Postprocedural Myocardial Infarction Research Articles

Off-Label Use of Peripheral Paclitaxel Drug-Coated Balloons in Management of Recurrent Coronary In-Stent Restenosis

BackgroundWhile not available for clinical use in the United States, dedicated drug-coated balloons (DCB) are currently under investigation for the management of coronary in-stent restenosis (ISR). Peripheral drug-coated balloons (P-DCB) have been used off-label for coronary ISR. Further data regarding this practice are needed. We aimed to describe outcomes in patients who underwent off-label P-DCB angioplasty for coronary ISR. MethodsWe analyzed data on P-DCB angioplasty for coronary ISR at a single high-volume center between April 1, 2015, and December 30, 2017. Demographic and procedural details were collected, with systematic follow-up as clinically indicated. ResultsData from 31 patients treated with P-DCB angioplasty (mean age 68.0 ± 10.7 years) with coronary ISR (17 recurrent and 14 first time) were analyzed. Most patients presented with high-grade angina (81%) or myocardial infarction (13%). Treated ISR lesions were in native coronary arteries (68%), saphenous vein grafts (SVG, 23%), and the left internal mammary artery (10%). Diffuse intrastent ISR was common (69%) with a mean lesion length of 21.7 ± 12.4 mm. No postprocedural myocardial infarction occurred and 1 nonprocedural mortality occurred during index admission. At follow-up (median: 283, interquartile range [IQR]: 354 days), repeat angiography was performed in 19 patients (median: 212, IQR: 188 days), and 11 patients had target lesion recurrent ISR (Kaplan-Meier event-free survival estimate: 44.7%, 95% CI, 26.1%-76.5%). ConclusionsIn the absence of availability of dedicated coronary DCB, treatment of coronary ISR using P-DCB angioplasty was feasible, although follow-up demonstrated continued risk for recurrent ISR in this high-risk population.

Findings of Angiography and Carotid Vessel Wall Imaging Associated with Post-Procedural Clinical Events after Carotid Artery Stenting.

Vessel wall imaging (VWI) for carotid plaque is better for detecting unstable carotid plaque such as intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), and thin/ruptured fibrous cap. However, the role of VWI before carotid artery stenting (CAS) is unclear. Thus, this study aimed to determine the findings of symptomatic carotid stenosis before CAS on angiography and carotid VWI and to evaluate the imaging findings associated with post-procedural clinical events after CAS. This retrospective study included 173 consecutive patients who underwent carotid VWI, CAS, and post-procedural diffusion-weighted imaging (DWI) after CAS. Findings of unstable plaque on carotid VWI and unstable findings on angiography were analyzed. We also analyzed the incidence of post-procedural clinical events, any stroke, myocardial infarction (MI), and death within 30 days of CAS. Of 173 patients, 101 (58.4%) had initial ischemic symptoms and positive findings on DWI. Symptomatic patients were significantly higher in patients with IPH than in patients without IPH (62.4% vs. 45.8%, P=0.031). Degree of stenosis, thrombus of the stenotic lesion, flow delay of internal carotid artery, and flow arrest by filter thrombus had significantly higher prevalence in the symptomatic group. Twenty patients (11.6%) had post-procedural clinical events such as any stroke, clinical symptoms, and/or MI. Hyperlipidemia and intraluminal thrombus on angiography were identified as significant factors influencing post-procedural events after CAS. An intraluminal thrombus on angiography was identified as a significant factor influencing post-procedural clinical events after CAS.

Outcomes of Orbital Atherectomy for the Treatment of Severely Calcified Coronary Artery Lesions.

Background Orbital atherectomy (OA) is used to prepare severely calcified coronary artery lesions before percutaneous coronary intervention (PCI). Intravascular ultrasound (IVUS) is used to determine the plaque volume and degree of stenosis within the arterial vessel. This study evaluated the safety and efficacy of OA for treating severely calcified coronary lesions and determined if IVUS impacted these outcomes. Methods We retrospectively collected data from a single center of patients with severe coronary artery calcification who underwent OA. The data on baseline characteristics and procedural and clinical outcomes were collected and analyzed. Results A total of 374 patients underwent OA. The mean age was 69 ± 12.7; 53.6% were Black, and 38% were female. Hypertension was present in 96% of the patients, followed by hyperlipidemia in 79.4%, diabetes mellitus in 53.7%, and chronic kidney disease (CKD) in 22.7%. More patients had presented with a non-ST-elevation myocardial infarction (NSTEMI) compared to ST-elevation myocardial infarction (STEMI) at 36.3% versus 4.3%, respectively. The radial artery was used in 35.4% of the cases, and the left anterior descending artery (LAD) was the most commonly treated vessel with OA at 61%, followed by the right coronary artery (RCA) at 30.7%. IVUS was utilized in 63.4% of cases. The most common complication of the procedure was perforation and dissection at an equal proportion of 1.3% among all patients. The no-reflow rate was 0.5%, and 0.5% developed post-procedural myocardial infarction (MI). The average length of stay was 4.7 days, while a marginal proportion, at 10.5%, had same-day discharge with no recorded complications. Conclusion In this analysis of patients with severely calcified coronary lesions, OA had low rates of major adverse cardiovascular events (MACE) and was considered a safe and effective treatment for complex coronary lesions.

Cardiac Troponin I in Patients Undergoing Percutaneous and Surgical Myocardial Revascularization: Comparison of Analytical Methods

The myocardial infarction (MI) types 4a and 5 guidelines recommend cardiac troponin (cTn) diagnostic decision limits of 5 and 10 times the 99th percentile, respectively. Different cTn kits elicit different responses, so the MI diagnosis is still challenging. The study aimed to establish the cutoff values and the accuracy of three different cTnI kits in the diagnosis of post-procedural MI. We analyzed 115 patients with multivessel stable chronic coronary artery disease; 26 underwent percutaneous coronary intervention, and 89 underwent coronary artery bypass graft. Delayed-enhancement magnetic resonance imaging was performed before and after each intervention for definitive MI diagnoses. Two contemporary and one high-sensitivity cTnI immunoassays were used. ROC curves determined the accuracy of each assay. Low accuracy was observed after applying the current guidelines recommendations. The three cTnI assays accuracies improved when adjusted by the new ROC cutoffs, reaching 82% for MI type 5 for all assays, and 78%, 88%, and 87% for MI type 4 for Siemens, Beckman, and Abbott, respectively. The ultrasensitive and contemporary tests' accuracy for MI types 4a and 5 diagnoses are equivalent when adjusted for these new cutoffs. The hs-cTnI assays had lower accuracy than contemporary tests for MI types 4a and 5 diagnoses.

The racial disparity among post transcatheter aortic valve replacement outcomes: A meta-analysis.

Racial disparities have been well described in cardiovascular disease. However, the impact of race on the outcomes post - Transcatheter aortic valve replacement (TAVR) remains unknown. We aim to evaluate the disparity among the race (black and white) post - TAVR. We systematically searched all electronic databases from inception until September 26, 2022. The primary outcome was in-hospital all-cause mortality, and secondary outcomes was myocardial infarction (MI), acute kidney injury (AKI), permanent pacemaker implantation (PPI) or ICD, stroke, vascular complications, and major bleeding. A total of three studies with 1,02,009 patients were included in the final analysis. The mean age of patients with white and black patients was 82.65 and 80.45years, respectively. The likelihood of in-hospital all-cause mortality (OR, 1.01(95%CI: 0.86-1.19), P=0.93), stroke (OR, 0.83(95%CI:0.61-1.13), P=0.23, I2=46.57%], major bleeding [OR, 1.05(95%CI:0.92-1.20), P=0.46), and vascular complications [OR, 0.92(95%CI:0.81-1.06), P=0.26), was comparable between white and black patients. However, patients with white race have lower odds of MI (OR, 0.65(95%CI:0.50-0.84), P<0.001), and AKI (OR, 0.84(95%CI:0.74-0.95), P=0.01) and higher odds of PPI or ICD (OR, 1.16(95%CI: 1.06-1.27), P<0.001, I2=0%) compared with black race patients. Our findings suggest disparity post - TAVR outcomes existed, and black patients are at higher risk of MI and AKI than white patients.Key Clinical Message:•What is already known on this topic: Disparity has been witnessed among patients with cardiovascular disease. However, no studies have drawn a significant association among post-TAVR patients' outcomes•What this study adds: Among patients who underwent TAVR, there is a difference in the adverse outcomes between black and white race patients. White patients have a lower risk of post-procedure MI and AKI compared with Black patients.•How this study might affect research, practice, or policy: These disparities need to be addressed, and proper guidelines need to be made along with engaging patients with better medical infrastructure and treatment options..

In-hospital Outcomes and Cost Associated With Treatments for Non-ST-elevation Myocardial Infarction.

Although variation in the management of patients with non-ST-elevation myocardial infarction (NSTEMI) is well documented across US hospitals, few data exist characterizing variation in outcomes following specific management strategies. Admissions for NSTEMI to hospitals performing coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery between 2016 and 2018 were identified from the National Inpatient Sample. Patients were categorized according to treatment rendered (medical therapy alone, angiography without revascularization, PCI, or CABG). The primary end point was variation in the incidence of composite in-hospital death, postprocedure myocardial infarction, or stroke, stratified by treatment rendered. Secondary outcomes included variation in length of stay (LOS), cost, and use of each treatment modality. Variation was characterized by the median odds ratio. Among 140,194 hospitalizations for NSTEMI, 35,748 (25.5%) patients received medical therapy alone, 28,678 (20.5%) underwent angiography without revascularization, 58,383 (41.6%) underwent PCI, and 17,385 (12.4%) underwent CABG. Despite adjusting for patient- and hospital-related factors, 2 similar patients were 25% more likely to experience the composite primary outcome following PCI and 45% more likely following CABG at 1 randomly selected hospital than at another. Significant hospital-level variations in LOS and cost were also apparent following each treatment modality. In a large national analysis of hospitalizations for NSTEMI, significant variation was observed in clinical outcome, LOS, and cost associated with each treatment modality, despite adjustment for patient- and hospital-related factors.

Does Opioid Addiction Influence Clinical and Angiographic Outcomes in STEMI Patients Undergoing Emergency PCI?

Despite recognizing the traditional coronary artery disease (CAD) risk factors, some secondary factors, such as opioid substance abuse, have to be considered. We aimed to assess the relationship between opioid consumption and emergency percutaneous coronary intervention (PCI) revascularization results, according to Thrombolysis in Myocardial Infarction (TIMI) flow and in-hospital survival outcomes in ST-elevation myocardial infarction (STEMI) patients. This case-control study was conducted on 186 patients (93 patients in each group) with acute STEMI, who were referred to Chamran Heart Center, Isfahan, Iran. Opioid addiction was diagnosed by patients' records and confirmed by conducting an interview based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria. Patients in both groups were evaluated and compared for angioplasty results based on the TIMI flow grade and in-hospital cardiovascular events and complications. Ninety-one patients (97.84%) of each group were male, and opioid-addicted patients were younger than the non-opioid users (52.95 9.91 vs. 57.90 12.17, P = 0.003). Among the CAD risk factors, prevalence of dyslipidemia was significantly higher in non-opioid users, whereas cigarette smoking was higher in opioid-addicted patients (P < 0.050). There was no significant difference between the two groups regarding pre- and post-procedural myocardial infarction complications as well as mortality rate (P > 0.050). Also, there were no significant differences between the opioid and non-opioid users regarding TIMI flow grading, and successful PCI rate based on achieving TIMI III was 60.21% versus 59.1% in opiate-dependent and non-opioid users, respectively (P = 0.621). Opioid addiction has no effects on post-PCI angiographic results and in-hospital survival outcomes in STEMI patients which undergoing emergency PCI.

759 LEFT MAIN PERCUTANEOUS OR SURGICAL REVASCULARIZATION AND SUBSEQUENT RISK OF ACUTE KIDNEY INJURY: INSIGHTS FROM THE LUCKY REGISTRY

Abstract Background Recent evidence has rendered percutaneous coronary intervention (PCI) a valuable alternative to coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). Nevertheless, the optimal management and patients selection is still subject to discussion Methods We retrospectively included 431 patients treated with PCI and 324 patients treated with CABG with the primary objective of comparing procedural failure according to revascularization strategy. Secondary endpoints were post procedural and clinically relevant myocardial infarction, in-hospital stroke, major bleeding defined according to the Bleeding Academic Research Consortium (BARC) criteria, death, and 1-year major adverse cardiac events (MACE). Results There was no observed difference in the rates of procedure failure in patients who received PCI compared to patients who received CABG (4.6% vs 3.7%, respectively) odds ratio [OR] 1.26; (95% confidence intervals [CI] 0.58-2.9, p= 0.52.) There was no significant difference in the defined ischemic outcome for PCI vs CABG (0.9% vs 2.4%, respectively) OR 0.37; (95% CI 0.08-1.4), P = 0.09. There was a mild increase in periprocedural myocardial infarction (MI) after PCI (4.2% vs 1.5%) compared to CABG; (OR = 2.8; 95% CI 0.99-9.8, P = 0.034). On the contrary there was a higher risk of major bleeding and transfusions in the patients who had been treated with CABG who has a clinical profile suited for PCI. Conclusions PCI did not significantly increase the risk for procedural failure or ischemic events compared to CABG in patients with LM CAD. The higher risk for post-procedural MI after PCI was offset by a higher risk for major bleeding events and transfusion requirements in those undergoing CABG, especially for those who were clinically suited for PCI.

760 IMPACT OF COMORBIDITIES AND PATIENTS PREFERENCE ON THE CHOICE BETWEEN PERCUTANEOUS OR SURGICAL REVASCULARIZATION FOR LEFT MAIN CORONARY ARTERY DISEASE

Abstract Background Recent evidence has rendered percutaneous coronary intervention (PCI) a valuable alternative to coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). Nevertheless, the optimal management and patients selection is still subject to discussion Methods We retrospectively included 431 patients treated with PCI and 324 patients treated with CABG with the primary objective of comparing procedural failure according to revascularization strategy. Secondary endpoints were post procedural and clinically relevant myocardial infarction, in-hospital stroke, major bleeding defined according to the Bleeding Academic Research Consortium (BARC) criteria, death, and 1-year major adverse cardiac events (MACE). Results There was no observed difference in the rates of procedure failure in patients who received PCI compared to patients who received CABG (4.6% vs 3.7%, respectively) odds ratio [OR] 1.26; (95% confidence intervals [CI] 0.58-2.9, p= 0.52.) There was no significant difference in the defined ischemic outcome for PCI vs CABG (0.9% vs 2.4%, respectively) OR 0.37; (95% CI 0.08-1.4), P = 0.09. There was a mild increase in periprocedural myocardial infarction (MI) after PCI (4.2% vs 1.5%) compared to CABG; (OR = 2.8; 95% CI 0.99-9.8, P = 0.034). On the contrary there was a higher risk of major bleeding and transfusions in the patients who had been treated with CABG who has a clinical profile suited for PCI. Conclusions PCI did not significantly increase the risk for procedural failure or ischemic events compared to CABG in patients with LM CAD. The higher risk for post-procedural MI after PCI was offset by a higher risk for major bleeding events and transfusion requirements in those undergoing CABG, especially for those who were clinically suited for PCI.

Bleeding complications in patients undergoing percutaneous coronary intervention in coronary artery bypass grafts: the impact of clinical presentation, access site and selection bias

Abstract Background Percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass graft (CABG) surgery is commonly done via the femoral approach. Relatively few cases are done via the radial approach. Purpose To assess bleeding complications in patients with either radial/brachial or femoral access when undergoing graft PCI, saphenous vein graft or internal mammary artery (IMA) graft. Method Data was collected for quality control on all patients that underwent PCI between 2010 and 2018 at 6 tertiary care hospitals in our system. Outcomes were classified and reported in accordance with the Bleeding Academic Research Consortium (BARC) criteria. BARC Type 4 (CABG-related) and BARC Type 5 (fatal) bleeds were excluded. Major bleeding was defined as BARC Type ≥3. Major adverse cardiac and cerebrovascular events (MACCE) was the combined endpoint of hospital death; post procedural myocardial infarction; cerebrovascular events (ischemic and hemorrhagic) and major bleeding complications. Due to the high intraclass correlation of procedures within patients, only the first procedure within the study period was selected from each patient for analysis. The two-sample t-test, Wilcoxon rank sum test, chi-square or Fisher's exact test were used as appropriate. Results A total of 1153 of 1196 patients who underwent graft intervention had BARC outcome data. Of these only 81 (7%) was via radial/brachial access. Baseline clinical characteristics are shown in the Table. A higher percentage of BARC ≥3 patients presented with NSTEMI/STEMI or had IMA graft intervention. Access site was not associated with bleeding complications. However, MACCE, post procedural heart failure (HF) and post procedural myocardial infarction (MI) rates were higher in patients who had femoral access (Figure). Conclusions In a large contemporary dataset of post CABG patients undergoing graft interventions: 1) the majority of patients (93%) underwent graft PCI via femoral access; 2) clinical presentation and acuity was associated with more severe bleeding complications; 3) access site did not seem to be associated with bleeding complications (possible selection bias); and 4) there was a trend towards higher MACCE rates in patients who had a femoral access. Additional analysis will be done to further investigate our findings. Funding Acknowledgement Type of funding sources: None.

Comparison of Percutaneous Coronary Intervention Outcomes Among Patients With Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease Overlap, and Pickwickian Syndrome (Obesity Hypoventilation Syndrome).

BackgroundObstructive sleep apnea (OSA) is often present in coronary artery disease patients and confers a high risk of complications following percutaneous coronary interventions (PCI). The impact of two commonly associated comorbid conditions, chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS, Pickwickian syndrome) in OSA patients undergoing PCI has never been studied.MethodsThe National Inpatient Sample (NIS; 2007-2014) was queried using the International Classification of Diseases, Clinical Modification 9 (ICD-9-CM) codes to compare baseline characteristics, comorbidities, and outcomes in adults undergoing PCI with OSA, COPD-overlap syndrome, and OSA+OHS.ResultsOf a total of 4,792,177 PCI-related inpatient encounters, OSA, OSA-COPD overlap syndrome, and OSA+OHS were found to be present in 153,706 (median age 62 years, 79.4% male), 65135 (median age 65 years, 66.0% male), and 2291 (median age 63 years, 58.2% males) patients, respectively. The OHS+OSA cohort, when compared to the COPD-OSA and OSA cohorts, was found to have the worst outcomes in terms of all-cause mortality (2.8% vs. 1.5% vs. 1.1%), hospital stay (median 6 vs. 3 vs. 2 days), hospital charges ($147, 209 vs. $101,416 vs. $87,983). Complications, including cardiogenic shock (7.3% vs. 3.4% vs. 2.6%), post-procedural myocardial infarction (11.2% vs. 7.1% vs. 6.0%), iatrogenic cardiac complications (6.1% vs. 3.5% vs. 3.7%), respiratory failure, acute kidney injury, infections, and pulmonary embolism, were also significantly higher in patients with OHS+OSA. Adjusted multivariable analysis revealed equivalent results with OHS+OSA having worse outcomes than OSA-COPD and OSA.ConclusionConcomitant OHS and COPD were linked to worse clinical outcomes in patients with OSA undergoing PCI. Future prospective studies are warranted to fully understand related pathophysiology, evaluate and validate long-term outcomes, and formulate effective preventive and management strategies.

Management and prognosis of catheter induced aortocoronary dissection: A multicentric observational study

Catheter-induced aortocoronary dissection(CIACD) is a rare but potentially devastating complication of percutaneous coronary interventions(PCI). We aimed to assess the incidence, management modalities and in-hospital outcomes of CIACD. This was a retrospective multicentric observational cohort from the national PCI registry. Dissections were defined using the NHLBI classification. The primary endpoint was the occurrence of in-hospital Major Adverse Cardiovascular Events(MACE): a composite clinical criterion including in-hospital cardiac death(CD), heart failure and post-procedural myocardial infarction(MI). Between 2011 and 2020,75556 PCI were performed. We identified 68 patients(0.09%) with CIACD. The mean age was 60 ± 11 yrs and the sex ratio was 1,7. The radial approach was predominant(58,8%). Judkins left and Judkins right catheters caused CIACD in respectively 33,8% and 35,3% of the population. 6 patients had previously normal coronary arteries. CIACD was located at the left main coronary artery in 55,9%. The majority of CIACD was Type C(39,7%). Associated aortic dissection (AAD) was observed in 6 patients (8,8%). Management modalities consisted mainly of immediate stenting of the dissection(75%), however, 16 operators (23,7%) preferred initial medical treatment. Dissections disappeared in 15 patients. 30% of PCI were performed by fellows. 10 patients (14,7%) presented in-hospital MACE. In hospital CD and post-procedural MI occurred in 4,4% and 7,4% of the population. Multivariate analysis showed that left dominance angiogram HR = 12[1,03-142] P= 0,013, AAD HR = 41[1,13-1555] P = 0,047 and procedure complications HR = 13[1,43-130] P = 0,023 were predictive of In-hospital MACE. The management of CIACD is still challenging. Our study was one of the largest series showing that stenting is the main treatment of CIACD; however selective patients who have been treated medically had a good clinical and angiographic evolution.

Abstract 11088: Trend, Predictors and Outcomes of Transcatheter Aortic Valve Implantation in Patients with Bicuspid Aortic Valve; A National Inpatient Sample Database Analysis

Background: Transcatheter aortic valve implantation (TAVI) has increasingly been utilized in patients with bicuspid aortic valve (BAV) related to aortic stenosis (AS) with insufficient data on its safety and efficacy. Hypothesis: TAVI in BAV has worst outcomes. Methods: The National Inpatient Sample (NIS) database was queried to identify patients undergoing TAVI for BAV-AS. The major adverse cardiovascular events (MACE), its components [in-hospital mortality, stroke, subsequent myocardial infarction (MI)] and procedure related complications were assessed using a propensity-matched analysis (PSM) to calculate adjusted odds ratios (aOR). Results: A total of 435,841 TAVI crude and 10,743 matched population [trileaflet aortic valve (TAV) 5347, BAV 5396] was included in the final analysis. On PSM, the adjusted odds of cardiac tamponade (aOR 0.61, 95% CI 0.41-0.90), vascular complications (aOR 0.37, 95% CI 0.24-0.56) and stroke (aOR 0.81, 95% 0.65-1.02) were significantly lower in the BAV group, while there was no difference in the risk of in-hospital mortality, post-procedural myocardial infarction, major bleeding, acute kidney injury (AKI) and need for hemodialysis between the two groups. The yearly trend of in-hospital endpoints showed a steady decline in the overall annual rate of complications among those with BAV undergoing TAVI. Compared to early years, the odds of mortality, MI, need for PPM and IABP were identical between the two groups in 2016-2018. A stratified analysis based on age (&lt;65 vs. &gt;66 years), sex (male vs. female), history of coronary artery disease (CAD) and end-stage renal disease (ESRD) followed the net results. Conclusion: TAVI utilization in patients with BAV has increased remarkably over the recent years. The resultant risk of procedural complications such as in-hospital mortality, major bleeding and the overall rate of complications are comparable to those having TAV-AS.

Optimized strategy of rotational atherectomy of underexpanded coronary stents in patients with acute coronary syndrome.

Stent under-expansion is a main cause of acute coronary syndrome (ACS), which can lead to serious clinical outcomes. The rotational atherectomy of underexpanded coronary stents (academically called stent ablation, SA) by intravascular ultrasound (IVUS) may provide more visual reference in the intervention. We aim to analyze the procedural and long-term outcomes of the optimized strategy of SA in patients with ACS and to provide real-world data on this technique. A total of 11 patients with ACS who underwent SA between April 2017 and January 2019 were analyzed. Clinical follow-ups were obtained either by telephone call or by scheduled visit. Clinical end-points included periprocedural and postprocedural myocardial infarction, stent thrombosis, target lesion revascularization, and major adverse cardiac events. The mean age of patients was 69.6±6.5 years, and five (45.5%) patients were males. All cases presented with unstable angina and were admitted with ACS. All patients required at least two burrs during the intervention and the size of the burr was selected based on the data of minimum lumen diameter (MLD), and the first and the second burr/stent MLD ratios were 0.93 (0.88-0.99) and 1.09 (1.02-1.14), respectively. Nine patients were treated with drug-eluting stents and two were treated with drug-coated balloons. There were no complications including no flow, perforation, or burr entrapment during the intervention. No in-hospital deaths or major adverse cardiac events were documented during the follow-up period. In our study, less contrast agent and a lower dose of radiation were used during the intervention. SA guided by IVUS can reduce the risk of complications, assess the results of surgery, inform the selection of stent size, and decrease the required dose of radiation and contrast.

Systematic review and meta-analysis of placebo-controlled invasive interventions for the management of chronic stable angina

Abstract Background The benefits of invasive therapies for chronic stable angina are in large part supported by open label studies comparing invasive procedures to medical therapy alone. Placebo effects are frequently unaccounted for as control arms rarely receive placebo (sham) interventions. This review pools studies comparing invasive therapies for chronic stable angina to placebo interventions and aims to measure the true effects of different invasive interventions. Methods We performed a systematic review and meta-analysis of double blinded randomized placebo-controlled trials of invasive therapies for the management of chronic stable angina. The outcomes of interest were change in exercise tolerance time, change in Canadian cardiovascular society angina grade and rate of post-procedural complications including myocardial infarction and all-cause mortality. Results Six randomized placebo-controlled trials were included, with a total of 742 participants. Median follow-up ranged from 6 weeks to 16 months. Contrary to data reported in individual studies, pooled analysis favored invasive therapies over placebo procedures: exercise tolerance time was higher (standard mean difference (SMD) 35.2 seconds [4.4- 66.0]), angina scores were more likely to improve by ≥1 class (Odds Ratio (OR) 2.16 [1.05- 4.46]) and by ≥2 classes (OR 1.76 [1.13- 2.74]). There was no difference in post-procedural myocardial infarction (incidence rate ratio (IRR) 2.91 [0.61–13.93]) and all-cause mortality (IRR 0.39 [0.35–4.27]). Conclusions This meta-analysis of placebo-controlled trials for chronic stable angina found a beneficial effect from invasive therapies. This favorable effect has not been seen in individual studies. Our findings suggest that sample sizes should be adjusted upwards in placebo-controlled studies to detect true treatment effects independent of the placebo effect. Funding Acknowledgement Type of funding source: None

Carotid revascularization in frail patients has implications for the management of asymptomatic carotid stenosis

A commonly held dictum is that carotid endarterectomy (CEA) and carotid artery stenting (CAS) are generally associated with minimal mortality and morbidity. This is supported by a multitude of studies demonstrating stroke rates approximating 1% and myocardial infarction of 2%-4%. However, this review of carotid revascularization in frail patients provides us with sobering results that have often been overlooked in our fixation on postprocedure stroke and myocardial infarction rates.1 Frail patients suffered 23.5% in-hospital complications, 5.2% died, and 14.9% were readmitted within 30 days.

Usefulness of intracoronary administration of fasudil, a selective Rho-kinase inhibitor, for PCI-related refractory myocardial ischemia

BackgroundIntra-procedural myocardial ischemia as an iatrogenic complication still remains a critical issue in contemporary interventional cardiology. The aim of this study was to examine the usefulness of fasudil, a selective Rho-kinase inhibitor, for percutaneous coronary intervention (PCI)-related myocardial ischemia. MethodsAmong 448 PCI sessions performed between October 2015 and December 2017, we retrospectively examined 36 patients (69.0 ± 9.1 [SD] yrs., M/F 26/10) who underwent intracoronary administration of fasudil during a procedure to resolve myocardial ischemia that was resistant to intracoronary nitrate administration. ResultsThe refractory myocardial ischemia was caused by distal embolization (69%), enhanced vasoconstriction at distal site of chronic total occlusion (11%), coronary spasm (11%), and coronary dissection (8%), most of which occurred immediately after balloon or stent dilatation. Intracoronary fasudil significantly improved corrected TIMI frame count (from 37 [30–56] to 24 [12–36]) and TIMI flow grade (from 2 [1–2.5] to 3 [2-3]) (both P < 0.001). Finally, 86% of all subjects successfully obtained TIMI flow grade 3 at the end of the procedure. Intracoronary fasudil tended to be more effective in patients with an attenuated plaque detected by intravascular ultrasound. Importantly, among the 19 elective cases, fasudil successfully prevented 17 patients from developing post-procedure myocardial infarction. Although fasudil-induced transient hypotension requiring a vasopressor was noted in 22% of the subjects, no other adverse effects were noted. ConclusionsThese results indicate that fasudil is a useful and safe therapeutic option for PCI-related myocardial ischemia refractory intracoronary nitrate.

Three-Year Clinical Results of Carotid Artery Stenting in Treating Patients with Contralateral Carotid Artery Occlusion

Patients presenting a carotid stenosis and contralateral carotid occlusion (CCO) have been historically considered at high risk of carotid surgical treatment, and there are few data regarding short-term recovery after stenting therapy in patients with CCO. The aim of this study is to evaluate the short-term recovery and safety of stenting for patients with CCO and different subgroup population. We retrospectively reviewed the records of consecutive patients with CCO who were treated with stenting endovascular methods between 2008 and 2014. The postoperative outcomes were analyzed according to age, ischemic symptom, cerebral infarction history, and collateral situation subgroups, respectively. Fifty-eight consecutive patients with CCO were treated and 49 (84.5%) completed a 3-year follow-up. There were significant higher stroke, myocardial infarction, or death events in the aged (≥75 years old) group and poor collateral group (P = .007 and .0024, respectively). There was no difference in the 3-year primary endpoint incidence between the cerebral ischemia symptom subgroups and cerebral infarction history subgroups. Event-free survival, aged group, and poor collateral group were lower (P = .007 and P = .0024, respectively). Carotid artery stenting (CAS) for patients with common carotid artery is a safe and effective therapy. Factors such as age 75 years or older and poor collateral are associated with a higher 3-year rate of postprocedural stroke, myocardial infarction and death, and lower event-free survival in patients with CCO treated by CAS. Meanwhile, our data do not show a significant impact of cerebral ischemic symptom and cerebral infarction history on clinical outcome of patients with CCO undergoing CAS.

The efficacy of statin administration prior to elective PCI in reducing the incidence of post-procedural myocardial infarction or all-cause mortality: a systematic review

Abstract Background: Observational studies show that statin-naïve patients presenting with acute coronary syndrome (ACS) undergoing elective percutaneous coronary intervention (PCI) have significantly higher rates of myocardial infarction (MI) and mortality. We plan to review the evidence for giving statin naïve patients statins 24 hours pre-PCI, with the aim of reducing post-procedural MI and mortality. Objective: To critically evaluate and appraise primary and secondary literatures that investigate the efficacy of pre-treatment loading of a statin in improving outcome for patients with ACS undergoing percutaneous coronary intervention (PCI). Review Question: What is the efficacy of statin administration prior to elective PCI in reducing the incidence of post-MI or all-cause mortality? Methods: We searched the Cochrane Database of Systemic Reviews for systemic reviews and NICE CKS database for relevant NICE clinical guidelines. We then searched the MEDLINE database and Cochrane Central Register of Controlled Trial (CENTRAL) for relevant randomised control trials (RCTs). Our search was limited to peer reviewed papers published in the last 10 years, between 1st February 2006 to 1st February 2016. Our exclusion criteria were as follows: patients previously on statin therapy; statin administration outside 24 hours of PCI; unsuitable outcomes measured; papers not available in full and non-randomised trials. We conducted a systematic review on eligible papers acquired from this search. Results: Our literature search yielded 86 papers. After reviewing these papers, 80 papers were excluded. Six papers were included in the final review in which 2207 patients received either high-dose statin treatment (n=1111) or placebo/usual care (n=1096). The ARMYDA-ACS trial showed that short-term pre-treatment with atorvastatin reduces the incidence of major cardiac events in patients with acute coronary syndromes undergoing elective PCI (OR=0.12, CI: 0.05-0.50; p=0.004). These findings were consistent with NAPLES II Trial in which preloading with atorvastatin reduced the risk of MI (OR=0.56 CI: 0.35-0.89). On the other hand, the ALPACS trial showed atorvastatin preloading had no significant benefits over usual care. They found that preloading with atorvastatin was not statistically significant reducing for post-procedural MI (OR=0.92, CI: 0.50-1.69) or mortality (OR=1.06, CI: 0.07-17.01). Three papers reported that the use of rosuvastatin given prior to elective PCI was associated with a significant reduction in post-procedural MI in patients. These were Yun KH. et al. (OR=0.50, CI: 0.25-0.98), Wang Z. et al. (OR=0.31, CI: 0.10-0.91) and Cay S. et al. (OR=0.05, CI: 0.01-0.41). Conclusion: 5 out of the 6 studies reviewed showed supported the effectiveness of pre-procedural statins use in reducing the risk of post-procedural major cardiac events in patients undergoing elective PCI. These findings support routine use of statins in patients with ACS undergoing elective PCI.

Post-procedural myocardial infarction following surgical aortic valve replacement and transcatheter aortic valve implantation

Myocardial injury assessed using cardiac biomarker release is ubiquitous following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI), preventing accurate discrimination between focal myocardial infarction (MI) and global injury. Cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging was used to compare rates of new MI following SAVR and TAVI. Identical CMR scans were obtained at baseline and six months post procedure in ninety-six patients undergoing SAVR (n=39) and TAVI (n=57). The rate of new MI was greater following SAVR than TAVI (SAVR, n=10 [26%] vs. TAVI, n=3 [5%], p=0.004). Infarct mass was similar between groups (SAVR 1.1±0.6 vs. TAVI 2.0±1.4 g, p=0.395). New MI did not impact on change in LV ejection fraction (SAVR:LGE[+]2.2±4.7 vs. LGE[-]0.9±8.0%, p=0.437, TAVI:LGE[+]-0.9±6.0 vs. LGE[-]2.0±7.8%, p=0.420). Thirty-four patients (60%) in the TAVI group had non-revascularised coronary artery disease (CAD) at the time of TAVI, of whom three (9%) had new MI. MI is an infrequent complication of TAVI but is more common following SAVR. Infarct size is small following both procedures. The low new infarct rate in TAVI, especially in the context of high rates of non-revascularised CAD, strengthens data from previous studies suggesting that coronary revascularisation pre-TAVI may be unnecessary.