Procedure-related Myocardial Injury Research Articles

Contemporary Strategies and Outcomes of Dedicated Chronic Total Occlusion Percutaneous Coronary Intervention Programs: A Prospective Multicentre Registry.

Background The field of CTO PCI is expanding, but successful and safe percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTO) requires a substantial resource and experience investment. We aimed to assess temporal trends in strategies and outcomes of 2 dedicated programs for CTO PCI. Methods Between 2011 and 2020, 920 CTO PCI procedures were prospectively included at 2 referral centres in Belgium. Temporal trends were assessed, and logistic regression models were built to identify predictors of outcome. Results Despite an increase in lesion complexity (the J-CTO score increased from 1.3 in year 1 to 1.7–2.0 in years 8-9, p < 0.001), technical success improved from 70.0% to 85.6% in year 9 (p value for trend <0.001). We observed the most significant improvement starting at years 3-4 (OR 2.3 in year 4 versus year 1, p=0.018). Together with an increase in success rates and lesions complexity, there was an increase in the use of dual injections, retrograde approaches, the number of balloons and stents, and the use of microcatheters. Conversely, there was a decrease in large bore access, an increase in radial approach, and a shift towards contemporary dissection/reentry techniques. This strategy resulted in a stable major complication rate of 4.7% (p value for trend 0.33). The rate of coronary procedure-related myocardial injury was high (71.0%) and was associated with the use of more intracoronary devices. Conclusions Three to four years after initiation of a dedicated CTO PCI program with 50 CTO PCIs per year, consistent high technical success and low complication rates are achieved using contemporary strategies.

Coronary microcirculation and peri-procedural myocardial injury during elective percutaneous coronary intervention

BackgroundCoronary microvascular dysfunction before percutaneous coronary intervention (PCI) predicts PCI-related myocardial injury in patients with stable coronary artery disease (CAD). Whether the dynamic changes of the microcirculation during PCI might be associated with the occurrence of procedure-related myocardial injury and infarction is still unclear. We aimed to investigate the impact of pre- and post-PCI microvascular function, evaluated with the index of microvascular resistance (IMR) on the occurrence of PCI-related myocardial injury and infarction. MethodsIn consecutive patients with stable CAD referred for elective PCI, coronary physiological indexes, including IMR, were measured before and after revascularization. High sensitivity Troponin T (hs-TnT) was assessed up to 24 h after PCI, and PCI-related myocardial injury and type 4a myocardial infarction (MI) were defined according to the fourth universal definition of myocardial infarction. ResultsIn the 50 patients enrolled, a significant correlation was found between maximum post-PCI hs-Tn and IMR, both at baseline (rho = 0.309, p=0.029) and post-PCI (rho = 0.378, p=0.007). Patients who developed type 4a MI, compared with patients who did not, presented significantly higher IMR levels, both at baseline (28.3 ± 12.2 vs. 19.6 ± 8.8, p=0.020) and post-PCI (45.4 ± 21.3 vs. 21.6 ± 11.2, p<0.0001). Patients with post-PCI IMR > 38 showed significantly higher maximum post-PCI hs-Tn levels (105.4 [49.4–126.9] vs. 22.4 [11.7–38.6] ng/ml, p<0.0001), and developed type 4a MI more frequently (66.8% vs. 4.9%, p<0.0001). ConclusionsDynamic changes of microvascular resistance post-PCI are strongly correlated with PCI-related myocardial injury and post-PCI IMR is a strong predictor of type 4a MI in patients with stable CAD undergoing elective PCI.

A Contemporary Definition of Periprocedural Myocardial Injury After Percutaneous Coronary Intervention of Chronic Total Occlusions

ObjectivesThe aim of this study was to assess the prognostic impact of post-procedural troponin T increase and mortality in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) to define the threshold at which procedure-related myocardial injury drives mortality. BackgroundCoronary CTO recanalization represents the most technically challenging PCI. The complexity harbors a significant increased risk for complications with CTO PCI with compared with non-CTO PCI. However, there are evidenced biomarker cutoff levels that help identify those patients at risk for unfavorable clinical outcomes. MethodsA total of 3,712 consecutive patients undergoing PCI for at least 1 CTO lesion were enrolled, and comprehensive troponin T measurements were performed 6, 8, and 24 h after the procedure. All-cause mortality was defined as the primary study endpoint. ResultsUsing spline curve analysis, a more than 18-fold increase of troponin above the upper reference limit was significantly associated with mortality. In a Cox regression analysis, the crude hazard ratio was 2.32 (95% confidence interval: 1.83 to 2.93; p < 0.001) for a ≥18-fold increase compared with patients with post-procedural troponin increase <18-fold of the upper reference limit. Results remained virtually unchanged after bootstrap- or clinical confounder–based adjustment. ConclusionsThis large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in patients with CTOs. A threshold was defined for procedure-related myocardial injury in patients with CTOs to differentiate them from those without CTOs that may help guide post-procedural clinical care in this high-risk patient population.

Abstract 12590: Usefullness of Early Release Peak of Cardiac Biomarkers for Detection of Myocardial Infarction Related to Coronary Revascularization Procedures. A Cardiac Magnetic Resonance Study

Background: The elevation of troponin (TnI) and creatine kinase-MB (CKMB) after coronary revascularization procedures is frequent, but may not be reliable at identifying a definitive procedure-related myocardial injury. Cardiac magnetic resonance (CMR) is the gold standard in the identification of small areas of myocardial necrosis by late gadolinium enhancement (LGE). The presence of a biomarker early release peak might indicate a nonlethal transient cellular myocardial damage and help to discriminate the patients without procedure-related myocardial lesion. Thus, our objective was to evaluate the amount and pattern of release of biomarkers after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) compared with the area of new LGE on CMR. Methods: Patients with indication for coronary revascularization were included. Measurements of high-sensitivity TnI and CK-MB were obtained before and after the procedures, every 6 hours until 48 hours after PCI, and up to 72 hours after CABG. We evaluated the area under the curve (AUC) and peak release of biomarkers and stratified before and 24 hours after the procedure. CMR was performed before and after procedures with quantification of necrosis by LGE. Results: From 150 patients who completed the study, 60 (40%) underwent CABG with cardiopulmonary bypass (CPB), 44 (29.3%) without CPB, and 46 (30.7%) underwent PCI. 130 (86.7%) exhibited release of cardiac biomarkers consistent with myocardial injury, however only 32 (21.3%) had new LGE on CMR. The AUC and peak release of TnI showed a moderate correlation with the mass of new myocardial LGE on CMR (AUC: r = 0.46, P &lt; 0.0001; TnI peak: r = 0.45, P &lt; 0.0001), as well as the AUC and peak release of CKMB (AUC: r = 0.33, P &lt; 0.0001; CK-MB peak: r = 0.35, P &lt;0.0001). Patients without new LGE on CMR had more frequently an early peak release of cardiac biomarkers when compared with those with new LGE: 63 (88.7%) vs. 8 (11.3%), P = 0.004. Conclusion: The elevation of cardiac biomarkers after coronary revascularization procedures had a low diagnostic power for the detection of new myocardial areas of infarction identified by LGE on CMR. The early release of biomarkers may be useful to rule out the diagnosis of peri-procedural myocardial infarction.

Colocalization of thin-cap fibroatheroma and spotty calcification is a powerful predictor of procedure-related myocardial injury after elective coronary stent implantation

Percutaneous coronary intervention (PCI)-related cardiac enzyme elevation is an independent risk factor for adverse clinical outcomes, but preprocedural predictors of this complication have not been established. This study evaluated the morphological characteristics of culprit lesions by frequency-domain optical coherence tomography (FD-OCT), and examined their predictive value for procedure-related myocardial injury in patients undergoing elective PCI. Sixty-eight patients treated by FD-OCT-guided elective PCI were studied. On the basis of the presence or absence of postprocedural plasma cardiac troponin T (cTnT) elevation, patients were divided into elevation (cTnT-E, n=25) and nonelevation (cTnT-nonE, n=43) groups. FD-OCT examinations of culprit lesions were performed before and after stent implantation, and tissue characteristics were evaluated within a 10-mm-long segment of each lesion. Clinical parameters were similar between the two groups. Stent length was significantly longer in the cTnT-E group than in the cTnT-nonE group. On baseline OCT images, thin-cap fibroatheroma and calcium deposition were more frequently observed within culprit segments of the cTnT-E group compared with the cTnT-nonE group (32.0 vs. 11.6%, P=0.043, and 72.0 vs. 46.5%, P=0.039, respectively). In addition, colocalization of these two findings was a powerful predictor of PCI-related cTnT elevation (odds ratio 8.40, 95% confidence interval 1.65-52.78, P<0.01). Further, the predictive value of this colocalization was enhanced when the analysis included only spotty calcification (odds ratio 21.00, 95% confidence interval 2.65-454.22, P=0.003). FD-OCT examination showed that colocalization of thin-cap fibroatheroma and spotty calcification was a powerful predictor of PCI-related cTnT elevation. FD-OCT is useful for stratifying risk during PCI to avoid procedure-related complications.

Release of biomarkers compared with cardiac magnetic resonance for the diagnosis of procedure-related myocardial injury. A prospective trial using the third definition of myocardial infarction

Background: The elevation of cardiac biomarkers after percutaneous interventions (PCI) or coronary artery bypass grafting (CABG) is frequent. However, the correlation between the release and the diagnosis of procedure-related myocardial infarction (MI) remains unknown, especially after the emergence of high-sensitive troponin assays. In this study we aim to compare the release of cardiac biomarkers after mechanical interventions with the presence of new late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR) and interpret these findings based on the third Task Force definitions for MI. Methods: We prospectively studied 79 patients with stable multivessel coronary artery disease and preserved ventricular function with formal indication for mechanical revascularization. Measurements of biomarkers such as high-sensitive troponin I (cTnI) and creatine kinase (CKMB) was systematically obtained before and after the procedure, six, twelve, 24, and 36 hours to PCI and until 72 hours to CABG. Furthermore, CMR and LGE was performed in all patients before and after procedures. The diagnosis of procedure-related myocardial injury was defined as up to 5 times and 10 times the 99th percentile, for PCI and CABG, respectively. Results: Of 79 patients studied, 58 (73.4%) underwent CABG and 21 (26.6%) underwent PCI. Using the Task Force definitions, for CABG patients, myocardial injury occurred in 55 (94.8%) with TnI and 14 (24.1%) with CKMB. For PCI patients, myocardial injury occurred in 14 (66.7%) with troponin and 1 (4.8%) with CKMB. 16 (20,3%) patients had new LGE on post procedure CMR, 15 (25.8%) after CABG and 1 (4.7%) after PCI. With the currents cutoffs, TnI has a sensitivity of 100% and specificity of 7.3% for CABG and a sensitivity of 100% and specificity of 5% for PCI. CKMB has a sensitivity of 53.3% and specificity of 85.4% for CABG and a sensitivity of 100% and specificity of 100% for PCI. Based on the receiver operating characteristic (ROC) curve, for CABG patients, the best cutoff of TnI was 3.38 ng/mL (85 times the 99th percentile) with a sensitivity of 80% and specificity of 66%, and of CKMB was 22.8 ng/mL (5 times the 99th percentile) with sensitivity of 73% and specificity of 64%. Conclusion: In this sample, compared with LGE in CMR, CKMB reached better accuracy than cTnl for the diagnosis of myocardial injury. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI.

Lack of Peri-Procedural Myocardial Necrosis Reduction from Abciximab in Patients on Dual Antiplatelet Therapy Revascularized with Rotational Atherectomy

Rotational atherectomy allows plaque remodeling in severely calcified lesions and, prior to the adoption of clopidogrel as standard therapy, small trials showed that abciximab reduces transient hypoperfusion associated with the procedure. However, no studies have evaluated it among patients receiving dual antiplatelet therapy. This study aimed to evaluate whether abciximab reduces procedure-related myocardial injury in a non-selected population of patients receiving dual antiplatelet therapy. The study comprised a retrospective review of a nonselected cohort of 139 consecutive procedures of rotational atherectomy performed in patients pre-treated with dual antiplatelet therapy. Abciximab was administered in 48 (34.5%) patients, whereas 91 (65.5%) did not receive it. The only difference between groups was a higher rate of diabetes mellitus in the abciximab group (89% vs. 51%, p=0.001). The rate of procedural complications was 10.5% for patients with abciximab vs. 6.2% for patients without (p=0.537). After 24 hours, the peak of biomarkers of myocardial damage (CKmb and TnT) did not differ, and the rate of procedure-related myocardial injury was 23.9% with abciximab and 20.7% without (p=0.664). In a restricted analysis to diabetic patients (n=84), the rate of myocardial injury was 27.5% with abciximab vs. 18.6% without, (p=0.435). After adjusting by clinical and procedural parameters in a logistic regression model, abciximab use did not confer any significant reduction on procedure-related myocardial injury. In conclusion, in a non-selected cohort of patients receiving dual antiplatelet therapy, the administration of abciximab in the setting of rotational atherectomy did not reduce the incidence of procedure related myocardial injury.

Abstract 3095: Prognostic Significance Of Post-revascularisation Irreversible Myocardial Injury Detected By Cardiovascular Magnetic Resonance Imaging

Background The prognostic significance of revascularization procedure related myocardial injury is uncertain. Delayed enhancement CMR (DE-CMR) has been shown to reliably identify areas of irreversible myocardial injury. We evaluated the prognostic significance of procedure related myocardial injury in a consecutive series of patients undergoing high risk PCI or CABG. Methods/Results 152 patients underwent DE-CMR pre and 1– 6 days post elective PCI or CABG. Primary endpoint was defined as total mortality, non-fatal MI, ventricular arrhythmia terminated by ICD (VA), and unstable angina or heart failure requiring hospitalization. Secondary endpoint was the composite of total mortality, non-fatal MI and VA. During a median follow-up of 2.9 years, 27 patients (18%) reached the primary endpoint and 12 patients (8%) the secondary endpoint. 49 patients (32%) had evidence of new myocardial hyperenhancement (HE) with a median mass of 5.0g (IQR 4.8 –7.1). In a univariate analysis, age, LV EF post intervention, and presence of new HE were predictive of the primary outcome. Elevated troponin (at 24 h) showed a trend towards poorer outcome. In a multivariate Cox regression analysis only age and presence of new HE (HR 2.7, 95% CI 1.1, 5.8) remained independently correlated with occurrence of the primary endpoint. New myocardial HE was the single independent predictor of the composite secondary endpoint (HR 4.2 95% CI 1.2, 16.1). Conclusion Even small amounts of procedure-related myocardial injury are associated with poorer medium term clinical outcomes. CMR identified myocardial injury may be a stronger prognostic marker than cardiac troponin in the setting of coronary revascularisation.

Preprocedural statin therapy reduces the risk and extent of cardiac biomarker release following percutaneous coronary intervention

This study evaluates the association between statin therapy in patients treated by percutaneous coronary intervention (PCI) for stable angina pectoris and postinterventional myocardial injury with subsequent long-term clinical outcome. Prospectively collected data on 400 consecutive patients with stable angina pectoris or evidence of inducible myocardial ischemia were analyzed. The incidence of myocardial infarction based on postinterventional release of troponin I>1.5 ng/ml was 12% in the statin pretreated patients and 20% in those not pretreated with statin therapy (P=0.04, odds ratio 1.84, 95% confidence interval 1.06-3.21). Of the patients experiencing a post-PCI troponin elevation>1.5 ng/ml, those pretreated with a statin pre-PCI had a lesser troponin elevation compared with those not receiving a statin pre-PCI (median: 2.9 ng/ml [1.9-11.5] vs 5.0 ng/ml [3.1-8.8]; P<0.001). In the multivariate model, preprocedural statin therapy was identified as the only independent negative predictor of procedure-related myocardial necrosis based on postprocedural troponin elevation. In the 21-month follow-up period, statin pretreated patients were observed to have fewer deaths, revascularizations, or myocardial infarction; however, this difference was not statistically significant. These results suggest that pretreatment with statins in patients undergoing PCI for stable angina pectoris reduces the risk and extent of procedure-related myocardial injury measured by troponin release.

Preprocedural hs-CRP Level Serves as a Marker for Procedure-Related Myocardial Injury During Coronary Stenting

Background and Objectives:Elevated hs-CRP (high sensitivity C-reactive protein) is well known as a biomarker reflecting the inflammatory process that might evoke the potential for microembolization of an atheromatous plaque, and imparts a poor prognosis in patients with coronary artery disease. We designed this study to evaluate whether the preprocedural hs-CRP level was associated with procedure-related myocardial injury following coronary stenting. Subjects and Methods:We obtained the plasma hs-CRP level from angina patient, who underwent coronary stenting, within 24 hours prior to the procedure, and divided the patients into either the normal CRP (hs-CRP <3 mg/L) or elevated CRP groups (hs-CRP ≥3 mg/L). We defined the reduction of TMP (TIMI myocardial perfusion) grade as at least one decrease in the TMP grade following coronary stenting compared with the pre-procedural TMP. We also evaluate the procedure-related myocardial damage by measuring CK-MB leakage after stenting. Results:We enrolled 279 lesions in 226 patients, who were divided into two groups: the normal CRP group (n=137, 1.28±0.71 mg/L) and the elevated CRP group (n=89, 6.89±4.23 mg/L). A reduction in the TMP grade was significantly more prevalent in the elevated CRP (20 lesions, 17.4%) compared to the normal CRP group (6 lesions, 3.7%, p=0.001). An elevated CRP level was related to an increased CK-MB leakage following stenting (elevated CRP group; 23 patients, 25.8%, normal CRP group; 21 patients, 15.3%, p=0.041). In a multivariable analysis, the only significant predictor of a reduction in the TMP grade following stenting was an elevated CRP level. Conclusion:Systemically detectable inflammatory activity, served by the plasma hs-CRP level, is associated with procedure-related microvascular injury, as assessed by a reduction in the TMP grade and CK-MB elevation following coronary stenting. (Korean Circulation J 2005;35:140-148)

Relationship of C-Reactive Protein to Adverse Cardiovascular Events in Patients Treated by Percutaneous Coronary Intervention for Stable Angina Pectoris

Low-grade inflammation as detected by increased C-reactive protein (CRP) levels predicts the risk of cardiovascular events. However, there is still controversy over the mid-term predictive value of CRP in patients referred for elective percutaneous coronary revascularization (PCI) for stable angina pectoris. The aim of this study was to assess the relationship between baseline CRP level and mid-term outcome of patients undergoing PCI. Two groups of patients with stable angina pectoris were prospectively studied. Group A consisted of 150 consecutive patients with a CRP level < or = 3 mg/L, and group B consisted of 150 consecutive patients with a CRP level > 3 mg/L undergoing PCI at our institution. Comparing both groups of patients, the analysis confirmed a significant difference between medians of the CRP levels (0.5 versus 8 mg/mL; P < 0.001). A higher level of CRP in group B was associated with a lower presence of male gender (P < 0.05) and history of myocardial infarction (P < 0.05). On the other hand, in group B there was higher occurrence of smoking (P < 0.001), hypertension (P < 0.05), hypertriglyceridemia (P < 0.001), and diabetes mellitus (P < 0.01). The incidence of myocardial infarction based on post-interventional release of TnI > 1.5 ng/mL reached 12% in group A and 14% in group B (P = 0.73). Analyses were repeated with adjustment for significant baseline variables, which did not change our findings. The incidence of adverse cardiovascular events during a six month follow-up was 13% in both groups (NS). Increased CRP serum prior to PCI was not associated with the risk and extent of procedure-related myocardial injury measured by TnI release and does not portend heightened cardiovascular risk at six months after percutaneous revascularization. On the other hand, a CRP level > 3 mg/L was associated with a higher occurrence of cardiovascular risk factors (smoking, hypertension, hypertriglyceridemia, and diabetes mellitus).

Troponin must be measured before and after PCI to diagnose procedure-related myocardial injury

Objective—To evaluate troponin I >99th percentile of normal as a criterion for myocardial injury after percutaneous coronary intervention (PCI).Design—Troponin I and creatine kinase monobasic (CK-MB) were measured in 327 patients before and after percutaneous transluminal coronary angioplasty (PTCA) with stent implantation.Results—Troponin I was elevated before PCI in 100 of a total of 222 patients with acute coronary syndrome (ACS). In 91 of these 100 patients, troponin I was elevated also after PCI but actual increases in troponin I concentrations from before to after PCI were found in only 32 patients. The increase of troponin I correlated with post-procedural CK-MB whereas post-procedural troponin I levels did not correlate. In the 122 patients with ACS but normal/normalized troponin I before PCI and in 105 patients with stable coronary artery disease post-procedural troponin I appeared to be a reliable indicator of myocardial infarction (MI), however more sensitive than CK-MB.Conclusion—Troponin I after PCI is sensitive to pre-procedural concentrations. To avoid false positive MI diagnoses we thus suggest that troponin I should be measured before as well as after the procedures and only actual increases should be regarded as indicating procedure-related MI.