comparisons of mid-term clinical and angiographic outcomes following CTO and non-CTO-PCI are missing. Purpose The aim of this study was to assess the clinical and angiographic outcomes of patients undergoing successful CTO-PCI as compared to a propensity matched cohort of patients undergoing PCI of non-occlusive coronary lesions. Methods All consecutive patients undergoing successful CTO recanalization procedures at our center between 2015 and 2018 were included (N=453; 472 lesions). For matching purposes, all patients undergoing non-CTO-PCI present in our database were included (N=14733; 23458 lesions). A 1-to-1 nearest neighbour matching using baseline clinical and angiographic variables was performed to identify one patient undergoing non-CTO-PCI (N=453; 472 vessels) for each patient undergoing CTO-PCI (N=453; 472 vessels). Surveillance angiography was scheduled at 6–9 months and clinical follow-up was performed up to 12 months. The primary clinical endpoint of interest was the incidence of major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR). The secondary angiographic endpoint was in-segment binary restenosis. Results Patients undergoing CTO-PCI displayed a tendency towards higher degrees of binary restenosis at surveillance angiography as compared to those undergoing non-CTO-PCI (CTO vs. non-CTO: 30.5% vs. 24.0%; P=0.058), despite not meeting statistical significance. Of note, the incidence of occlusive restenosis was low and comparable between groups (2.2% vs. 1.4%; P=0.603). At 12 months follow-up, MACE occurred in 83 patients (19.7%) in the CTO-PCI and 59 patients (14.1%) in the non-CTO-PCI group (hazard ratio [HR] = 1.44; 95% confidence interval [CI]: 1.03–2.01; P=0.033). TLR rates were significantly higher following CTO- as compared to non-CTO-PCI (17.2% vs. 10.3%; HR=1.72 [1.18–2.51], P=0.005). The incidence of all-cause death (2.6% vs. 3.3%; P=0.548) and MI (0.5% vs. 1.4%; P=0.177) was not significantly different between the groups. Conclusion In this large, propensity-matched comparison of clinical and angiographic outcomes following CTO- vs. non-CTO-PCI, we found CTO-PCI to be associated with a higher MACE rate at 12 months, primarily driven by significantly higher TLR rates. The incidence of occlusive restenosis was low and comparable between groups. Funding Acknowledgement Type of funding sources: None.

Coronary perforation incidence and temporal trends (COPIT): systematic review and meta-analysis

Abstract Background Despite advancements in Percutaneous Coronary Intervention (PCI) technology and techniques, iatrogenic coronary artery perforation (CAP) remains a dreaded potential complication within the cardiac catheterisation laboratory. Data detailing the incidence of coronary perforation during PCI has previously been obtained from relatively small datasets. A swell of large data published in recent times provides invaluable information regarding PCI related CAP. Purpose COPIT is a systematic review and meta-analysis targeted at detailing the incidence, outcomes, etiology and treatment modalities of PCI related CAP including evaluation of temporal trends since the inception of PCI to contemporary practice. Additionally, COPIT provides hypothesis generating data regarding predictors of CAP during PCI. Methods A prospective systematic review and meta-analysis using MEDLINE and EMBASE via the OVID interface (PROSPERO ID: CRD42020207881) was performed according to the PRISMA guidelines. Identified relevant studies were used in a pre-specified sensitivity analysis to detail incidence, outcomes, etiology, treatment modalities and risk factors of PCI complicated by CAP. Studies limited to PCI in high risk populations only such as CTO-PCI or rotational atherectomy only were excluded. Results 67 studies met eligibility criteria detailing 5,568,191 PCIs over a 38-year period (1982–2020). The pooled incidence of CAP was 0.39% (95% CI: 0.34–0.45%) with no change in incidence over that time. Approximately 1 in 5 perforations led to cardiac tamponade (21.1%). Ellis 3 perforations are increasing in frequency and account for 43% of all perforations. Mortality due to perforation occurs in 7.5% of all CAP (95% CI 6.7% - 8.4%) but has declined over the studied period. Meta-regression suggested that female gender, hypertension, chronic kidney disease and previous coronary bypass grafting were all associated with higher incidence of CAP. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%. Conclusion Coronary perforations occurs in approximately 1 in 250 all-comer PCI procedures. A tendency towards increase in coronary perforations is likely reflective of contemporary trends towards high pressure post-dilatation with 1:1 vessel sizing as well as an ageing population with increasingly complex, calcific coronary disease. However, reduction in CAP related mortality suggests earlier recognition and effective treatment with transcatheter techniques. Funding Acknowledgement Type of funding sources: None.