Periprocedural Myocardial Infarction Research Articles

Frequency of periprocedural myocardial injury and infarction stratified by cardiac troponin I and cardiac troponin T

BackgroundThere are different definitions of periprocedural myocardial infarction (PPMI) both in terms of thresholds for cardiac biomarkers and the ancillary criteria for myocardial ischemia. Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are used interchangeably to diagnose PPMI. ObjectivesThis study evaluated the frequency of periprocedural myocardial injury and infarction as defined by the Society of Cardiovascular Angiography & Interventions (SCAI), the Academic Research Consortium-2 (ARC-2), and the 4th Universal definition of MI (4UDMI) stratified using cTnT versus cTnI, among patients with chronic coronary syndrome (CCS) and unstable angina. ResultsAmong 830 patients, PPMI rates according to the SCAI, ARC2 and 4UDMI criteria were 4.34 %, 2.05 %, and 4.94 % respectively, with higher rates seen for all definitions when using cTnI versus cTnT (SCAI: 9.84 % vs. 1.91 %, p < 0.001; ARC 2: 3.15 % vs. 1.56 %, p = 0.136; and 4UDMI 5.91 % vs. 4.51 %, p = 0.391). Minor and major periprocedural myocardial injury was respectively observed in 58.31 % and 27.10 % of patients, with rates of both significantly higher when using cTnI versus cTnT (Minor: 69.29 % vs. 53.47 %, p < 0.001, Major: 49.21 % vs. 17.36 %, p < 0.001). ConclusionsAmong patients with CCS and unstable angina, PPMIs defined by SCAI occurred more frequently when using cTnI as opposed to cTnT, whereas the type of troponin had no impact on the incidence of PPMIs according to the ARC-2 and 4UDMI.

Periprocedural myocardial infarction after percutaneous coronary intervention and long-term mortality: a meta-analysis.

Conflicting data are available regarding the association between periprocedural myocardial infarction (PMI) and mortality following percutaneous coronary intervention. The purpose of this study was to evaluate the incidence and prognostic implication of PMI according to the Universal Definition of Myocardial Infarction (UDMI), the Academic Research Consortium (ARC)-2 definition, and the Society for Cardiovascular Angiography and Interventions (SCAI) definition. Studies reporting adjusted effect estimates were systematically searched. The primary outcome was all-cause death, while cardiac death was included as a secondary outcome. Studies defining PMI according to biomarker elevation without further evidence of myocardial ischaemia ('ancillary criteria') were included and reported as 'definition-like'. Data were pooled in a random-effect model. A total of 19 studies and 109 568 patients were included. The incidence of PMI was progressively lower across the UDMI, ARC-2, and SCAI definitions. All PMI definitions were independently associated with all-cause mortality [UDMI: hazard ratio (HR) 1.61, 95% confidence interval (CI) 1.32-1.97; I2 34%; ARC-2: HR 2.07, 95% CI 1.40-3.08, I2 0%; SCAI: HR 3.24, 95% CI 2.36-4.44, I2 78%]. Including ancillary criteria in the PMI definitions were associated with an increased prognostic performance in the UDMI but not in the SCAI definition. Data were consistent after evaluation of major sources of heterogeneity. All currently available international definitions of PMI are associated with an increased risk of all-cause death after percutaneous coronary intervention. The magnitude of this latter association varies according to the sensitivity and prognostic relevance of each definition.

Influence of Pathophysiological Patterns of Coronary Artery Disease on Immediate Percutaneous Coronary Intervention Outcomes.

Diffuse coronary artery disease (CAD) impacts the safety and efficacy of percutaneous coronary intervention (PCI). Pathophysiological CAD patterns can be quantified using fractional flow reserve (FFR) pullbacks incorporating the pullback pressure gradient (PPG) calculation. This study aimed to establish the capacity of PPG to predict optimal revascularisation and procedural outcomes. This prospective, investigator-initiated, single-arm, multicentre study enrolled patients with at least one epicardial lesion with an FFR ≤ 0.80 scheduled for PCI. Manual FFR pullbacks were employed to calculate PPG. The primary outcome of optimal revascularisation was defined as a post-PCI FFR ≥ 0.88. 993 patients with 1044 vessels were included. The mean FFR was 0.68 ± 0.12, PPG 0.62 ± 0.17, and post-PCI FFR 0.87 ± 0.07. PPG was significantly correlated with the change in FFR after PCI (r=0.65, 95% CI 0.61-0.69, p<0.001) and demonstrated excellent predicted capacity for optimal revascularisation (AUC 0.82, 95% CI 0.79-0.84, p<0.001). Conversely, FFR alone did not predict revascularisation outcomes (AUC 0.54, 95% CI 0.50-0.57). PPG influenced treatment decisions in 14% of patients, redirecting them from PCI to alternative treatment modalities. Periprocedural myocardial infarction occurred more frequently in patients with low PPG (<0.62) compared to those with focal disease (OR 1.71, 95% CI: 1.00-2.97). Pathophysiological CAD patterns distinctly affect the safety and effectiveness of PCI. The PPG showed an excellent predictive capacity for optimal revascularisation and demonstrated added value compared to a FFR measurement.

Illusion of revascularization: does anyone achieve optimal revascularization during percutaneous coronary intervention?

This Perspective article is a form of 'pastiche', inspired by the 1993 review by Lincoff and Topol entitled 'Illusion of reperfusion', and explores how their concept continues to apply to percutaneous revascularization in patients with coronary artery disease and ischaemia. Just as Lincoff and Topol argued that reperfusion of acute myocardial infarction was facing unresolved obstacles that hampered clinical success in 1993, we propose that challenging issues are similarly jeopardizing the potential benefits of stent-based angioplasty today. By analysing the appropriateness and efficacy of percutaneous coronary intervention (PCI), we emphasize the limitations of relying solely on visual angiographic guidance, which frequently leads to inappropriate stenting and overtreatment in up to one-third of patients and the associated increased risk of periprocedural myocardial infarction. The lack of optimal revascularization observed in half of patients undergoing PCI confers risks such as suboptimal physiology after PCI, residual angina and long-term stent-related events, leaving an estimated 76% of patients with an 'illusion of revascularization'. These outcomes highlight the need to refine our diagnostic tools by integrating physiological assessments with targeted intracoronary imaging and emerging strategies, such as co-registration systems and angiography-based computational methods enhanced by artificial intelligence, to achieve optimal revascularization outcomes.

The Impact of Radial Vs Femoral Access on Vascular Complications and Patients Outcomes in Complex PCI

Background: Percutaneous coronary intervention (PCI) is a primary treatment modality for coronary artery disease, particularly in complex cases involving multivessel disease, chronic total occlusions, or bifurcation lesions. The choice of vascular access site—radial versus femoral—can significantly impact patient outcomes and the incidence of vascular complications. Recent trends favor radial access due to its potential advantages in safety and recovery. Objective: To evaluate the impact of radial versus femoral access on vascular complications and patient outcomes in complex PCI. Methods: This randomized control trial was conducted at the Chaudhary Pervaiz Elahi Institute of Cardiology, Wazirabad, Pakistan, over a six-month period from September 2023 to February 2024. A total of 350 patients undergoing complex PCI were enrolled, with 210 assigned to radial access and 140 to femoral access. Baseline characteristics, including age, BMI, and prevalent comorbidities (dyslipidemia, hypertension, and diabetes mellitus), were recorded. Major outcomes measured included periprocedural myocardial infarction, in-hospital mortality, and stent thrombosis. Statistical analysis was performed using SPSS Version 26. Results: The mean age of participants was 52.90 ± 8.07 years. No significant differences were found in BMI and comorbid conditions between the groups. In-hospital mortality was 1.4% in the radial group compared to 4.3% in the femoral group (P=0.05). Rates of periprocedural myocardial infarction were similar between groups (0.5% radial vs 0.7% femoral, P=0.77). Stent thrombosis was observed in 0.5% of the radial group and was absent in the femoral group. Conclusion: Radial access in complex PCI was associated with lower in-hospital mortality compared to femoral access, with similar rates of myocardial infarction and stent thrombosis. These findings suggest that radial access may provide a safer alternative, supporting its increasing use in clinical practice.

Frequency and Prognostic Value of Acute Periprocedural Myocardial Injury in Elective Percutaneous Coronary Interventions

Background. Periprocedural myocardial injury (PMI) is an acute complication of percutaneous coronary interventions (PCI) in patients with stable coronary artery disease. Its frequency and relationship with the prognosis of the disease are especially important in elective interventions due to the low risk of ischemic events in this cohort of patients. However, according to the literature, there are significant differences in the criteria for PMI and type 4a myocardial infarction (MI), and, accordingly, their frequency and their prognostic value. Aim. To study the frequency and magnitude of PMI during elective PCI in terms of the level of periprocedural increase in cardiospecific biomarkers, as well as to determine the relationship of PMI with long-term adverse events in patients with chronic coronary artery disease. Materials and methods. A single-center open retrospective cohort study was conducted, which included 435 patients (367/84.4 % men, mean age 58.3±8.6 years) from the elective PCI registry. PMI was diagnosed with an increase in the level of creatine phosphokinase MB fraction (CK-MB) or or cardiac troponin I (cTn I) &gt;1×99 percentile URL (Upper Reference Limit), while the level of increase in biomarkers &gt;1, 2, 3, 4 or &gt;5×99 percentile URL was recorded. An increase in biomarkers &gt;5x99 URL percentile was assessed as a large PMI, and in the presence of clinical and imaging evidence of new loss of viable myocardium, as periprocedural MI type 4a. Depending on the level of periprocedural increase in biomarkers, the relative risk (RR) of developing long-term (within 5 years after index PCI) adverse cardiovascular events, death, as well as clinically significant bleeding and newly diagnosed malignant oncological diseases was calculated. In addition, the correlation between PMI and the above endpoints was summarized using Kaplan-Meier analysis. Results. The frequency of periprocedural PMI diagnosed by increased biomarkers &gt;1×99 percentile URL was 40.2 %, &gt;2×99 percentile URL — 9.7 %, &gt;3×99 percentile URL — 6.7 %, &gt;4×99 percentile URL — 4.8 %, &gt;5×99 percentile URL — 3.5 %, type 4a MI — in 2 patients (0.46 %). An association of “major” PMI (&gt;5x99 percentile URL) with cardiovascular complications within 3 years after elective PCI, including fatal ones, was revealed: for acute myocardial infarction (AMI), RR — 6.516, confidence interval (CI) [2.375-17.881]; for death from cardiovascular causes RR — 6.538, CI [1.695-25.227]. An association of “moderate” PMI (&gt;3, but &lt;5 ×99 URL percentile) with acute ischemic events within 3 years after elective PCI was shown: for AMI, RR was 4.073, CI [1.598 — 10.378]. An association of “minor” AKI (&gt;1, but &lt;5 ×99 URL percentile) with acute ischemic events within 3 years after elective PCI was shown: for AMI, RR was 4.073, CI [1.598 — 10.378]. An association of “minor” AKI (&gt;1, but &lt;3 ×99 URL percentile) with newly diagnosed malignant oncological diseases within 5 years after index PCI was revealed: RR 2.319; CI [1.248- 4.310]. An association of late thrombotic events, such as stent thrombosis (index and re-interventions), stent occlusion (index and non-index) as a reason for re-intervention within 5 years after index PCI, was found with most PMI subgroups. Kaplan-Meier analysis of the dependence of clinically significant bleeding within 5 years after index PCI on the development of “moderate” PMI (p=0.003), as well as the association of non-cardiovascular death within 5 years after index PCI with “minor” PMI (p= 0.007). Conclusion. Registration of periprocedural increase in cardiac biomarkers should be carried out during planned PCI not only for the purpose of diagnosing and predicting acute and late ischemic events, but also for assessing the risk of developing stent occlusion, clinically significant bleeding and prognostically important comorbidities in the long-term (5-year) period in order to identification of groups of patients requiring active monitoring, additional examination and selection of an optimal treatment regimen at the outpatient stage of rehabilitation.

Periprocedural myocardial infarction and injury.

Periprocedural myocardial infarction (PMI) and injury, pertinent to both cardiac and non-cardiac procedures, have gained increasing recognition in clinical practice. Over time, diverse definitions for diagnosing PMI have been developed and validated among patient populations undergoing coronary revascularization. However, this variety in definitions presents considerable challenges in clinical settings and complicates both the design and interpretation of clinical trials. The necessity to accurately diagnose PMI has spurred significant interest in establishing universally accepted and prognostically meaningful thresholds for cardiac biomarkers elevation and supportive ancillary criteria. In fact, elevations in cardiac biomarkers in line with the 4th Universal Definition of Myocardial Infarction, have been extensively confirmed to be associated with increased mortality and cardiovascular events. In the context of non-coronary cardiac procedures, such as Transcatheter Aortic Valve Implantation, there is a growing acknowledgment of both the high incidence rates and the adverse impact of PMI on patient outcomes. Similarly, emerging research underscores the significance of PMI and injury in non-cardiac surgery, highlighting the urgent need for effective prevention and risk management strategies in this domain.

The Use of Coronary Imaging for Predicting Future Cardiovascular Events.

Despite advancements in coronary artery disease (CAD) treatment with drug-eluting stent, its morbidity and mortality remain high. In context, intravascular imaging-guided percutaneous coronary intervention (PCI) is increasingly recommended for better clinical outcomes in patient with CAD. Near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS), as one of the intravascular imaging methods, is effective in detecting lipid-rich plaques, which is crucial for identifying high-risk or vulnerable plaques employing near-infrared light. High lipid core burden, as identified by NIRS-IVUS, correlates with an increased risk of adverse cardiac events and shows varying degrees of efficacy in plaque management and event prevention. This article addresses about how NIRS-IVUS can be used to predict event of CAD. The study highlights the crucial role of NIRS-IVUS in predicting future cardiovascular events. Findings indicate that the presence of high lipid core burden is related to increased risks of periprocedural myocardial infarction and reduced coronary flow during PCI. The study also outlines the predictive value of NIRS-IVUS in non-culprit lesions, where plaques with high lipid core burden significantly increase the occurrence of major adverse cardiac events as demonstrated in the PROSPECT II trial. In terms of therapeutic strategies, the study reviews the effectiveness of high-intensity lipid-lowering strategies in stabilizing vulnerable plaques, as evidenced in trials such as the YELLOW and PACMAN AMI trials. NIRS-IVUS emerges as a valuable diagnostic tool in treating CAD. It effectively identifies vulnerable plaques and aids in predicting and preventing future adverse cardiac events. However, to enhance its practicality and promote widespread adoption in clinical settings, further long-term outcome research of NIRS-IVUS-guided PCI is necessary. These efforts can potentially make NIRS-IVUS a more accessible and indispensable tool in cardiovascular disease management.

Early-Staged Carotid Artery Stenting Prior to Coronary Artery Bypass Grafting: Analysis of the Early and Mid-Term Results in Comparison with a Consecutive Cohort of Isolated Coronary Artery Surgery Patients.

The aim of the present study was to analyze retrospectively the results of patients who underwent early-staged, i.e., within 24-48 h, carotid artery stenting (e-s CAS) before coronary artery bypass grafting (CABG). Between December 2014 and December 2022, 1046 consecutive patients underwent CABG; 31 of these patients (3%) were subjected to e-s CAS prior to CABG (e-s CAS + CABG group). Preoperative and intraoperative variables and early and mid-term results of the e-s CAS + CABG group were compared with those of patients who underwent isolated CABG (CABG group). As compared with the CABG group, the e-s CAS + CABG group showed a worse clinical risk profile due to higher Euroscore-2 values and incidence of obstructive pulmonary disease and bilateral carotid artery and peripheral artery diseases (p < 0.05, for all comparisons). The combined end point of operative mortality, periprocedural myocardial infarction, and stroke was 3.2% (0%/0%/3.2%) in the e-s CAS + CABG group vs. 5.9% (2.2%/2.8%/0.9%) in the CABG group (p > 0.5, for all measurements). At 5 years, actuarial survival was 74% ± 16% in the e-s CAS + CABG group vs. 93% ± 4.0% in the CABG group, freedom from cardiac death was 100% vs. 98% ± 1.0% (p = 0.6), and freedom from MACCEs was 85% ± 15% vs. 97% ± 2.5% (p > 0.1, for all comparisons). Independent predictors of all-causes death were advanced age at the operation (p < 0.0001), a lower value for left ventricular ejection fraction (p = 0.05), and a high Euroscore-2 (p = 0.04). CABG preceded by e-s CAS appears to be associated with satisfactory early outcomes while limiting the risk of myocardial infarction to a very short time interval between the two procedures. Freedom from late all-causes death, cardiac death, and MACCEs were comparable and equally satisfactory, underscoring the positive protective effects of CAS and CABG on the carotid and coronary territories over time.

In-hospital outcomes of transcatheter aortic valve replacement in patients with chronic and end-stage renal disease: a nationwide database study

BackgroundChronic kidney disease (CKD) and end-stage renal disease (ESRD) have been associated with worse outcomes after transcatheter aortic valve replacement (TAVR). With TAVR indications extending to a wider range of patient populations, it is important to understand the current implications of chronic renal insufficiency on clinical outcomes. We aim to determine the impact of CKD and ESRD on in-hospital outcomes after TAVR.MethodsWe queried the National Inpatient Sample for TAVR performed between 2016 and 2020 using International Classification of Diseases-10th Revision codes. We compared in-hospital mortality and clinical outcomes between three groups: normal renal function, CKD and ESRD. The association between CKD/ESRD and outcomes was tested with multivariable logistic regression analyses, using normal renal function as baseline.ResultsIn the five-year study period, 279,195 patients underwent TAVR (mean age 78.9 ± 8.5 years, 44.4% female). Of all patients, 67.1% had normal renal function, 29.2% had CKD, and 3.7% had ESRD. There were significant differences in age, sex, and prevalence of comorbidities across groups. In-hospital mortality was 1.3%. Compared to patients with normal renal function, patients with renal insufficiency had higher in-hospital mortality, with the highest risk found in patients with ESRD (adjusted odds ratio: 1.4 [95% confidence interval: 1.2–1.7] for CKD; adjusted odds ratio: 2.4 [95% confidence interval: 1.8–3.3] for ESRD). Patients with CKD or ESRD had a higher risk of cardiogenic shock, need for mechanical circulatory support, and vascular access complications, compared to those with normal renal function. In addition, patients with ESRD had a higher risk of cardiac arrest and periprocedural acute myocardial infarction. The incidence of conversion to open heart surgery was 0.3% and did not differ between groups. Post-procedural infectious and respiratory complications were more common among patients with CKD or ESRD.ConclusionPatients with CKD and ESRD are at higher risk of in-hospital mortality, cardiovascular, and non-cardiovascular complications after TAVR. The risk of complications is highest in patients with ESRD and does not result in more frequent conversion to open heart surgery. These results emphasize the importance of individualized patient selection for TAVR and procedural planning among patients with chronic renal insufficiency.

Predictors of periprocedural myocardial infarction after rotational atherectomy.

Rotational atherectomy (RA) presents superior efficacy over traditional balloon angioplasty in managing calcified plaques, albeit being associated with a perceived heightened aggressiveness and increased risk of periprocedural complications. To assess the frequency and predictive factors of periprocedural myocardial infarction (MI) following RA. This was a retrospective observational study, encompassing 534 patients. The definition of periprocedural MI was consistent with the 4th universal definition of MI. Periprocedural MI occurred in 45 (8%) patients. This subset tended to be older (74.6 ±8.2 vs. 72 ±9.3%; p = 0.04) with SYNTAX Score (SS) > 33 points (p = 0.01), alongside elevated rates of no/slow flow (p = 0.0003). These patients less often fulfilled the indication for RA, which is a non-dilatable lesion. The incidence of traditional risk factors was similar in both groups. Univariable logistic regression models revealed: male gender (OR = 0.54; p = 0.04), non-dilatable lesion (OR = 0.41; p = 0.01), prior coronary artery bypass grafting (CABG) (OR = 0.07; p = 0.01) as negative and SS > 33 (OR = 2.8; p = 0.02), older age (OR = 1.04; p = 0.04), no/slow flow (OR = 7.85; p = 0.002) as positive predictors. The multivariable model showed that occurrence of no/slow flow (OR = 6.7; p = 0.02), SS > 33 (OR = 2.95; p = 0.02), non-dilatable lesion (OR = 0.42; p = 0.02), and prior CABG (OR = 0.08; p = 0.02) were independent predictors of periprocedural MI. Periprocedural MI after RA was not an uncommon complication, occurring in nearly one-twelfth of patients. Our analysis implicated female gender, older age, and more severe coronary disease in its occurrence. As expected, the presence of no/slow flow amplified the risk of periprocedural MI, whereas prior CABG and non-dilatable lesions mitigated this risk.

Percutaneous Coronary Intervention in a Saphenous Vein Graft Failure: A Case Report

Abstract: Recent published data from the Society of Thoracic Surgery (STS) national database displayed that among patients aged &gt;65 years old who survived following an initial coronary artery bypass graft (CABG) operation, rates of repeat revascularization at 1, 5, 10, and 18 years were 2%, 8%, 16%, and 25%, respectively. The most preferred mode of revascularization was percutaneous coronary intervention (PCI). While remain the most frequently used conduits beside left internal mammary artery (LIMA), saphenous vein grafts (SVGs) have high failure rates. Percutaneous coronary intervention in SVGs is associated with an increased risk of distal coronary embolization, commonly resulting in periprocedural MI. We reported a 79-year-old male patient admitted due to progressive symptoms of chronic coronary syndrome. The patient had a history of hypertension and a CABG surgery in 2012. Electrocardiogram showed ischemia and old myocardial infarction (OMI) in inferior leads as well as poor R wave progression in the precordial leads. Transthoracic echocardiogram displayed a normal ejection fraction but impaired left ventricular (LV) diastolic relaxation. Diagnostic coronary angiography revealed a 70% tubular stenosis in proximal part of SVG supplying posterior descending artery, patent LIMA graft to left anterior descending artery, and complex lesion on native vessel (chronic total occlusion in mid right coronary artery). Implantation of drug eluting stent in SVG-posterior descending artery was performed. Direct-stenting PCI technique using undersized-stent was done to prevent any complications. In conclusion, despite the high risk of complications, vein graft intervention was successfully performed without any complications. Since the high rates of in-stent restenosis following PCI in SVGs, long-term dual antiplatelet therapy should be commenced in this patient. Keywords: saphenous vein graft; vein graft intervention; percutaneous coronary intervention

Incidence and prediction of periprocedural myocardial infarction in elective PCI: The ALPHEUS-MI sub-study

Incidence and prediction of periprocedural myocardial infarction in elective PCI: The ALPHEUS-MI sub-study

Robotic-assisted percutaneous coronary intervention: experience in Switzerland.

Percutaneous coronary intervention (PCI) exposes operators to ionizing radiation. Robotic-assisted PCI (RA-PCI) is a novel technology that enables interventional cardiologists to operate coronary devices remotely from a radiation-shed cockpit. The aim of this study is to describe the experience and challenges during the initiation of a RA-PCI program and to report outcomes of the first 21 patients undergoing RA-PCI in Switzerland. All patients undergoing RA-PCI using the CorPath GRX Vascular Robotic System between 06/2021 and 12/2021 at Inselspital, Bern University Hospital were included in this retrospective registry study. Baseline, procedural and clinical follow-up data were prospectively assessed as part of the Cardiobase Bern PCI registry (NCT02241291). The two endpoints of interest were clinical success [defined as <30% residual diameter stenosis in the absence of in-hospital major adverse cardiovascular events (MACE: composite of death, periprocedural myocardial infarction, target-vessel revascularization, and stroke)] and robotic success (defined as clinical success and completion of RA-PCI without or with partial manual assistance). Additional outcome measures include clinical long-term outcomes at one year. Twenty-five lesions in 21 patients were treated with RA-PCI (age 62.4 ± 9.1 years, 24% female). Clinical success was achieved in 100%, and robotic success in 81% (17/21 procedures, including 4 procedures requiring partial manual assistance). Manual conversion (e.g. manual completion of the procedure) occurred in 19% (4 procedures). Reasons for manual assistance or conversion were poor guiding-catheter back-up or platform limitations (4), adverse events (2x transient slow-flow that was solved manually), safety decision (1x vasovagal reaction not related to robotic approach), and software error (1). No in-hospital MACE occurred. During 12 months of follow-up, one patient suffered a non-target-vessel myocardial infarction requiring repeat PCI. RA-PCI can safely be performed without clinically relevant robot-associated complications in selected patients with approximately 80% of procedures conducted without or with partial manual assistance.

Risk factors for peri-procedural stroke or death in internal carotid artery stenting: A neurology team experience

Background and Objectives: Suitable cases of extracranial internal carotid artery (ICA) stenosis can be treated with carotid artery stenting (CAS) or carotid endarterectomy. However, major complications in the peri-procedural period, like stroke and death, are more common with CAS. We therefore investigated the risk factors for stroke and death during the peri-procedural period following CAS. Methods: In this study, the files of patients who were treated with CAS by a neurology team during 2020–2022 were retrospectively analyzed. Patient age, gender, vascular risk factors, use of antiplatelet therapy, type of carotid artery stenosis (symptomatic or asymptomatic), measured stenosis degrees, contralateral carotid stenosis, types of aortic arch, balloon angioplasty, use of a filter-type embolism protection device, stent cell design (open or closed), and peri-procedural death, stroke, or myocardial infarction (MI) were recorded. All patients were followed up for the first 30 days after CAS. Results: The mean age of 219 patients included in our study was 67.8 ± 8.38 years and 68.5% were male. The most common comorbid diseases in the patients were hypertension (76.7%), hyperlipidemia (53.4%) and diabetes mellitus (DM) (43.4%). Stroke or death occurred in the peri-procedural period in 15 (6.85%) of the patients, but MI did not occur. No statistically significant difference was observed in terms of age or gender when comparing with the cases without stroke or death. Of the patients suffering stroke or death, ischemic stroke developed in 13 (86.67%), cerebral hemorrhage in two (13.33%) and two patients (13.33%) died. Two-thirds of the strokes were either minor (n=7, 46.67%) or moderate (n=4, 26.67%); 13 (86.67%) were ipsilateral, and 14 (93.33%) were in the anterior circulation. The complication risk was found to be significantly higher in patients with prior stroke (OR=3.865; 95% CI 1.282 to 11.652 p=.016), DM (OR=3.634; 95% CI 1.102 to 11.992 p=.034) and pre-dilation angioplasty (OR=13.100; 95% CI 1.762 to 97.422 p=.012). Conclusion: Prior stroke, DM and pre-dilation angioplasty increase peri-procedural stroke and death in CAS. However, even if a stroke complication develops after CAS, it is often not severe.

Halftime rotational atherectomy: a unique concept for diffuse long severely calcified lesions

Rotational atherectomy (RA) is technically more difficult in a diffuse calcified lesion than in a focal calcified lesion. We hypothesized that taking a halftime can be another option for RA to the diffuse calcified lesions. Halftime was defined as at least one long break during RA, in which an operator pulled out the Rotablator system from the guide catheter before crossing the lesion. This study aimed to compare the complications between RA with and without halftime. We included 177 diffuse long severely calcified lesions (lesion lengths ≥ 30 mm) that required RA, and divided those lesions into a halftime group (n = 29) and a no-halftime group (n = 148). The primary outcome was periprocedural myocardial infarction (MI). The reference diameter was smaller in the halftime group than in the no-halftime group [1.82 (1.70–2.06) mm versus 2.17 (1.89–2.59) mm, p = 0.002]. The total run time was longer in the halftime group than in the non-halftime group [133.0 (102.0–223.0) seconds versus 71.5 (42.0–108.0) seconds, p < 0.001]. Although creatinine kinase (CK) and CK–myocardial band (MB) was significantly higher in the halftime group than in the no-halftime group [CK: 156 (97–308) U/L versus 99 (59–216) U/L, p = 0.021; CK–MB: 15 (8–24) U/L versus 5 (3–15) U/L, p < 0.001], periprocedural MI was not observed in the halftime group. In conclusion, periprocedural MI was not observed in RA with halftime. This preliminary study suggests that halftime RA may be a safe option for diffuse severely calcified lesions.Graphical abstract

Predictors of periprocedural myocardial infarction after left main bifurcation percutaneous coronary intervention guided by optical coherence tomography imaging: the PREVENT study

Abstract Background PMI is one of the most common and relevant complications that occur after PCI, but it is still a matter of controversy. This clinical entity has been frequently correlated to peculiar plaque morphological features by several intravascular imaging studies. PCI of the LM coronary artery is a complex procedural setting, where the prognostic value of PMI is higher. Intravascular ultrasound (IVUS) has a traditional predominance in the guidance of LM-PCI, but optical coherence tomography (OCT) outperforms IVUS in spatial resolution and has affirmed itself as a strong support to PCI. Purpose The aim of this study is to identify preprocedural and postprocedural optical coherence tomography (OCT) findings potentially related to periprocedural myocardial infarction (PMI) in patients undergoing percutaneous coronary intervention (PCI) for non-ostial left main (LM) bifurcation disease. Methods We retrospectively analyzed 76 patients who underwent OCT before and after LM-PCI. Definitions of OCT findings were derived from expert consensus documents and major OCT studies. PMI was defined in accordance with the Academic Research Consortium-2 (ARC-2) definition. Results The presence of TCFA was found to be an independent predictor of PMI, and coherently a significantly higher lipid core arc was observed in the PMI group. Mean stent area was the only post-PCI feature to result significantly higher in the PMI group. Conclusions We found the presence of TCFA at pre-PCI OCT was an independent predictor of PMI. A higher mean stent area at post-PCI OCT in patients who developed PMI may suggest that aggressive stent expansion could not always be the right choice in such a context.

Appropriate ischemic criteria for type 4a myocardial infarction: insights from the ALPHEUS trial

Abstract Background Different troponin thresholds have been proposed to define periprocedural myocardial injury based on post percutaneous coronary intervention (PCI) troponin increase only, whereas the definition of type 4a myocardial infarction (MI) needs the association of post procedural troponin and one ischemic criterion. These criteria which evolved from the 3rd to the 4th Universal Definition of Myocardial Infarction (UDMI) are frequently under-reported in studies on periprocedural MI. Purpose We aimed to describe rates of type 4a MI additional diagnostic criteria among the ranges of post PCI troponin elevation in the randomized ALPHEUS trial which compared ticagrelor to clopidogrel in high-risk elective PCI patients. Methods 1698 patients with normal pre-PCI troponin values and centralized core laboratory angiogram analyzes were divided into 4 groups according to maximal post PCI troponin elevations (≤ 1x upper reference limit (URL) for group 1; &amp;gt; 1xURL and ≤ 5xURL for group 2; &amp;gt; 5xURL and &amp;lt; 35xURL for group 3 and ≥ 35xURL for group 4). The type 4a MI additional criteria (ischaemic imaging changes, ischaemic ECG changes, chest pain and angiographic complications) as defined by the 3rd and 4th UDMI were reported and the different angiographic complications were detailed for each group. Results The most prevalent additional ischemic criterion was the presence of angiographic complications detected by the core laboratory. The rate of angiographic complications increased in a stepwise manner with higher post PCI troponin elevation (Figure). Interestingly, we found a similar rate of angiographic complications in patients without any increase in post PCI troponin and troponin elevations below the 5xURL threshold (8.4% and 9.9% respectively). Most angiographic complications were related to transient main branch dissection and/or thrombosis, and transient or permanent side branch occlusions (Table). ECG changes and chest pain ischemic criteria also increased in a stepwise manner and were rarely found below the 5-fold threshold increase, although they might be underreported. Conclusion When using a core laboratory, angiographic complications are found even in patients with no or minor troponin elevation. Above the 5 xURL threshold the rates of angiographic complications are 2 to 3-fold more frequent, and ECG changes and chest pain ischaemic criteria are likely to be present. Our findings support the use of angiographic core laboratory in clinical trial using periprocedural MI as an endpoint; similarly, chest pain -which disappeared from the 4th UDMI- should be reconsidered as a diagnostic ischemic criterion.

Double kissing inflation outside the stent versus jailed balloon technique for coronary bifurcation lesions

Abstract Background Side branch (SB) occlusion remains challenging in percutaneous coronary intervention (PCI) for bifurcation lesions even in the era of jailed balloon technique (JBT). Our previous single-arm study introduced a novel method to protect SB named double kissing inflation outside the stent (DKo), which features twice inflation of the protective balloon kissing with the stent balloon and post-dilation balloon. Objective To confirm whether DKo can protect SB better than JBT in a large sample of bifurcation lesions. Methods This retrospective, single-center cohort study enrolled 875 consecutive patients underwent bifurcation PCI either in DKo (n=209) or JBT group (n=666). The primary endpoint was transient SB loss after removal of the protective balloon. The secondary endpoints included rates of SB rewiring, final kissing balloon inflation (FKBI), SB stenting, final SB loss, and peri-procedural myocardial infarction (PMI). Results Transient SB loss occurred in only 1 patient (0.5%) in DKo but 32 patients (4.8%) in JBT (p&amp;lt;0.005). Transient loss in JBT group was triggered by rewiring (n=21), post-dilation (n=8) and severe dissection (n=3). DKo caused lower rates of rewiring (0.5% vs. 13.8%, p&amp;lt;0.001), FKBI (0.5% vs. 7.7%, p&amp;lt;0.001) and PMI (0.5% vs. 2.9%, p=0.045). SB stenting and final SB loss showed a lower tendency in DKo [0% vs. 0.8%, p=0.21; 0% vs. 1.2%, p=0.11]. DKo was the only protector against transient SB loss [odds ratio=0.08, 95% confidence interval (0.01-0.59), p=0.013]. Conclusion DKo protects SB better than JBT in PCI for bifurcation lesions. Randomized controlled studies are required to confirm the long-term benefit.

Residual Microvasuclar Dysfunction (RMVD) after percutaneous coronary intervention (PCI) assessed by stress- transthoracic Doppler echocardiography (S-TDE)

Abstract Background Microvascular dysfunction (MVD) has been increasingly acknowledged as a relevant cause of myocardial ischemia and worse prognosis. Coronary flow velocity reserve (CFVR), an integrated marker of coronary circulation, can be obtained noninvasively by stress-TDE. However, limited data is available regarding residual MVD (RMVD) of the target territory after percutaneous coronary intervention (PCI) assessed by stress- transthoracic Doppler echocardiography (S-TDE). Purpose This study aimed to investigate the echocardiographic predictors for RMVD after PCI assessed by S-TDE. Methods This study prospectively included 175 patients with chronic coronary syndrome who were scheduled for elective PCI at a single tertiary-care center between April 2019 and November 2022. All patients had anginal symptoms with de novo, functionally significant, proximal left anterior descending (LAD) lesions and underwent fractional flow reserve (FFR)-guided elective single vessel PCI for LAD. Exclusion criteria were patients with reduced left ventricular (LV) systolic function (ejection fraction &amp;lt; 50%), periprocedural myocardial infarction as defined by the fourth universal definition of myocardial infarction. Eligible patients underwent pre- (1 day before) and post-procedural (3 days after) LAD coronary flow assessments by S-TDE. Coronary flow velocity reserve (CFVR) was calculated as the ratio of the hyperemic peak diastolic flow velocity to the basal peak diastolic flow velocity. We also excluded the patients with suboptimal S-TDE imaging. We defined an RMVD after PCI as a post-PCI CFVR impairment (CFVR&amp;lt;2.0). Association between RMVD and echocardiographic parameters were evaluated. Results A total of 150 patients were included in the final analysis. RMVD was observed in forty-five (30.0%) patients after successful LAD PCI. Patients with RMVD had older age (74 [67-79] versus 72 [59-76], P=0.042) and lower estimated glomerular filtration rate (eGFR) (58.4 [37.6-75.1] mL/min/1.73m2 versus 65.9 [54.3-75.5] mL/min/1.73m2, P=0.045) than those without RMVD. Univariate logistic regression analyses revealed that higher age, lower eGFR, pre-PCI higher ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (E/e’), shorter deceleration time of diastolic coronary flow (DDT) and lower pre-PCI CFVR were associated with post-PCI RMVD. Multivariate logistic regression analyses including age and eGFR as covariates showed higher E/e’ (adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25, P=0.022), shorter DDT (OR 0.999, 95% CI 0.998-1.000, P=0.045) and lower pre-PCI CFVR (OR 0.336, 95% CI 0.165-0.683, P=0.003) were independently predictive of RMVD. Conclusions In patients with preserved LV ejection fraction who underwent successful elective FFR-guided PCI for LAD, pre-PCI LV diastolic dysfunction was associated with post-PCI residual microvascular dysfunction of LAD territory.