Percutaneous Coronary Intervention Group Research Articles

Complete revascularisation versus culprit lesion only PCI in patients with non-ST-elevation myocardial infarction and multivessel disease.

Abstract Background The incidence of non-ST-elevation myocardial infarction (NSTEMI) is escalating, with patients diagnosed with multivessel disease (MVD) facing more adverse clinical outcomes. Yet, optimal treatment strategies for NSTEMI patients with MVD remain uncertain. Objectives This study aimed to assess the clinical outcome of NSTEMI patients with MVD who underwent complete revascularization compared to those treated with the culprit lesion only. Methods Between 2014 and 2017, patients presenting with NSTEMI and MVD undergoing successful percutaneous coronary intervention (PCI) were retrospectively included. MVD was defined as patients having more than one lesion considered angiographically significant, exhibiting at least 50% stenosis of the vessel diameter on visual estimation, or having a Coronary Angiography-Derived Fractional Flow Reserve (caFFR) measurement of 0.80 or less. The main exclusion criteria were single vessel disease, and previous coronary-artery bypass grafting surgery. The primary endpoint of this study was major adverse cardiac events (MACE) at 3 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. Results A total of 358 patients were included (mean age: 67.34±12.77; male: 70.1%), 155 and 203 patients were stratified into complete revascularisation group and culprit-lesion-only PCI group respectively. During 3-year follow-up, the culprit-lesion-only PCI group exhibited a significantly elevated risk of MACE compared to the complete revascularization group (17.7% vs 7.74%; hazard ratio [HR] 2.412, 95% confidence interval [CI] 1.255 - 4.636, P = 0.008). The increase 3-year MACE rate was mainly driven by the higher rate of ischaemia-driven revascularization in the culprit-lesion-only PCI group (11.3% vs 3.23%, HR 3.637, 95% CI 1.383 - 9.566, P = 0.009). Conclusion In NSTEMI patients with MVD, complete revascularization was superior to culprit-lesion-only PCI in mitigating the risk of future MACE at 3 years, which is predominantly attributed by a reduced incidence of repeat revascularisations.

Percutaneous revascularization in late-presenting STEMI with absence of viability: effects on left ventricular remodeling and scar

Abstract Introduction In patients with ST-elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) should be conducted within 12 hours of symptom onset. The potential benefits attributable to late reperfusion in STEMI fall under the "open artery hypothesis" where the stunned peri-infarction zone after revascularization would restore blood supply and contractility. Purpose To estimate the differences on the LV ejection fraction (LVEF), indexed LV end-systolic volume (iLVESV) and scar in patients with STEMI without viabilitity randomized to optimal medical therapy (OMT) alone or OMT and a late percutaneous coronary intervention (PCI) performed between 24 hours and 30 days after the event. Methods Patients with non-reperfused STEMI were evaluated from September 2021 to June 2022 at a tertiary cardiology hospital. The patients underwent Cardiac Magnetic Resonance (CMR) to assess myocardial viability and were classified as non-viable if they had only 1 wall segment with less than fifty percent thickness of the affected wall with late gadolinium enhancement. The patients were randomized to PCI or OMT alone. CMR was repeated at 6 months to evaluate LVEF, iLVESV and fibrosis. This summary presents a planned partial analysis of the 6-month results (N=51). Descriptive statistics analysis included central and dispersion estimators, or absolute and relative frequencies. To explore the differences between groups and time, Mann-Whitney and Wilcoxon tests were run, and results were given as point-estimates and confidence intervals at 95% (95% CI). A significance level of 5% was adopted for inferential analysis. Results 51 patients (60±11 years, 71% male) were included in the analysis. Of this total, 24 were randomized to PCI + OMT, and 27 to isolated OMT. The groups showed balanced distribution regarding clinical characteristics and initial CMR parameters (LVEF, iLVESV, and fibrosis). The difference in LVEF at the end of 6 months between the OMT and PCI groups was 2.07%, favoring the OMT group; however, this difference was not significant (p= 0.677, 95% CI: -5 to 10). Between the groups, the difference at the end of 6 months in iLVESV was -6.82 ml/m², also without statistical significance (p= 0.858, 95% CI: -19 to 11). There was a significant reduction in the amount of fibrosis in both PCI group with -14.68g (p= 0.011) and in the OMT group with -12.57g (p= 0.009). Detailed results are presented in Table 1. Conclusion Despite a significant reduction in fibrosis in both groups, there was no superiority observed in late PCI compared to isolated OMT in reducing reverse remodeling and fibrosis in patients with non-viable STEMI when compared to isolated OMT.Remodeling changes.

Impact of the complexity of percutaneous coronary intervention on clinical outcomes in patients with atrial fibrillation: a real-world study

Abstract Background Atrial fibrillation (AF) always coexisted with percutaneous coronary intervention (PCI), and complex PCI has increased in recent years. However, limited data exist on clinical outcomes in patients with AF and underwent complex PCI. Purposes We aimed to explore the prognosis of patients with AF who had underwent PCI. Methods This was a prospective, observational study which enrolled 1132 participants consecutively. Complex PCI was defined as PCI performed to ≥ 3 separate major coronary vessels; ≥3 stents implanted; ≥3 lesions treated; or total stented > length 60 mm. The primary endpoint was defined as major adverse cardiovascular event (MACE) including all-cause death, spontaneous myocardial infarction (MI), stroke, systemic embolism or ischemia-driven revascularization. Major bleeding events were defined according to Thrombolysis in Myocardial Infarction (TIMI) criteria. Results A total of 1132 patients who underwent PCI with AF were enrolled. The mean age was 66.6 ±8.9, and 75.1% were male. 320 participants (28.2%) were undergoing complex PCI. During a median follow-up of 1045 days, the primary outcome occurred in 52 of 320 patients (16.2%) in the complex PCI group and 105 of 812 patients (12.9%) in the non-complex PCI group (adjusted hazard ratio: 1.31; 95% confidence interval: 1.08-1.58; P = 0.007), driven by higher rate of MI ( aHR=2.17, 95%CI, 1.00-4.70 and ischemic driven revascularization (aHR=1.86, 95%CI, 1.01-3.45). TIMI major bleeding events were more commonly observed in complex PCI group (aHR=1.15, 95%CI, 1.01-1.31). Conclusion The complexity of PCI was an independent risk factor of adverse clinical outcomes, especially in MI, revascularization and TIMI major bleeding events in patients with AF.K-M curves of eventsK-M curves of events

Clinical impact of perfusion balloon for ST-segment elevated myocardial infarction: RYUSEI study

Abstract Background Drug-eluting stents have significantly contributed to reducing mortality in patients with ST-segment elevation myocardial infarctions (STEMIs), but slow flow/no-reflow phenomenon and in-stent restenosis are still clinical problems. On the other hand, perfusion balloons (PBs) can compress thrombi and ruptured plaque for long inflation without ischemia and can be used as a delivery device for infusion of nitroprusside to distal risk area during ballooning. Purpose We conducted RYUSEI (Reduction of risk bY perfUsion balloon for ST-segment Elevated myocardial Infarction) study to evaluate whether PBs before stenting are more effective than conventional stenting for STEMIs. Methods We divided consecutive patients with STEMIs who underwent optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) into PB group who were treated with PBs before stenting and the conventional PCI (CP) group. In PB group, we inflated PB at the culprit lesion for five minutes to compress thrombi and ruptured plaque as a pre-stent lesion modification. In addition, an intra-coronary injection of nitroprusside (total dose: 120 µg; slow bolus injection of 24 µg/5mL every minute [5 times]) into the distal vascular bed to the culprit lesion through the PB was performed during a 5-minute PB ballooning. We compared clinical results including slow flow/no-reflow phenomenon, OCT findings, and one-year clinical events including cardiac death, target vessel-related myocardial infarctions, target lesion revascularization and stent thromboses between the two groups. Results We finally analyzed 34 patients in PB group and 90 in CP group. After propensity score matching, PB and CP groups consisted of 23 patients, respectively. In the propensity score-matched cohort, there were no significant differences of the patients’ backgrounds and lesion and procedural characteristics between the two groups. In the cohort, regarding post PCI angiographic and OCT findings, the incidence of slow flow/no-reflow phenomenon and maximum protrusion area detected by OCT were significantly lower (P=0.047 and P=0.019, respectively) and TIMI flow grade 3 was significantly higher (P=0.022) in the PB group than CP group while the other parameters were similar (Table). Kaplan-Meier analysis revealed a significantly better one-year clinical outcome in PB group than CP group (p=0.038) (Figure). Conclusions The RYUSEI study revealed a pre-stent lesion modification in addition to nitroprusside infusion using PB is useful to achieve better clinical course in STEMI patients.Post PCI Angiographic and OCT FindingsComparison of One-year Clinical Outcome

Ten-year comparative long-term outcomes of PCI versus CABG in multi-vessel coronary artery disease

Abstract Background While coronary artery bypass grafting (CABG) is the standard treatment for patients with multi-vessel coronary artery disease (CAD), percutaneous coronary intervention (PCI) has been an alternative approach. The study aims to evaluate the long-term outcomes of PCI versus CABG in treating patients with CAD. Methods A total of 9569 patients with CAD (age 68.60±12.24 years, 81.7% men) who underwent PCI (n=7429) or CABG (n=1635) were retrospectively recruited from January 2000 to December 2014 at a tertiary medical center. Propensity score-matched analysis were conducted. The primary outcome was all-cause mortality during a 10-year follow-up duration. Results During a median follow-up duration of 6.97±4.54 years, there were 1634 deaths. Crudely, there was no difference in 10-year mortality between PCI and CABG groups (26.3% vs. 23.02%; P= 0.135). After accounting for age, renal function, previous myocardial infarction, and heart failure, the 10-year survival rate remained similar between the two groups. The subgroup analysis showed inferior outcomes with PCI than CABG if any bare-mental stent (BMS) was used (10-year risk of mortality 36.1% vs. 24.7%; P= 0.032). In addition, CABG was also associated with better survival than PCI in diabetic subjects (10-year risk of mortality 24.9% vs. 30.9%, P=0.086). In contrast, PCI demonstrated superior long-term benefits in subjects with left main (LM) and single-vessel disease, whereas CABG showed better long-term outcomes for individuals with left main (LM) and multivessel disease. Conclusions PCI demonstrated comparable long-term outcomes with CABG in treating subjects with CAD when purely drug-eluting stents were used. Any use of BMS is not encouraged to treat patients with left main or multivessel CAD. In contrast, PCI was related to superior long-term survival among patients with LM and single-vessel disease.

Favorable impact of FFRCT on myocardial revascularization outcomes: results from an observational real-world registry

Abstract Background Based on excellent clinical outcomes data, coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) is endorsed by guidelines to diagnose obstructive coronary artery disease (OCAD)(1). Dedicated outcome analyses in revascularized patients are essential to assess the additional value of FFRCT in revascularization. Purpose To assess the impact of FFRCT use on the postprocedural myocardial injury (PMI) and long-term outcomes of patients with OCAD undergoing myocardial revascularization. Methods Patients with suspected OCAD on CCTA (at least one stenosis of >50% in any vessel) were included from a 2013-2021 tertiary hospital registry. Propensity score adjusted Cox- regression and logistic regression analysis were used to assess the impact of FFRCT on the outcomes of OCAD patients post-revascularization. PMI was defined as cardiac troponin (cTn)>5 times the 99th percentile URL for percutaneous coronary intervention (PCI) and cTn>10 times the 99th percentile URL for coronary artery bypass graft (CABG) (2). Major adverse cardiovascular events (MACE) comprised all – cause mortality, acute myocardial infarction (AMI), stroke, hospitalization for heart failure (HHF) and new revascularization. Results From a registry of 7541 patients, suspected CCTA - derived OCAD was reported in 1601 cases. 559 OCAD patients were revascularized: 386(69.05%) by PCI, 166(29.7%) by CABG and 7(1.25%) by PCI and CABG. FFRCT was performed in 252(45.1%) patients. During a follow-up of 4.4±2.2 years, MACE occurred in 137(24.5%) patients: 43(7.7%) died, 21(3.8%) patients were hospitalized for AMI, 14(2.5%) patients had a stroke, 12 (2.1%) patients had HHF and 77(13.8%) patients had a new revascularization. Survival analysis indicated significant differences in MACE and all-cause mortality–rates between FFRCT use and no FFRCT use (log- rank p = 0.033 and 0.004, Fig 1). Multivariable propensity–adjusted Cox–regression analysis showed a non–significant trend towards reduced MACE risk by using FFRCT (HR 0.736, 95% CI 0.513-1.055, P=0.095) and a significant reduction in all-cause mortality risk (HR 0.476, 95% CI 0.230–0.985, P=0.046). Sub-analysis in the PCI and CABG groups showed no significant association between FFRCT and MACE. Among the 477 patients with available cTn values, 203 (42.5%) had PMI. In the CABG group, FFRCT use correlated with low PMI incidence (5.3% vs. 15.6%, p=0.044). However, multivariable Cox regression analysis revealed no significant association between FFRCT use and PMI(Fig 2). Conclusion This observational designed study reveals for the first time that FFRCT reduces post-myocardial revascularization MACE, primarily driven by reduced all-cause mortality. No clear reduction of PMI was observed suggesting that FFRCT value extends beyond procedural enhancements. Although derived from a large real-world registry, these promising observations need to be confirmed by randomized studies.Figure 1Figure 2

Percutaneous coronary intervention versus coronary arterial bypass grafting in patients with left main coronary artery disease and chronic kidney disease: a systematic review and meta-analysis

Abstract Background Left main coronary artery disease (LMCAD), defined as a stenosis of >50%, is a potentially lethal condition that should be treated intensively by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) depending on the anatomy. The presence of chronic kidney disease (CKD) complicates LMCAD, acting as a potential worsening factor for this group of patients, as well as impairing the effectiveness and outcomes of both revascularization treatments. Purpose This systematic review and meta-analysis aims to comprehensively compare the outcomes of PCI and CABG in patients with LMCAD and CKD. Methods A systematic search of the available literature was conducted in PubMed, Embase, and CENTRAL. Studies that compared PCI versus CABG in patients with LMCAD and CKD were included. The primary endpoints comprised major adverse cardiac and cerebrovascular events (MACCE) and all-cause death, while secondary endpoints included components of MACCE, such as myocardial infarction (MI), stroke and new revascularization events. The results were qualitatively and quantitatively synthesized and pooled hazard ratios (HR) were calculated. The statistical analysis was conducted in R. Results A total of 767 titles were initially retrieved, with five studies finally included in the analysis (n = 2,337 patients). The pooled analysis revealed that patients treated with PCI experienced more MACCE (HR: 1.50, 95% CI: 1.26-1.78, p < 0.001), an outcome primarily driven by MI (HR: 1.75, 95% CI: 1.17-2.62, p = 0.01) and revascularization rates (Hazard Ratio: 3.66, 95% CI: 1.84-7.30, p < 0.001), while no significant difference was shown in stroke rates (HR: 0.70, 95% CI: 0.40-1.22, p = 0.21). A trend towards increased all-cause death was observed for the PCI group, although this outcome slightly failed to reach statistical significance (HR: 1.30, 95% CI: 1.00-1.68, p = 0.05). Conclusion The present systematic review and meta-analysis indicated that PCI appears inferior to CABG in patients with LMCAD and CKD, with respect to most long-term outcomes. This includes higher rates of MACCE, and particularly MI and new events of revascularization for patients undergoing PCI, while all-cause death was marginally higher for this group. Further randomized controlled trials are needed to provide more robust evidence for guiding revascularization strategies in this high-risk population.

Association between completeness of revascularization and cardiovascular outcomes in patients with diabetes and non-ST elevation myocardial infarction: a population-based registry analysis

Abstract Introduction Approximately one-third of the patients presenting with non-ST elevation myocardial infarction (NSTEMI) have diabetes. From these, two-thirds have multivessel coronary disease. The impact of completeness of revascularization in this population remains unclear. Purpose To evaluate the contemporary patterns of coronary revascularization among patients with diabetes and NSTEMI, and the clinical outcomes stratified by anatomic completeness of revascularization. Methods All patients with diabetes and multivessel disease admitted for NSTEMI between April 2009 and March 2020 in Ontario, Canada were included. Patients with previous coronary artery bypass graft surgery (CABG) at any time, percutaneous coronary intervention (PCI) in the previous 90 days, or shock were excluded. Patients were classified in four groups, from the most to the least complete revascularization strategy: CABG, complete revascularization with PCI, incomplete revascularization with PCI, or no revascularization. Outcomes included all-cause death and the composite of all-cause death, myocardial infarction, and stroke. Multivariable Cox regression was used to account for confounding (demographics, comorbidities, left ventricular function, coronary anatomy, laboratory tests, and diabetes treatment). Results We included 14,511 patients (mean age: 68.7±11.5y; 69.6% males). A total of 4,525 (31.2%) patients were treated with CABG, 3,008 (20.7%) with complete PCI, 3,624 (25.0%) with incomplete PCI and 3,354 (23.1%) were not revascularized. Patients with more complex coronary disease were more frequently treated with CABG, while PCI was more common in those with less complex disease (p<0.001; Fig 1). The mean number of grafts in the CABG group was 3.4±1.0. The mean number of stents in the complete and incomplete PCI groups was 2.4±1.3 and 1.7±0.9, respectively. Adjusted 5-y risks of all-cause death following CABG, complete PCI, incomplete PCI and no revascularization were, respectively, 25.9%, 29.8%, 32.2%, and 39.4%. Over a median follow-up of 5.8ys, CABG was associated with reduced all-cause death compared with complete PCI (HR 0.82; 95%CI 0.75 - 0.90), incomplete PCI (HR 0.73; 95%CI 0.67 - 0.80), or no revascularization (HR 0.54; 95%CI 0.50 - 0.58); p<0.001 for all (Fig 2). Adjusted 5-y risks of the composite endpoint following CABG, complete PCI, incomplete PCI and no revascularization were, respectively, 34.0%, 41.5%, 44.6%, and 52.9%. CABG was associated with reduced rates of the composite endpoint compared with complete PCI (HR 0.75; 95%CI 0.69 - 0.81), incomplete PCI (HR 0.67; 95%CI 0.62 - 0.72), or no revascularization (HR 0.50; 95%CI 0.47 - 0.54); p<0.001 for all. Conclusion In this contemporary real-world cohort study, almost a quarter of the patients with diabetes and NSTEMI did not receive any revascularization procedure. Cardiovascular outcomes were incrementally improved with CABG or complete revascularization with PCI, compared to no revascularization.Figure 1Figure 2

Elevated high-sensitive cardiac troponin T in emergency department patients: insights from a retrospective descriptive cohort study

BackgroundHigh-sensitive cardiac troponin T (hs-cTnT) assessments are routinely conducted in German emergency departments (EDs). However, data describing a large number of ED patients with pathological hs-cTnT levels and subsequent clinical outcomes are limited.MethodsThis retrospective descriptive analysis included 141.892 patients who presented to the interdisciplinary ED at Klinikum rechts der Isar in Munich, Germany, between January 2019 and December 2021. Patients with trauma diagnoses were excluded, focusing on those with elevated hs-cTnT levels. These patients were categorized into three groups based on the International Classification of Procedures in Medicine (ICPM): those with elevated hs-cTnT who received no coronary angiography (NCA), those who underwent diagnostic coronary angiography (DCA), and those who received percutaneous coronary intervention (PCI). The objective of this study was to characterize a large emergency department patient cohort and assess their subsequent clinical outcomes.ResultsAfter initial Manchester Triage Sytem (MTS) categorization, 32.6% (46.307/141.892) of patients were identified as non-trauma cases. Of these, 9.9% (4.587/46.307) had hs-cTnT levels exceeding 14 ng/L. Within this subset, 70.4% (3.230/4.587) did not undergo coronary angiography, 15.4% (705/4.587) underwent DCA and 14.2% (652/4.587) received PCI. Chest pain occurred more frequently in the PCI group (28.0%, 160/652) compared to the DCA group (18.3%, 113/705) or NCA group (5.7%, 159/3230), p < 0.001. However, breathing problems occurred more frequently in the NCA group (23.2%, 647/3230) compared to the PCI group (17.7%, 101/652) or DCA group (21.8%, 135/705), p < 0.001. Also, collapse was more frequent in patients in the NCA group (4.0%, 112/3230) compared to the DCA group (3.4%, 21/705) or PCI group (3.5%, 20/652), p < 0.001. Overall, in-hospital mortality was significantly higher in the NCA group (7.9%, 256/3230) compared to the DCA group (2.3%, 16/705) or PCI group (4.1%, 27/652), p < 0.001.ConclusionEmergency patients with elevated hs-cTnT who did not undergo coronary angiography faced a higher risk of in-hospital mortality in our retrospective descriptive study. Given the heterogeneous nature of presenting complaints in emergency departments, identifying at-risk patients can pose challenges for treating physicians.

Optical coherence tomography-guided versus angiography-guided percutaneous coronary intervention for patients with complex lesions (OCCUPI): an investigator-initiated, multicentre, randomised, open-label, superiority trial in South Korea

Despite the detailed imaging information provided by optical coherence tomography (OCT) during percutaneous coronary intervention (PCI), clinical benefits of this imaging technique in this setting remain uncertain. The aim of the OCCUPI trial was to compare the clinical benefits of OCT-guided versus angiography-guided PCI for complex lesions, assessed as the rate of major adverse cardiac events at 1 year. This investigator-initiated, multicentre, randomised, open-label, superiority trial conducted at 20 hospitals in South Korea enrolled patients aged 19-85 years for whom PCI with drug-eluting stents was clinically indicated. After diagnostic angiography, clinical and angiographic findings were assessed to identify patients who met the criterion of having one or more complex lesions. Patients were randomly assigned 1:1 to receive PCI with OCT guidance (OCT-guidance group) or angiography guidance without OCT (angiography-guidance group). Web-response permuted-block randomisation (mixed blocks of four or six) was used at each participating site to allocate patients. The allocation sequence was computer-generated by an external programmer who was not involved in the rest of the trial. Outcome assessors were masked to group assignment. Patients, follow-up health-care providers, and data analysers were not masked. PCI was done according to conventional standard methods with everolimus-eluting stents. The primary endpoint was major adverse cardiac events (a composite of cardiac death, myocardial infarction, stent thrombosis, or ischaemia-driven target-vessel revascularisation), 1 year after PCI. The primary analysis was done in the intention-to-treat population. The margin used to establish superiority was 1·0 as a hazard ratio. This trial is registered with ClinicalTrials.gov (NCT03625908) and is completed. Between Jan 9, 2019, and Sept 22, 2022, 1604 patients requiring PCI with drug-eluting stents for complex lesions were randomly assigned to receive either OCT-guided PCI (n=803) or angiography-guided PCI (n=801). 1290 (80%) of 1604 patients were male and 314 (20%) were female. The median age of patients at randomisation was 64 years (IQR 57-70). 1588 (99%) patients completed 1-year follow-up. The primary endpoint occurred in 37 (5%) of 803 patients in the OCT-guided PCI group and 59 (7%) of 801 patients in the angiography-guided PCI group (absolute difference -2·8% [95% CI -5·1 to -0·4]; hazard ratio 0·62 [95% CI 0·41 to 0·93]; p=0·023). Rates of stroke, bleeding events, and contrast-induced nephropathy were not significantly different across the two groups. Among patients who required drug-eluting stent implantation for complex lesions, OCT guidance resulted in a lower incidence of major adverse cardiac events at 1 year compared with angiography guidance. These findings indicate the existence of a therapeutic benefit of OCT as an intravascular imaging technique for PCI guidance in patients with complex coronary lesions. Abbott Vascular and Cardiovascular Research Center. For the Korean translation of the abstract see Supplementary Materials section.

Timing of percutaneous coronary intervention and risk of new-onset acute ischemic stroke in non-ST elevation myocardial infarction: A retrospective cohort study insight into the National Inpatient Sample Database (2016-2019).

For patients with high-risk non-ST elevation myocardial infarction (NSTEMI), current guidelines recommend an early invasive strategy within 24 h. New-onset acute ischemic stroke (NAIS) is a rare but fatal complication of percutaneous coronary intervention (PCI). However, the effect of the timing of PCI and the risk of NAIS in NSTEMI is poorly defined. Patients with NSTEMI who underwent PCI were queried from the National Inpatient Sample Database (2016-2019) and stratified into three groups: early (<24 h), medium (24-72 h), and late (>72 h) PCI. Multivariate logistic regression models were used to determine the association between timing of PCI and NAIS. Among 633,115 weighted hospitalizations, patients in the late PCI group had a higher incidence of NAIS (1.3%) than those in the early (0.67%) and medium (0.71%) PCI groups. Patients undergoing late PCI were older, more likely to be female, and had a greater incidence of comorbidities (e.g., diabetes mellitus, chronic pulmonary and renal illness, and atrial fibrillation) than those undergoing early or medium PCI. After adjustment, only late PCI was significantly associated with a 54% increased NAIS risk (adjusted odds ratio: 1.54 [95% confidence interval: 1.29-1.84]). Additionally, there was heterogeneity in the magnitude of risk by age and sex. Younger people (<65 years) (p for interaction <0.001) and men (interaction-value p = 0.040) were more likely to encounter NAIS. Late PCI was associated with a higher risk of NAIS than early PCI, particularly among men and those aged <65 years.

Efficacy of revascularization in CTO patients based on hibernating myocardium therapy.

The effectiveness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is still uncertain, especially for patients with ischemic left ventricular dysfunction. This study aimed to assess hibernating myocardium (HM), as determined by single-photon emission computed tomography (SPECT) and 18F-FDG positron emission tomography (PET), and to compare the benefits of PCI and optimal medical therapy (OMT). A retrospective study collected data from 332 patients with CTO and ischemic left ventricular dysfunction. The study compared patients who underwent PCI or OMT via propensity score matching (PSM) analysis which was performed with a 1:2 matching protocol using the nearest neighbour matching algorithm. The primary endpoint of the study was the occurrence of major adverse cardiac events (MACE), defined as a composite of cardiac death, readmission for worsening heart failure (WHF), revascularization and myocardial infarction (MI). After PSM, there were a total of 246 individuals in the PCI and OMT groups. Following Cox regression, hibernating myocardium/total perfusion defect (HM/TPD) was identified as an independent risk factor (hazard ratio (HR): 1.03, 95% confidence interval (CI): 1.008-1.052, p = .007). The cut-off value of HM/TPD was 38%. The results of the subgroup analysis suggest that for patients with HM/TPD >38%, the OMT group had a greater risk of MACE (p = .035). A sensitivity analysis restricting patients with single-vessel CTO lesions, HM/TPD remained an independent predictor (HR 1.025, 95% CI 1.008-1.043, p = .005). HM/TPD is an independent predictor of MACE, and for patients with HM/TPD > 38%, CTO-PCI had a lower risk of MACE compared with OMT. However, further validation is still needed through large-scale studies.

PCI in Patients Undergoing Transcatheter Aortic-Valve Implantation.

The benefit of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease and severe aortic stenosis who are undergoing transcatheter aortic-valve implantation (TAVI) remains unclear. In an international trial, we randomly assigned, in a 1:1 ratio, patients with severe symptomatic aortic stenosis and at least one coronary-artery stenosis with a fractional flow reserve of 0.80 or less or a diameter stenosis of at least 90% either to undergo PCI or to receive conservative treatment, with all patients also undergoing TAVI. The primary end point was a major adverse cardiac event, defined as a composite of death from any cause, myocardial infarction, or urgent revascularization. Safety, including bleeding events and procedural complications, was assessed. A total of 455 patients underwent randomization: 227 to the PCI group and 228 to the conservative-treatment group. The median age of the patients was 82 years (interquartile range, 78 to 85), and the median Society of Thoracic Surgeons-Procedural Risk of Mortality score (on a scale from 0 to 100%, with higher scores indicating a greater risk of death within 30 days after the procedure) was 3% (interquartile range, 2 to 4). At a median follow-up of 2 years (interquartile range, 1 to 4), a major adverse cardiac event (primary end point) had occurred in 60 patients (26%) in the PCI group and in 81 (36%) in the conservative-treatment group (hazard ratio, 0.71; 95% confidence interval [CI], 0.51 to 0.99; P = 0.04). A bleeding event occurred in 64 patients (28%) in the PCI group and in 45 (20%) in the conservative-treatment group (hazard ratio, 1.51; 95% CI, 1.03 to 2.22). In the PCI group, 7 patients (3%) had PCI procedure-related complications. Among patients with coronary artery disease who were undergoing TAVI, PCI was associated with a lower risk of a composite of death from any cause, myocardial infarction, or urgent revascularization at a median follow-up of 2 years than conservative treatment. (Funded by Boston Scientific and the Danish Heart Foundation; NOTION-3 ClinicalTrials.gov number, NCT03058627.).

Long-Term Outcomes of Percutaneous Coronary Intervention in Patients with Prior Coronary Artery Bypass Graft - A Retrospective Experience

To evaluate the long-term clinical outcomes of percutaneous coronary intervention (PCI) in patients who had previously undergone coronary artery bypass grafting (CABG). A total of 219 patients who had a history of CABG and underwent PCI at tertiary care centre were retrospectively enrolled in this study. Clinical endpoints such as major adverse cardiac events (MACE; cardiac death, non-fatal myocardial infarction [MI], and target vessel revascularization), any death, cardiac death, MI, target vessel revascularization (TVR), and target lesion revascularisation (TLR) were reported at long-term follow-up. About 66.6% patients were treated on the native vessel, and 24.2% on grafts vessel. In all, 360 stents [83.3% drug-eluting stent (DES) and 16.6% bare metal stent (BMS)] were implanted. Diabetes mellitus (p=0.03), LVEF<55% for PCI (p=0.04), stent type [BMS (p<0.001) and DES (p<0.001)] and chronic kidney disease [(CKD) p<0.01] were appeared to be the significant predictors of mortality. Age at CABG>50 years (p=0.04), stent type [BMS (p=0.03) and DES (p<0.01)] and CKD (p<0.01) as independent predictors for MACE. Higher event rate was reported in graft-vessel PCI group as compared to native-vessel PCI group: ISR (p<0.01), TLR (p=0.01), mortality (p=0.04), MACE (p<0.01) and MI (p=0.05). Mortality (p<0.001), MACE (p<0.001) and MI (p<0.001) were significantly lower in DES vs. BMS groups. Native-vessel PCI was associated with better clinical outcomes than graft-vessel PCI that also with the use of DES as the first choice in patients with a history of CABG.

Percutaneous coronary interventions for aneurysmatic right coronary artery in acute coronary syndrome: RIGHTMARE registry outcomes

BackgroundThe optimal strategy during percutaneous coronary intervention (PCI) of aneurysmatic right coronary artery (ARCA) remains uncertain and has never been tested in the acute setting. ObjectivesTo compare the in-hospital and long-term outcomes of immediate and staged PCI strategies for ARCA as culprit lesions during acute coronary syndrome (ACS). MethodsAmong 102.376 PCIs performed in 18 European centers, a total of 85 patients presenting with acute coronary syndrome undergoing ARCA PCI were finally included in the analysis. PCI strategy (stenting performed during the immediate vs staged procedure) and pharmacological approach adopted were collected. The primary outcome was procedural success (technical success without in-hospital MACE). ResultsThe primary outcome occurred in 48.2 % of cases, with no significant differences observed between the immediate and staged PCI groups (50.9 % vs 43.3 %, p = 0.504). Patients in the staged-PCI group had a significantly higher rate of intravenous anticoagulant use (83.3 % vs 48.1 %, p = 0.002), BARC type 3 and 5 bleedings (12.9 % vs 1.9 %, p = 0.037), and longer in-hospital stay (7.40 ± 5.11 vs 9.5 ± 5.25 days, p = 0.049). After multivariate analysis, no independent predictors for procedural success were found in either group. Target lesion failure occurred in 24.1 % of cases without differences between groups at a median follow-up of three years. ConclusionsAmong patients undergoing ARCA PCI in the setting of ACS, immediate or staged PCI were associated with similar in-hospital and long-term outcomes. However, staged PCI was associated with a higher risk of major bleeding events and longer length of stay compared to immediate PCI strategy.

The Usefulness of Coregistration with iFR in Tandem or Long Diffuse Coronary Lesions: The iLARDI Randomized Clinical Trial.

Background. Despite technical advancements, patients with sequential or diffuse coronary lesions undergoing percutaneous coronary intervention (PCI) have an increased risk of cardiovascular events at follow-up. We aimed to analyze the utility of a SyncVision/iFR (S-iFR)-guided PCI strategy versus an angiography-guided strategy in patients with this type of lesions. Methods. Randomized, multicenter, controlled, and open-label trial to compare S-iFR versus angiography-guided PCI in patients with sequential or diffuse angiographic coronary stenosis (ClinicalTrials.gov identifier: NCT04283734). The primary endpoint was the implanted stent length. The main secondary endpoint was targeting vessel failure (TVF) at one year. Results. A total of 100 patients underwent randomization, with 49 patients assigned to the S-iFR group and 51 to the angiography-guided PCI group. There were no differences between groups regarding clinical and anatomical characteristics. The baseline iFR was 0.71 ± 0.16 vs. 0.67 ± 0.19 (p = 0.279) in the S-iFR and angiography group, respectively. The mean lesion length was 42.3 ± 12 mm and 39.8 ± 12 (p = 0.297). The implanted stent length was 32.7 ± 17.2 mm in the S-iFR group and 43.1 ± 14.9 mm in the angiography group (mean difference, -10.4 mm; 95% confidence interval [CI], -16.9 to -4.0; p = 0.002). At one year, target vessel failure (TVF) occurred in four patients: three (6.1%) in the S-iFR group vs. one (1.9%) in the angiography group (p = 0.319). Conclusions. Among patients with sequential or long diffuse coronary lesions, a S-iFR-guided PCI strategy resulted in a reduction of the total stent length compared to an angiography-guided PCI strategy. A nonsignificant increase in TVF was observed in the S-iFR group.

A comparative study of shockwave intravascular lithotripsy and conventional percutaneous coronary intervention in the treatment of severe coronary artery calcification lesions

BackgroundThe purpose of this study was to evaluate the effectiveness of intravascular lithotripsy (IVL) in the treatment of severe coronary artery calcification (CAC) lesions.MethodsIn this study, we selected patients diagnosed with severe CAC lesions confirmed by coronary angiography (CAG) who were hospitalized in Yulin First People’s Hospital between December 2021 and December 2022 and required percutaneous coronary intervention (PCI). Using a random number table, we divided all patients into the IVL group and the PCI group in the order of interventional therapy. We compared both groups in terms of the surgical success rate, intraoperative manipulation characteristics, procedural complication, and cumulative incidence of major adverse cardiovascular events (MACE).Results(1) There were no differences in the surgical success rate, incidence of MACE, and occurrence of procedural complication between the two groups; (2) Compared with the conventional PCI group, patients in the IVL group used fewer predilatation balloons, and the difference was statistically significant (all P < 0.05); (3) Compared with the conventional PCI group, patients in the IVL group had lesser surgery time and lesser radiation time, with lesser proportion of patients who were assisted with stent implantation using coronary artery rotational atherectomy, and this difference was statistically significant (P < 0.05); (4) The mean stent diameter and length in the IVL group was greater than those in the conventional PCI group but the difference was not statistically significant (P > 0.05).ConclusionIn this study, we found that IVL was a highly safe and effective procedure in the treatment of severe CAC lesions that did not increase the surgery and radiation time, and it could also reduce the use of predilatation balloons, thus improving the management of CAC lesions. Thus, IVL can be a novel choice in treating severe CAC lesions.

In-Hospital Outcomes of Revascularization in Patients with Left Ventricular Systolic Dysfunction and Coronary Chronic Total Occlusion

Background: The in-hospital outcomes of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with left ventricular systolic dysfunction (LVSD) and chronic total occlusion (CTO) remain unclear. Methods: From 2014 to 2020, patients with LVSD and CTO who underwent PCI or CABG were collected. The primary endpoint was in-hospital major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of all-cause mortality, cardiovascular mortality, stroke, myocardial infarction (MI), and target vessel revascularization. Inverse probability of treatment weighting (IPTW) was performed to evaluate the association between revascularization strategies and in-hospital outcomes. The hazard ratio (HR) and 95% confidence interval (CI) were calculated using the Cox proportional hazards model. Results: Of the 773 patients who met the inclusion criteria, 543 (70.2%) underwent PCI, and 230 (29.8%) underwent CABG. The primary endpoint was observed in 25 (3.2%) patients. The incidence of in-hospital MACCE (6.5% vs. 1.8%, p &lt; 0.001) was significantly higher in the CABG group than in the PCI group. After IPTW, the risk of in-hospital MACCE was not found to be significantly different between CABG and PCI groups (HR = 1.81; 95% CI: 0.37–8.82; p = 0.460). Compared with patients who underwent PCI, those who underwent CABG exhibited a significantly higher risk of MI (HR = 6.92; 95% CI: 1.24–38.60; p = 0.027). Conclusions: Patients with LVSD and CTO could experience better outcomes with PCI, which offers a safer alternative coronary revascularization strategy and a reduced risk of MI.

Patterns of 12-Month Post-Myocardial Infarction Medication Use According to Revascularisation Strategy: Analysis of 15,339 Admissions in Victoria, Australia

Clinical guidelines recommend secondary prevention medications following myocardial infarction (MI) regardless of revascularisation strategy. Studies suggest that there is variation in post-MI medication use following percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG). We investigated initial dispensing and 12-month patterns of medication use according to revascularisation strategy following non-ST-elevation MI (NSTEMI). We included all public and private hospital admissions for NSTEMI for patients aged ≥30 years in Victoria, Australia, between July 2012 and June 2017. We investigated initial dispensing of P2Y12 inhibitors (P2Y12i), statins (total and high intensity), angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), and beta blockers within 60 days after discharge. Twelve-month post-MI medication use was estimated as the proportion of days covered (PDC) over a 12-month period from the date of hospital discharge. Analyses were performed using adjusted regression models, stratified by revascularisation strategy. There were 15,399 admissions for NSTEMI: 11,754 with PCI and 3,645 with CABG. Following adjustments, predicted probability of initial dispensing in the PCI and CABG groups, respectively, was 0.94 (95% confidence interval 0.93-0.95) vs 0.17 (0.13-0.21) for P2Y12i; 0.69 (0.66-0.71) vs 0.42 (0.37-0.48) for ACEi/ARB; 0.59 (0.57-0.62) vs 0.69 (0.64-0.74) for beta blockers; 0.89 (0.87-0.91) vs 0.89 (0.85-0.92) for statins; and 0.60 (0.57-0.62) vs 0.69 (0.63-0.73) for high intensity statins. The 12-month PDC in the PCI and CABG groups, respectively, was 0.82 (0.80-0.83) vs 0.12 (0.09-0.15) for P2Y12i; 0.62 (0.60-0.65) vs 0.43 (0.39-0.48) for ACEi/ARB; 0.53 (0.51-0.55) vs 0.632 (0.58-0.66) for beta blockers; 0.79 (0.78-0.81) vs 0.78 (0.74-0.81) for statins; and 0.49 (0.47-0.51) vs 0.55 (0.50-0.59) for high intensity statins. Post-discharge dispensing of secondary prevention medications differed with respect to revascularisation strategy from 2012 to 2017, despite clear evidence of benefit during this period. Interventions may be needed to address possible clinician and patient uncertainty about the benefits of secondary prevention medications, regardless of revascularisation strategy.

Long-Term Outcomes of Sex Differences in Three-Vessel Coronary Disease with Different Treatment Strategies: A Large Cohort Study.

The information assessing sex differences in outcomes of patients with three-vessel coronary disease (TVD) after different treatment strategies is sparse. This study aimed to investigate long-term outcomes of TVD among women compared with men after medical therapy (MT) alone, percutaneous coronary intervention (PCI), or coronary artery bypass grafting surgery (CABG). Consecutive 8943 patients with TVD were enrolled. Associations between sex and all-cause death and major adverse cardiac and cerebrovascular events (MACCE) (all-cause death, myocardial infarction, or stroke) were assessed. Of the 8943 patients, 1821 (20.4%) were women. During a median follow-up of 6.6 years, women had comparable incidences of all-cause death (16.6% vs. 14.9%, P = 0.079) and MACCE (27.2% vs. 26.1%, P = 0.320) to men. After multivariable analysis, women showed lower adjusted risks of all-cause death (HR: 0.777; P = 0.001) and MACCE (HR: 0.870; P = 0.016) than men in the entire cohort. Subgroup analysis revealed that the less all-cause death risk of women relative to men was significant in PCI (HR: 0.702; P = 0.009), and CABG groups (HR: 0.708; P = 0.047), but not in MT alone group. Lower MACCE risk for women vs. men was significant only in PCI group (HR: 0.821; P = 0.037). However, no significant interaction between sex and three strategies was observed for all-cause death (P for interaction = 0.312) or MACCE (P for interaction = 0.228). The cardiovascular prognosis of TVD female patients is better than that of men, which has no interaction with the treatment strategies received (MT alone, PCI, or CABG).