Percutaneous Coronary Revascularization In Patients Research Articles

Improvement of the frontal QRS-T angle after successful percutaneous coronary revascularization in patients with chronic total occlusion.

The QRS-T angle (QRS-Ta) is a novel marker of myocardial repolarization heterogeneity which is related to adverse cardiovascular events. Our aim in this study was to investigate the effect of successful percutaneous coronary intervention (PCI) on frontal QRS-Ta in patients with chronic total occlusion (CTO). A total of 132 patients undergoing PCI for CTO were included in this study. Successful PCI of CTO segment was performed in 84 patients (group 2) while 48 who failed CTO were observed (group 1). Baseline demographic and clinical variables were evaluated and, 12-lead surface ECGs of all subjects were recorded before performing coronary angiography and 1-month and 6-month after the index procedure. QRS-Ta values significantly decreased during follow-up visits compared to baseline values [92.5 (63.25-110.75); 85.0 (59.0-101.0); 80.0 (53.0-99.0), P < 0.001] in group 2 patients. Moreover, there was no significant difference in frontal QRS-Ta measurements in group 1 patients in their clinical 6-month follow-up [87.0 (48.25-103.0); 86.5 (46.0-101.75); 84.0 (49.0-103.75); P = 0.320]. First month frontal QRS-Ta values [92.5 (63.25-110.75); 85.0 (59.0-101.0), P = 0.002] and sixth month frontal QRS-Ta values [92.5 (63.25-110.75); 80.0 (53.0-99.0), P < 0.001] were lower than baseline values while sixth month values [85.0 (59.0-101.0); 80.0 (53.0-99.0), P = 0.002] was lower compared to first month values. Additionally, a decrease in frontal QRS-Ta was observed regardless of target vessel or Rentrop classification. Successful percutaneous revascularization of CTO was effective in ventricular repolarization. Frontal QRS-Ta significantly decreased after successful PCI on CTO patients at a 6-month follow-up.

Percutaneous Coronary Revascularization in Patients With Single Coronary Artery

IntroductionSingle coronary artery (SCA) is a rare congenital coronary anomaly. Its incidence in various angiographic series is from 0.024% to 0.066%. Percutaneous coronary intervention (PCI) of coronary artery disease (CAD) in these patients is technically challenging. MethodsWe retrospective analyzed the cardiac catheterization procedures of last 15 years and found 12 cases of SCA (incidence 0.084%). To determine the course of anomalous coronaries, angiographic “dot and eye” method and computed tomography (CT) were used. The course of the SCA was classified as per the modified Lipton criteria. PCI was performed as per the standard protocol for a significant epicardial coronary artery stenosis. ResultsOut of total 12 patients of SCA, 9 patients had PCI of significant CAD. The mean age of 9 PCI patients was 63.8 ± 8.2 years (5 males, 4 females). The origin of the SCA was from the right sinus of Valsalva in 6 cases and from left sinus of Valsalva in 3 cases. Eleven successful PCI procedures were performed, which included PCI of left main, coronary bifurcation lesion, chronic total occlusion, and multi-vessel disease. Four patients had intravascular imaging and 3 patients had rotablation of calcified lesions. ConclusionPCI of SCA is technically challenging, which requires considerable expertise and experience. An appropriate selection of hardware along with technical expertise can make the procedure simpler with optimal end results.

278Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patients with three-vessel disease: 3-year follow-up of the SYNTAX II study

Abstract Background The clinical implication of state-of-art PCI at long term follow-up in patients with three vessel disease is undetermined. Purpose The purpose of the study was to investigate whether the favourable outcomes of state-of-the-art PCI in the SYNTAX-II trial, demonstrated up to 2 years, are maintained at 3-year follow-up. Methods The SYNTAX-II study was a multicentre, single arm study that investigated the impact of a state-of-art PCI strategy on clinical outcomes in patients with de novo three vessel coronary artery disease, without left main disease. State-of-art PCI includes: heart team decision-making utilizing the SYNTAX score II, hybrid iFR-FFR decision-making strategy, intravascular ultrasound guided stent implantation, contemporary chronic total occlusion revascularization techniques and guideline-directed medical therapy. The primary endpoint is major adverse cardiac and cerebrovascular events (MACCE – a composite of all-cause death, any stroke, myocardial infarction, or revascularization) at 3 years. Clinical outcomes in SYNTAX-II were compared to the predefined PCI (SYNTAX-I PCI) and coronary artery bypass graft (SYNTAX-I CABG) cohorts from the landmark SYNTAX Trial (SYNTAX-I), selected on the basis of equipoise for long-term (4-year) mortality utilising the SYNTAX Score II. Results Between February 2014 and November 2015, 454 patients out of 708 screened patients were enrolled in SYNTAX-II. In SYNTAX-I, 643 (58.8%) patients with 3VD without left main disease had an equipoise recommendation for CABG or PCI based on the SYNTAX Score II and were used as the comparator. At 2 years, MACCE rate in SYNTAX-II was significantly lower compared to SYNTAX-I PCI (13.2% vs. 21.9%, p=0.001). Furthermore, similar two-year outcomes for MACCE were evident between SYNTAX II-PCI and SYNTAX-I CABG (13.2 vs. 15.1%, p=0.42). Three-year results will be presented at ESC2019. Conclusions Three-year results of his study may offer an attractive option of revascularization strategy in predefined patients with de novo 3VD (SYNTAX Score II inclusion) even if the patients have moderate to severe anatomical complexity (anatomic SYNTAX score &gt;22). Acknowledgement/Funding European Cardiovascular Research Institute (ECRI) with unrestricted research grants from Volcano and Boston Scientific

Clinical outcomes of state-of-the-art percutaneous coronary revascularisation in patients with three-vessel disease: two-year follow-up of the SYNTAX II study.

The purpose of the study was to investigate whether the favourable outcomes of state-of-the-art PCI in the SYNTAX II trial, demonstrated at one year, were maintained at two-year follow-up. The SYNTAX II study was a multicentre, single-arm study that investigated the impact of a contemporary PCI strategy on clinical outcomes in 454 patients with de novo three-vessel coronary artery disease, without left main disease. Clinical outcomes in SYNTAX II were compared to the predefined PCI (SYNTAX-I PCI) and coronary artery bypass graft (SYNTAX-I CABG) cohorts from the landmark SYNTAX trial (SYNTAX-I), selected on the basis of equipoise for long-term (four-year) mortality utilising the SYNTAX score II. At two years, major adverse cardiac and cerebrovascular events (MACCE: a composite of all-cause death, any stroke, myocardial infarction, or revascularisation) in SYNTAX II were significantly lower compared to SYNTAX-I PCI (13.2% vs. 21.9%, p=0.001). Furthermore, similar two-year outcomes for MACCE were evident between SYNTAX II PCI and SYNTAX-I CABG (13.2% vs. 15.1%, p=0.42). At two years, clinical outcomes with the SYNTAX II strategy remained superior to the predefined SYNTAX-I PCI cohort, and similar to the predefined SYNTAX-I CABG cohort.

Surgical vs percutaneous coronary revascularization in patients with diabetes following an acute coronary syndrome.

Surgical vs percutaneous coronary revascularization in patients with diabetes following an acute coronary syndrome.

TCT-683 Long-term prognosis of complete percutaneous coronary revascularization in patients with chronic total occlusion: a comparison between preserved and impaired renal function

Chronic kidney disease (CKD) and coronary artery disease with chronic total occlusion (CTO) are prognostic factors strongly related to reduced long-term survival. Few data exist about prognostic impact of successful percutaneous coronary intervention of CTO (CTO-PCI) and completeness of

TCT-8 Fate of deferred lesions using state-of-art percutaneous coronary revascularization in patients with de novo three vessel disease: lesion level analysis at 2 years of the SYNTAX II study

The long-term safety of FFR guided PCI in patients with multivessel disease has been established. However, the long-term safety and efficacy of hybrid iFR-FFR decision-making strategy in patients with de novo three vessel disease is unknown. We sought to compare 2-year lesion outcomes between

Surgical Versus Percutaneous Coronary Revascularization in Patients With Diabetes and Acute Coronary Syndromes

BackgroundRandomized trial data support the superiority of coronary artery bypass grafting (CABG) surgery over percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary artery disease (MV-CAD). However, whether this benefit is seen in a real-world population among subjects with stable ischemic heart disease (SIHD) and acute coronary syndromes (ACS) is unknown. ObjectivesThe main objective of this study was to assess the generalizability of the FREEDOM (Future REvascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-vessel Disease) trial in real-world practice among patients with diabetes mellitus and MV-CAD in residents of British Columbia, Canada. Additionally, the study evaluated the impact of mode of revascularization (CABG vs. PCI with drug-eluting stents) in diabetic patients with ACS and MV-CAD. MethodsIn a large population-based database from British Columbia, this study evaluated major cardiovascular outcomes in all diabetic patients who underwent coronary revascularization between 2007 and 2014 (n = 4,661, 2,947 patients with ACS). The primary endpoint (major adverse cardiac or cerebrovascular events [MACCE]) was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. The risk of MACCE with CABG or PCI was compared using multivariable adjustment and a propensity score model. ResultsAt 30-days post-revascularization, for ACS patients the odds ratio for MACCE favored CABG 0.49 (95% confidence interval [CI]: 0.34 to 0.71), whereas among SIHD patients MACCE was not affected by revascularization strategy (odds ratio: 1.46; 95% CI: 0.71 to 3.01; pinteraction <0.01). With a median follow-up of 3.3 years, the late (31-day to 5-year) benefit of CABG over PCI no longer varied by acuity of presentation, with a hazard ratio for MACCE in ACS patients of 0.67 (95% CI: 0.55 to 0.81) and the hazard ratio for SIHD patients of 0.55 (95% CI: 0.40 to 0.74; pinteraction = 0.28). ConclusionsIn diabetic patients with MV-CAD, CABG was associated with a lower rate of long-term MACCE relative to PCI for both ACS and SIHD. A well-powered randomized trial of CABG versus PCI in the ACS population is warranted because these patients have been largely excluded from prior trials.

Corrigendum to: 'Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patients with de novo three vessel disease: 1-year results of the SYNTAX II study.

Corrigendum to: 'Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patients with de novo three vessel disease: 1-year results of the SYNTAX II study.

Effects of statin therapy on platelet reactivity after percutaneous coronary revascularization in patients with acute coronary syndrome.

Statin use is associated with enhanced pharmacodynamic response to clopidogrel in patients with stable coronary artery disease undergoing percutaneous coronary intervention (PCI). However, the impact of statin therapy on clopidogrel response profiles in patients with acute coronary syndrome (ACS) undergoing PCI has not been established and represents the objective of this investigation. On-treatment P2Y12 platelet reactivity was measured using the vasodilator stimulated phosphoprotein (VASP) phosphorylation assay before PCI, at hospital discharge, and at 1month after PCI in ACS patients enrolled in the multicenter, prospective GEne polymorphisms, Platelet Reactivity, and Syntax Score (GEPRESS) study (n = 962). High platelet reactivity (HPR) was defined as platelet reactivity index ≥50%. Statins were prescribed at hospital discharge in 87% (n = 835) of patients. All patients were followed for 1year. The 1-month HPR rate was lower in statin than in non-statin treated patients (39.6 vs 52%, respectively, p = 0.009). This finding was confirmed also among statin-treated patients with high Syntax score (≥15). After adjustment for differences in baseline characteristics, statin use at discharge was independently associated with 1-month HPR rate (odds ratio, 0.58, 95% confidence interval, 0.38-0.89; p = 0.015). In ACS patients undergoing PCI treated with clopidogrel the use of statins at discharge was associated with significantly lower 1-month HPR rates compared with patients not treated with statins.

Ranolazine After Incomplete Percutaneous Coronary Revascularization in Patients With Versus Without Diabetes Mellitus: RIVER-PCI Trial

BackgroundChronic angina is more common in patients with diabetes mellitus (DM) with poor glucose control. Ranolazine both treats chronic angina and improves glucose control. ObjectivesThis study sought to examine ranolazine’s antianginal effect in relation to glucose control. MethodsThe authors performed a secondary analysis of the RIVER-PCI (Ranolazine in Patients with Incomplete Revascularization after Percutaneous Coronary Intervention) trial, a clinical trial in which 2,604 patients with chronic angina and incomplete revascularization following percutaneous coronary intervention were randomized to ranolazine versus placebo. Mixed-effects models were used to compare the effects of ranolazine versus placebo on glycosylated hemoglobin (HbA1c) at 6- and 12-month follow-up. Interaction between baseline HbA1c and ranolazine’s effect on Seattle Angina Questionnaire angina frequency at 6 and 12 months was tested. ResultsOverall, 961 patients (36.9%) had DM at baseline. Compared with placebo, ranolazine significantly decreased HbA1c by 0.42 ± 0.08% (adjusted mean difference ± SE) and 0.44 ± 0.08% from baseline to 6 and 12 months, respectively, in DM patients, and by 0.19 ± 0.02% and 0.20 ± 0.02% at 6 and 12 months, respectively, in non-DM patients. Compared with placebo, ranolazine significantly reduced Seattle Angina Questionnaire angina frequency at 6 months among DM patients but not at 12 months. The reductions in angina frequency were numerically greater among patients with baseline HbA1c ≥7.5% than those with HbA1c <7.5% (interaction p = 0.07). ConclusionsIn patients with DM and chronic angina with incomplete revascularization after percutaneous coronary intervention, ranolazine’s effect on glucose control and angina at 6 months was proportionate to baseline HbA1c, but the effect on angina dissipated by 12 months.

Rationale and design of the Japan-USA harmonized assessment by randomized, multicenter study of OrbusNEich's combo StEnt (Japan-USA HARMONEE): Assessment of a novel DES platform for percutaneous coronary revascularization in patients with ischemic coronary disease and non–ST-elevation acute coronary syndrome

Tissue trauma associated with stent implantation continues to generate early thrombosis rates of 0.9% to 1.3% for both bare-metal and drug-eluting stent platforms. The Combo sirolimus-eluting stent combines an abluminal, bioabsorbable polymer with a luminal CD34+ antibody designed to capture endothelial progenitor cells. This article describes the design and methods of the HARMONEE trial (NCT02073565), which represents the first randomized controlled trial of the Combo design against a best-in-class contemporary everolimus-eluting stent. Up to 50 sites in Japan and the United States will enroll 286 subjects (271 evaluable) in each of 2 arms, for a total sample size of 572 subjects (542 evaluable). The statistical plan includes both superiority to imputed bare-metal stent control and noninferiority to everolimus-eluting stent on a primary clinical end point of target vessel failure at 1 year. In addition, fractional flow reserve assessment to evaluate the physiology of target vessels in the entire population will augment the end point definition of ischemia-driven target vessel revascularization. Finally, key safety considerations will be evaluated with a subpopulation with optical coherence tomography imaging for strut coverage, late strut malapposition, and plaque volume, as well as serial human antimurine antibody assessments. As the first international prospective randomized coronary intervention study under the "Harmonization by Doing" program, this study represents a unique collaboration between regulators and investigators in Japan and the United States.

Long-term prognosis of complete percutaneous coronary revascularisation in patients with diabetes with multivessel disease

ObjectiveThere is a paucity of data on the impact of complete revascularisation (CR) following percutaneous coronary intervention (PCI) among patients with diabetes with multivessel coronary disease. In this study, we...

Percutaneous revascularization strategies in small-vessel disease

Percutaneous coronary intervention (PCI) of small coronary vessels represents a real challenge for myocardial revascularization because of the high risk of stent-restenosis and increased risk of adverse clinical events. Moreover, small coronary arteries supply small myocardial territories therefore questioning the clinical significance of small-vessel stenoses. The definition of small-vessel disease and PCI-strategies used are very heterogeneous across studies. The present review will focus on percutaneous coronary revascularization in patients with small vessel coronary artery disease.

Long-Term Clinical Outcome After Fractional Flow Reserve–Guided Percutaneous Coronary Revascularization in Patients With Small-Vessel Disease

Small coronary vessels supply small myocardial territories. The clinical significance of small-vessel stenoses is therefore questionable. Moreover, percutaneous coronary intervention (PCI) of nonfunctionally significant lesions does not improve clinical outcome and might be associated with potential procedural or stent related risks. The aim of this study was to assess the clinical outcome of fractional flow reserve (FFR)-guided PCI in the treatment of small coronary vessel lesions as compared with an angio-guided PCI. From January 2004 to December 2008, all patients treated with PCI for stable or unstable angina in small native coronary vessels (reference vessel diameter and stent size <3 mm) were retrospectively analyzed. Patients were divided into angio-guided and an FFR-guided PCI groups. A total of 717 patients were enrolled (495 angio-guided, 222 FFR-guided). End points were death, nonfatal myocardial infarction (MI), combined death or nonfatal MI, target vessel revascularization (TVR), and procedure costs. Major adverse cardiac events (MACE) were defined as death, nonfatal MI, and TVR. Clinical follow-up was obtained in 97.5% (median follow-up: 3.3 [from 0.01-5] years) of the patients. Seventy-eight patients (35%) had a significant FFR (<0.80) and underwent PCI. Using a propensity score adjusted Cox analysis, patients treated with FFR-guided PCI had significantly lower combined death or nonfatal MI (hazard ratio [HR], 0.413; 95% confidence interval [CI], 0.227-0.750; P=0.004), nonfatal MI (HR, 0.063; 95% CI, 0.009-0.462; P=0.007), TVR (HR, 0.517; 95% CI, 0.323-0.826; P=0.006), and MACE (HR, 0.458; 95% CI, 0.310-0.679; P<0.001). No difference was observed in mortality alone (HR, 0.684; 95% CI, 0.355-1.316; P=0.255). Procedure costs were also reduced in the FFR guided strategy (3253±102 Euros versus 4714±37 Euros, P<0.0001). FFR-guided PCI of small coronary arteries is safe and results in better clinical outcomes when compared with an angio-guided PCI.

Revascularización coronaria percutánea en pacientes con insuficiencia renal crónica

Background and objectiveAn ideal strategy of percutaneous coronary revascularization in patients with renal insufficiency has not been established yet. Our aim was to compare in this group the clinical results of bare metal stents and drug-eluting stents, and identify predictors. Patients and methodIn a group of 200 patients with renal disease, 93 received bare metal stents and 107 drug-eluting stents; for over 2 years we studied rates of a combined event: death, non fatal myocardial infarction, or target lesion revascularization. ResultsWe did not identify differences in the combined event. With multivariate analysis, peripheral arterial disease, left ventricular ejection fraction <45% and treatment with statins were predictor factors. ConclusionsWe had no evidence of the superiority of any type of stent in the revascularization in patients with chronic renal insufficiency.

Health Related Quality of Life After Percutaneous Coronary Revascularisation in Patients with Previous Coronary Artery Bypass Grafts: A Two-Year Follow Up Study

Percutaneous coronary revascularisation [PCR] improves angina and health related quality of life [HRQOL] compared to standard medical therapy. It is unknown whether PCR has the same benefits for patients with a history of CABG. Over a period of 5 years, we assessed HRQOL of patients undergoing PCR using Part 1 of the Nottingham Health Profile [NHP] at baseline 3, 12 and 24 months. We compared HRQOL after PCR in 255 patients with CABG to 2680 without. There were more males [81.1% v 69.6% p = 0.002] and older patients [mean age 60.1 years v. 58.0 p = 0.03] in CABG group. Perceived HRQOL improved at 24 months for pain, energy and emotional reaction but the improvement was less in the CABG group. However, mean NHP scores at 24 months for those with CABG had returned to baseline levels for sleep [34.9] and for physical function was worse than at baseline [22.0 vs 30.7]. This relationship persisted after adjustment for male sex, history of previous MI and coronary stent usage. Patients with previous CABG had less improvement in HRQOL after PCR. Further work is needed to assess the benefits and cost effectiveness of PCR in these patients.

Percutaneous coronary intervention for small vessel coronary artery disease

Symptomatic coronary artery disease may be commonly due to significant atherosclerotic disease involving coronary vessels of relatively small caliber (i.e., with reference vessel diameter <2.75 mm). Whenever medical therapy fails and in other selected cases, revascularization by means of percutaneous coronary intervention (PCI) or bypass surgery is indicated even for small vessel coronary disease. However, despite the numerous developments and improvements in devices and techniques, PCI of small coronary vessels is still fraught with a significant risk of midterm restenosis after both balloon-only PCI and bare-metal stent implantation. Drug-eluting stents, especially those associated with very low angiographic late lumen loss (<0.20 mm), appear to significantly improve angiographic and clinical outcomes after PCI of small coronary vessels. The present article provides a concise and updated review on percutaneous coronary revascularization in patients with symptomatic small vessel coronary artery disease.

Percutaneous coronary revascularization in patients with formerly "refractory angina pectoris in end-stage coronary artery disease" – Not "end-stage" after all

BackgroundPatients with refractory angina pectoris in end-stage coronary artery disease represent a severe condition with a higher reduction of life-expectancy and quality of life as compared to patients with stable coronary artery disease. It was the purpose of this study to invasively re-evaluate highly symptomatic patients with formerly diagnosed refractory angina pectoris in end-stage coronary artery disease for feasible options of myocardial revascularization.MethodsThirty-four Patients formerly characterized as having end stage coronary artery disease with refractory angina pectoris were retrospectively followed for coronary interventions.ResultsOf those 34 patients 21 (61.8%) were eventually revascularized with percutaneous interventional revascularization (PCI). Due to complex coronary morphology (angulation, chronic total occlusion) PCI demanded an above-average amount of time (66 ± 42 minutes, range 25–206 minutes) and materials (contrast media 247 ± 209 ml, range 50–750 ml; PCI guiding wires 2.0 ± 1.4, range 1–6 wires). Of PCI patients 7 (33.3%) showed a new lesion as a sign of progression of atherosclerosis. Clinical success rate with a reduction to angina class II or lower was 71.4% at 30 days. Surgery was performed in a total of8 (23.5%) patients with a clinical success rate of 62.5%. Based on an intention-to-treat 2 patients of originally 8 (25%) demonstrated clinical success. Mortality during follow-up (1–18 months) was 4.8% in patients who underwent PCI, 25% in patients treated surgically and 25% in those only treated medically.ConclusionThe majority of patients with end-stage coronary artery disease can be treated effectively with conventional invasive treatment modalities. Therefore even though it is challenging and demanding PCI should be considered as a first choice before experimental interventions are considered.

A new approach to percutaneous coronary revascularization in patients requiring undeferrable non-cardiac surgery

Optimal strategy for patients who need coronary revascularization before undeferrable non-cardiac surgery is still unknown. We performed a pilot study of dual antiplatelet therapy discontinuation followed by major non-cardiac surgery and endovascular aortic repair early after successful endothelial-progenitor cell-capture coronary stent deployment. Thirty consecutive patients underwent coronary angioplasty plus stenting, before upcoming endovascular or surgical procedures requiring early interruption of antiplatelet therapy. An optimal acute procedural result was observed in all patients. Antiplatelet therapy was stopped before surgery in all patients, achieving an average antiplatelet therapy time of 12.2 ± 3.9 days. Surgery was performed after antiplatelet therapy interruption at an average time interval from revascularization of 17.2 ± 3.9 days. No patient suffered cardiac events during the perioperative period. At thirty day follow-up after surgery there were no cardiac events in all patients. Our preliminary data might suggest a role for EPC-capture stent in patients requiring surgical procedures early after coronary stent placement. Further studies on larger population are needed to confirm the clinical impact of our findings.