Repeat Percutaneous Coronary Intervention Research Articles

Abstract 4138788: Outcomes of Percutaneous Coronary Interventions Following Transcatheter Aortic Valve Replacement: Insights from the National Cardiovascular Data Registry (NCDR) CathPCI Registry

Background: Although transcatheter aortic valve replacement (TAVR) devices can impair coronary access, there are limited real-world data on rates of percutaneous coronary intervention (PCI) and PCI outcomes in post-TAVR patients. Research Question: How often do patients who undergo TAVR develop coronary events, and do they have different procedural characteristics or rates of adverse events when undergoing PCI compared to patients without a TAVR? Methods: We used CMS claims data for the Medicare fee-for-service population to evaluate the incidence of PCI after TAVR between 2011-2017. Then, using data from the NCDR CathPCI Registry linked with Medicare claims, we compared procedural characteristics and PCI outcomes between patients with a history of TAVR vs. propensity-matched patients who did not have a history of TAVR. Results: Of the 52,780 Medicare fee-for-service patients who underwent TAVR between 2011-2017, the incidence of acute myocardial infarction (AMI) was 10.6% and of PCI was 5.4% at five years. Among those patients, 5.6% had a PCI in the three months preceding their TAVR. After propensity-score matching, the procedural success rates for PCI were similar between patients with vs. without a history of TAVR. However, in the propensity-matched comparison, PCI in post-TAVR patients required greater fluoroscopic time (21.9 vs 17.7 mins, p<0.001) and was associated with a greater incidence of post-procedural stroke (0.8% vs 0.4%, p=0.02) and bleeding (5.1% vs 2.9%, p < 0.001). At three-year follow-up post-PCI, there were no differences in the rates of AMI between patients with vs. without a history of TAVR (HR: 1.22, 95% C.I.: 0.97, 1.54, p=0.08). However, patients with prior TAVR were more likely to have repeat PCI in the three years following their index procedure (HR: 1.38, 95% C.I.: 1.12, 1.73, p=0.003). Conclusion: Among Medicare fee-for-service patients, one in 20 patients undergoing TAVR subsequently underwent PCI within 5 years. Although the rates of procedural success were similar, patients with a history of TAVR who underwent PCI had longer fluoroscopic times, more frequent in-hospital adverse events, and a higher likelihood of a repeat PCI compared with matched patients without a history of TAVR.

Characteristics of Young Women Presenting With Acute Myocardial Infarction: The Prospective, Multicenter, Observational Young Women Presenting Acute Myocardial Infarction in France Study.

The percentage of women <50 years of age hospitalized with myocardial infarction is increasing. We describe the clinical, morphological, and biological characteristics, as well as the clinical outcomes of this population. This prospective, observational study included consecutive women <50 years of age admitted for myocardial infarction at 30 centers in France (May 2017-June 2019). The primary outcome was the composite of net adverse clinical events: all-cause death, cardiovascular death, recurrent myocardial infarction, stent thrombosis, any stroke, or major bleeding occurring during hospitalization with a 12-month follow up. Three hundred fourteen women were included. The mean age was 43.0 (±5.7) years, 60.8% presented with ST-segment-elevation myocardial infarction, 75.5% were current smokers, 31.2% had a history of complicated pregnancy, and 55.1% reported recent emotional stress. Most (91.6%) women presented with typical chest pain. Of patients on an estrogen-containing contraceptive, 86.0% had at least 1 contraindication. Of patients with ST-segment-elevation myocardial infarction, 17.8% had myocardial infarction with nonobstructive coronary arteries and 14.6% had spontaneous coronary artery dissection, whereas 29.3% presented with multivessel vessel disease. During hospitalization, 11 net adverse clinical events occurred in 9 (2.8%) women, but no deaths or stent thromboses occurred. By 12 months, 14 net adverse clinical events occurred in 10 (3.2%) women; 2 (0.6%) died (from progressive cancer) and 25 (7.9%) had an ischemia-driven repeat percutaneous coronary intervention. Most young women with myocardial infarction reported typical chest pain and had modifiable cardiovascular risk factors. History of adverse pregnancy outcomes and prescription of combined oral contraceptive despite a contraindication were prevalent, emphasizing the need for comprehensive cardiological and gynecological evaluation and follow-up. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03073447.

Feasibility and Effectiveness of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra-Aortic Balloon Pump Assisted High-Risk Percutaneous Coronary Intervention in Complex Coronary Disease.

Mechanical circulatory support may facilitate high-risk percutaneous coronary intervention (PCI). This study aimed to assess the feasibility, safety and effectiveness of high-risk PCI under the support of venoarterial extracorporeal membrane oxygenation (VA-ECMO) combined with intra-aortic balloon pump (IABP). We enrolled patients who received VA-ECMO plus IABP-assisted PCI procedures at our center from April 2012 to June 2018. Major adverse cardiac events (MACEs) included all-cause death, myocardial infarction, and target vessel revascularization. A total of 10 patients were included, with a mean age of 71 years, EuroSCORE II of 19.9%, and SYNTAX score of 39.8. Procedural success was achieved in nine (90%) patients. The mean duration of ECMO support was 1.5 hours, and 2.6 stents were implanted per patient. Major complications included contrast-induced nephropathy needing hemodialysis in one (10%) patient, significant hemoglobin drop requiring blood transfusion in two (20%) patients, pulmonary infection in one (10%) patient, and local surgical incision infection in one (10%) patient. The accumulative mortality rates for the nine patients with procedural success were 0, 22.2%, and 44.4% at 1, 3, and 5 years follow-up, respectively. However, cardiac death occurred in only one (11.1%) patient. In addition, two patients received repeat PCI or coronary artery bypass grafting within two years following the index procedure. The overall incidence rates of MACEs were 11.1%, 44.4%, and 66.7% at 1, 3, and 5 years follow-up, respectively. VA-ECMO plus IABP-assisted high-risk PCI was feasible in patients with complex coronary disease, with a high procedural success rate and acceptable mid-term clinical outcomes.

Impact of Prolonged Dual Antiplatelet Therapy After Bifurcation Percutaneous Coronary Intervention in Patients with High Ischemic Risk.

The aim of this study was to evaluate the impact of prolonged dual antiplatelet therapy (DAPT) on clinical outcomes in patients undergoing percutaneous coronary interventions (PCI) for bifurcation coronary lesions. A total of 1000 patients who underwent PCI for coronary bifurcation lesions and had clinical follow-up were divided into two groups based on the duration of DAPT: DAPT >12 months and DAPT ≤12 months). Patients who experienced a myocardial infarction, required repeat PCI, or died within 1 year after the initial procedure were excluded. Among the 1000 eligible patients, 394 patients received DAPT for > 12 months (39.4%). Most patients in our study presented with chronic coronary disease (61%). The majority of patients in our study (62.8%) had a low bleeding risk.The median follow-up duration was 35 months (interquartile range 20.6-36.5). There were no significant differences in the major adverse cardiovascular events (MACE) between groups of prolonged DAPT (>12 month) and DAPT ≤12 months (18.8% vs. 14.9%, p = 0.11). Patients with clinical features of high ischemic risk (HIR) had a significantly increased risk of MACE (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.12-3.26, p = 0.015) when compared with patients without clinical features of HIR. Compared with DAPT ≤12 months, extended DAPT (>12 months) did not improve outcomes in patients with clinical (HR 1.24, 95% CI 0.90-1.72, p = 0.19) and technical features (HR 1.04, 95% CI 0.67-1.63, p = 0.85) of HIR. In this multicenter real-world registry, administration of DAPT for more than 12 months in patients who have undergone PCI for bifurcation lesion is not associated with a reduced incidence of MACE in long-term follow-up. ClinicalTrials.gov identifier no. NCT03450577.

Association between statin therapy and long-term clinical outcomes in patients with stable coronary disease undergoing percutaneous coronary intervention

This longitudinal cohort study examined the long-term effect of statin therapy on clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). A total of 1760 patients with stable coronary artery disease (CAD) were divided by receipt of statin therapy or not after index PCI. Baseline clinical characteristics, risk factors, angiographic findings, and medications after interventional procedure were assessed to compare long-term clinical outcomes between groups. Predictors for all-cause death and major adverse cardiovascular events (MACE), including myocardial infarction (MI), cardiovascular death, and repeated PCI procedures, were also analyzed. The statin therapy group had higher average serum cholesterol and more elevated low-density lipoprotein cholesterol (LDL-C) than the non-statin therapy group (189.0 ± 47.9 vs 169.3 ± 37.00 mg/dl, 117.2 ± 42.6 vs 98.7 ± 31.8 mg/dl, respectively, both P < 0.001). The non-statin group had higher rates of all-cause death and cardiovascular death compared to statin group (both P < 0.001). After adjustment for age, diabetes, and chronic kidney disease, Cox proportion hazard analysis revealed statin use significantly reduced all-cause death and repeated PCI procedure (hazard ratio: 0.53 and 0.69, respectively). Statin use seemed not reduce the hazard of cardiovascular death or MI in patients with stable CAD after PCI; however, statin therapy still was associated with reduced rates of all-cause death and repeat PCI procedure.

Contemporary Predictors of Major Adverse Cardiovascular Events Following Percutaneous Coronary Intervention: A Nationally Representative US Sample.

Background: Patient outcomes after percutaneous coronary intervention (PCI) have improved over the last 30 years due to better techniques, therapies, and care processes. This study evaluated contemporary predictors of post-PCI major adverse cardiovascular events (MACE) and summarized risk in a parsimonious risk prediction model. Methods: The Cardiovascular Patient-Level Analytical Platform (CLiPPeR) is an observational dataset of baseline variables and longitudinal outcomes from the American College of Cardiology's CathPCI Registry® and national claims data. Cox regression was used to evaluate 2-6 years of patient follow-up (mean: 2.56 years), ending in December 2017, after index PCI between 2012 and 2015 (N = 1,450,787), to examine clinical and procedural predictors of MACE (first myocardial infarction, stroke, repeat PCI, coronary artery bypass grafting, and mortality). Cox analyses of post-PCI MACE were landmarked 28 days after index PCI. Results: Overall, 12.4% (n = 179,849) experienced MACE. All variables predicted MACE, with cardiogenic shock, cardiac arrest, four diseased coronary vessels, and chronic kidney disease having hazard ratios (HRs) ≥ 1.50. Other major predictors of MACE were in-hospital stroke, three-vessel disease, anemia, heart failure, and STEMI presentation. The index revascularization and discharge prescription of aspirin, P2Y12 inhibitor, and lipid-lowering medication had HR ≤ 0.67. The primary Cox model had c-statistic c = 0.761 for MACE versus c = 0.701 for the parsimonious model and c = 0.752 for the parsimonious model plus treatment variables. Conclusions: In a nationally representative US sample of post-PCI patients, predictors of longitudinal MACE risk were identified, and a parsimonious model efficiently encapsulated them. These findings may aid in assessing care processes to further improve care post-PCI outcomes.

Percutaneous coronary intervention before transcatheter aortic valve implantation: A propensity score matched analysis

BackgroundThe role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) who subsequently undergo transcatheter aortic valve replacement (TAVR) remains uncertain. Therefore, we conducted this study to assess the association of PCI before TAVR with mortality and cardiovascular outcomes. MethodsWe used the TriNetX database (Jan 2012 - Aug 2022) and grouped patients into PCI (3 months or less) before TAVR and no PCI. We performed propensity score matched (PSM) analyses for outcomes at 30 days and 1 year. ResultsOf 17,120 patients undergoing TAVR, 2322 (14 %) had PCI, and 14,798 (86 %) did not have PCI before TAVR. In the PSM cohort (2026 patients in each group), PCI was not associated with lower all-cause mortality at 30 days (HR: 1.25, 95 % CI: 0.82–1.90) or 1 year (HR: 1.02, 95 % CI: 0.83–1.24). Frequency of repeat PCI after TAVR was low in both no PCI vs. PCI (2.4 % vs. 1.2 %) at 1 year; PCI was associated with a lower rate of repeat PCI (HR: 0.49, 95 % CI: 0.30–0.80). Sensitivity analysis revealed an E-value of 3.5 for repeat PCI (E-value for lower CI for HR: 1.81). PCI was not linked to reductions in MI, heart failure exacerbation, all-cause hospitalization, major bleeding, or permanent pacemaker/implantable cardioverter defibrillator. ConclusionThis analysis showed that PCI prior to TAVR was not associated with improvement in all-cause mortality. However, PCI was associated with a reduced rate of repeat PCI at 1 year.

The Influence of Coronavirus Infection on the Results of Percutaneous Coronary Intervention in Patients with Coronary Artery Disease

Objective — to determine the impact of coronavirus infection incidence on the post-procedural condition of patients after percutaneous coronary intervention (PCI). Materials and methods. This single-centre study was conducted at the «Ukrainian Children’s Cardiac Center, Clinic for Adults» from June 1, 2020, to December 31, 2021. A total of 158 patients participated, of whom 78 had a history of COVID-19 infection and 80 did not, all with stable obstructive coronary artery disease (CAD). All patients underwent PCI, and their long-term outcomes were evaluated within a 6-month period. The study endpoints included repeated myocardial revascularization (defined as narrowing of the stented lumen by more than 70 % in diameter or acute stent thrombosis) and an assessment of CAD progres­sion (formation or progression of atherosclerotic plaques compared to baseline coronary angio­graphy). Results and discussion. The frequency of repeated coronary angio in the first 6 months after PCI due to tension angina or acute coronary syndrome was equal to 10 (12.8 %) patients in the COVID-19 +-group and 3 (3.8 %) cases in the COVID-19 — –group (p &lt; 0.05). According to the study data, patients with coronavirus infection tended to reach endpoints more quickly during the 6-month follow-up, in contrast to patients who did not have the incidence of COVID-19 during the same period. The frequency of repeated PCI within 6 months after the primary PCI in the group of patients with previous PCI was higher — 8 cases out of 78 patients compared to patients in the second group who did not suffer from COVID-19 in the first 6 months after the initial PCI (2 cases out of 80, c2 = 4 .0, p = 0.045). Conclusions. Patients with a mild and moderate course of coronavirus infection and existing stable coronary heart disease with atherosclerotic lesions of the coronary arteries were more likely to undergo repeat PCI within 6 months of the initial PCI. The most common causes of repeat PCI in patients with previous COVID-19 were thrombosis and restenosis of the stent, as well as progression of stenosis at a site other than the location of the previous PCI.

Influence of Previous Coronary Artery Bypass Grafting on Clinical Outcomes After Percutaneous Coronary Intervention: A Meta-Analysis of 250 684 Patients.

Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is the preferred strategy for treating obstructive coronary artery disease. Existing literature suggests the worsening of clinical outcomes in patients with previous coronary artery bypass grafting (CABG) history. In light of this, a comprehensive systematic review and meta-analysis was performed. Databases including PubMed, Cochrane Library, and ScienceDirect were utilized for the inclusive systematic search dating from inception to September 01, 2023. The risk of bias assessment was performed using the Newcastle-Ottawa scale for cohort studies, and the Cochrane Risk of Bias Tool for randomized controlled trials. Ultimately, there were 16 eligible studies pooled together, involving a total of 250 684 patients, including 231 552 CABG-naïve patients, and 19 132 patients with a prior history of CABG. Overall, patients with CABG history were associated with significantly greater short-term mortality (P = .004), long-term mortality (P = .005), myocardial infarction (P < .00001), major adverse cardiovascular events (P = .0001), and procedural perforation (P < .00001). Contrastingly, CABG-naïve patients were associated with significantly greater risk of cardiac tamponade (P = .02) and repeat CABG (P = .03). No significant differences in stroke, bleeding, revascularization, or repeat PCI were observed. Comparatively worsened clinical outcomes were observed, as patients with prior CABG history typically exhibit complex coronary anatomy, and have higher rates of comorbidities in comparison to their CABG-naïve counterparts. The refinement of current procedural and surgical techniques, in conjunction with continued research endeavors, are needed in order to effectively address this trend.

Impact of Target Lesion Revascularization on Long-Term Mortality After Percutaneous Coronary Intervention for Left Main Disease

BackgroundAlthough target lesion revascularization (TLR) after percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) disease is not rare, its timing of occurrence and prognostic impact on long-term mortality is uncertain. ObjectivesThis study sought to investigate TLR incidence over time and its impact on mortality after PCI with drug-eluting stents (DES) for LMCA disease. MethodsUsing a pooled data from 4 multicenter observational registries (IRIS-DES [Interventional Cardiology Research Incorporation Society-Drug-Eluting Stents], IRIS-MAIN [Interventional Cardiology Research Incorporation Society-Left MAIN Revascularization], MAIN-COMPARE [Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization], and PRECOMBAT [PREmier of Randomized COMparison of Bypass Surgery versus AngioplasTy Using Drug-Eluting Stent in Patients with Left Main Coronary Artery Disease]), we evaluated 1,397 patients with LMCA disease treated with DES and available long-term mortality data. The association between TLR and the 10-year risk of mortality was examined by multivariable Cox proportional hazards regression, with TLR as a time-varying covariate. ResultsDuring maximum follow-up of 10 years (median 6.8 years), TLR occurred in 118 patients and its 10-year cumulative incidence was 10.8%. TLR mostly occurred within 2 years after initial PCI and decreased over time: early-stage TLR (within 2 years) in 73 (61.9%) patients and late-stage TLR (beyond 2 years) in 45 (38.1%) patients. Among all TLR patients, 23 patients underwent coronary artery bypass grafting and 95 underwent repeat PCI. In the time-varying multivariable Cox model, the presence of TLR was not significantly associated with an increased risk of mortality (adjusted HR: 0.90; 95% CI: 0.50-1.63; P = 0.73). ConclusionsAlthough the incidence of ischemia-driven TLR was mostly common within 2 years after left main PCI, TLR occurred steadily during the 10-year follow-up period. However, given that such patients were optimally revascularized, the prognostic impact of TLR on mortality was not substantial. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133; Observational Study for Left Main Disease Treatment [IRIS-MAIN]; NCT01341327; Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease [MAIN COMPARE]; NCT02791412; Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968)

Beyond β-Blockade: ACE Inhibitors Reduce Non-Cardiac Mortality in High Killip Grade AMI Patients.

This study evaluates the 3-year clinical outcomes of high Killip grade (III/IV) acute myocardial infarction (AMI) patients treated with either β-blockers (BB) and angiotensin-converting enzyme inhibitors (ACEI) or BB and angiotensin receptor blockers (ARB). A total of 13,105 patients were registered at the Korea Acute Myocardial Infarction Registry at the National Institute of Health (KAMIR-NIH). Among them, 871 patients with high Killip classification AMI were divided into the BB + ACEI group (n = 489) and the BB + ARB group (n = 381). Following propensity score matching, 343 patients were selected in each group. All patients completed a 3-year follow-up period. The results indicate no significant differences between the BB + ACEI group and BB + ARB group in terms of cardiac death, recurrent myocardial infarction, and the rate of repeat percutaneous coronary intervention. However, the BB + ACEI group exhibited significantly lower risks in major adverse cardiac events (HR = 0.574, 95% CI: 0.421-0.783, p < .001), all-cause mortality (HR = 0.561, 95% CI: 0.404-0.778, p = .001), and non-cardiac death (HR = 0.365, 95% CI: 0.208-0.639, p < .001) compared to the BB + ARB group. Our results suggest that BB + ACEI treatment is more beneficial than BB + ARB for high Killip grade AMI patients. Additionally, the BB + ACEI group has a superior preventative effect on mortality compared to the BB + ARB group.

Cost-effectiveness of intravascular ultrasound-guided percutaneous intervention in patients with acute coronary syndromes: A UK perspective.

Use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes over angiography alone. Despite this, the adoption of IVUS in clinical practice remains low. To examine the cost-effectiveness of IVUS-guided PCI compared to angiography alone in patients with acute coronary syndromes (ACS). A one-year decision tree and lifetime Markov model were constructed to compare the cost-effectiveness of IVUS-guided PCI to angiography alone for two hypothetical adult populations consisting of 1,000 individuals: ST-elevation myocardial infarction (STEMI) and unstable angina/ non-ST-elevation myocardial infarction (UA/NSTEMI) patients undergoing drug-eluting stent (DES) implantation. The UK healthcare system perspective was applied using 2019/20 costs. All-cause death, myocardial infarction (MI), repeat PCI, lifetime costs, life expectancy and quality-adjusted life-years (QALYs) were assessed. Over a lifetime horizon, IVUS-guided PCI was cost-effective compared to angiography alone in both populations, yielding an incremental cost-effectiveness ratio of £3,649 and £5,706 per-patient in STEMI and UA/NSTEMI patients, respectively. In the one-year time horizon, the model suggested that IVUS was associated with reductions in mortality, MI and repeat PCI by 51%, 33% and 52% in STEMI and by 50%, 29% and 57% in UA/NSTEMI patients, respectively. Sensitivity analyses demonstrated the robustness of the model with IVUS being 100% cost-effective at a willingness-to-pay (WTP) threshold of £20,000 per QALY-gained. From a UK healthcare perspective, an IVUS-guided PCI strategy was highly cost-effective over angiography alone amongst ACS patients undergoing DES implantation due to the medium- and long-term reduction in repeat PCI, death, and MI.

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.

Abstract 15646: Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Patients With Prior Coronary Artery Bypass Graft Surgery

Background: The long-term outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI) in patients with prior coronary artery bypass graft surgery (CABG) have received limited study. Methods: We examined the baseline characteristics and outcomes of CTO PCIs performed at 47 US and non-US centers between 2012 and 2023. Results: Of the 12,164 patients who underwent CTO PCI during the study period, 3,475 (29%) had prior CABG. Prior CABG patients were older, more likely to be men, with higher incidence of comorbidities and lower left ventricular ejection fraction and eGFR. Their CTOs were more likely to have moderate/severe calcification and proximal tortuosity, proximal cap ambiguity, longer lesion length and higher J-CTO scores. The first and final successful crossing strategy was more likely to be the retrograde approach. They had lower technical (82.1% vs 88.2%, p&lt;0.001) and procedural (80.8% vs 86.8%, p&lt;0.001) success, but similar incidence of in-hospital major complications. The incidence of in-hospital death (0.8% vs 0.3%, p&lt;0.001), acute myocardial infarction (0.9% vs 0.5%, p=0.007) and perforation (7.0% vs 4.2%, p&lt;0.001) was higher in prior CABG patients, while pericardial tamponade was less common (0.1% vs 1.3%, p&lt;0.001). At 2-year follow-up, the incidence of major adverse cardiac events, repeat PCI and acute coronary syndromes was significantly higher in prior CABG patients, while all-cause mortality was similar. Conclusions: Prior CABG patients undergoing CTO PCI have more complex clinical and angiographic characteristics and lower success rate, but similar incidence of in-hospital major complications, and had higher incidence of MACE but similar all-cause mortality during long-term follow-up. Abbreviations: eGFR= estimated glomerular filtration rate

Recurrent Revascularization at 10 Years After Percutaneous Treatment of Drug-Eluting Stent Restenosis

BackgroundTreatment of patients with recurrence of in-stent restenosis (ISR) remains particularly challenging, with data and guideline recommendations for repeat percutaneous coronary intervention being scant. ObjectivesThe aim of this study was to investigate the long-term incidence of recurrent revascularization events after percutaneous treatment of drug-eluting stent (DES) ISR. MethodsIn this post hoc analysis, 402 patients (500 lesions) assigned to plain balloon (PB), drug-coated balloon (DCB), or DES treatment in the randomized ISAR-DESIRE 3 (Efficacy Study of Paclitaxel-Eluting Balloon, -Stent vs. Plain Angioplasty for Drug-Eluting Stent Restenosis) trial were followed up over a median of 10.3 years. The primary endpoint was total repeat target lesion revascularization (R-TLR) including all, first and recurrent, events. ResultsAt the end of follow-up, first R-TLR was required in 204 lesions, 82 in the PB group, 70 in the DCB group, and 52 in the DES group. The total number of R-TLRs was 373: 162 in the PB group, 124 in the DCB group, and 87 in the DES group. During the first year of follow-up, the risk for total R-TLR was reduced by DCB (HR: 0.36; 95% CI: 0.24-0.54) and DES (HR: 0.23; 95% CI: 0.14-0.38) treatment compared with PB treatment. After 1 year, the risk for total R-TLR was nonsignificantly reduced by DCB treatment (HR: 0.77; 95% CI: 0.51-1.16) and significantly reduced by DES treatment (HR: 0.61; 95% CI: 0.39-0.95) compared with PB treatment. Risk in the DCB and DES groups was similar during (HR: 1.54; 95% CI: 0.89-2.69) and after (HR: 1.26; 95% CI: 0.82-1.92) 1 year. ConclusionsThe total number of R-TLRs over 10 years after treatment of patients with DES ISR was high. DCBs and particularly DES were able to reduce the need for both first and recurrent revascularization compared with PB treatment.

Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Patients With Previous Coronary Artery Bypass Graft Surgery

The outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) in patients with previous coronary artery bypass graft (CABG) surgery have received limited study. We examined the baseline characteristics and outcomes of CTO PCIs performed at 47 United States and non-United States centers between 2012 and 2023. Of the 12,164 patients who underwent CTO PCI during the study period, 3,475 (29%) had previous CABG. Previous CABG patients were older, more likely to be men, and had more comorbidities and lower left ventricular ejection fraction and estimated glomerular filtration rate. Their CTOs were more likely to have moderate/severe calcification and proximal tortuosity, proximal cap ambiguity, longer lesion length, and higher Japanese CTO scores. The first and final successful crossing strategy was more likely to be retrograde. Previous CABG patients had lower technical (82.1% vs 88.2%, p <0.001) and procedural (80.8% vs 86.8%, p <0.001) success, higher in-hospital mortality (0.8% vs 0.3%, p <0.001), acute myocardial infarction (0.9% vs 0.5%, p=0.007) and perforation (7.0% vs 4.2%, p <0.001) but lower incidence of pericardial tamponade and pericardiocentesis (0.1% vs 1.3%, p <0.001). At 2-year follow-up, the incidence of major adverse cardiac events, repeat PCI and acute coronary syndrome was significantly higher in previous CABG patients, whereas all-cause mortality was similar. In conclusion, patients with previous CABG who underwent CTO PCI had more complex clinical and angiographic characteristics and lower success rate, higher perioperative mortality, and myocardial infarction but lower tamponade, and higher incidence of major adverse cardiac events with similar all-cause mortality during follow-up.

Clinical outcomes after successful revascularization of long chronic total occlusions using amphilimus-eluting polymer-free stent: a single center experience.

Chronic total occlusions (CTOs) are complex lesions that usually require stenting of long segments, and, therefore more prone to restenosis and/or thrombosis. Polymer-free stents to avoid chronic inflammatory response in the vessel wall are a potential solution to reduce target lesion revascularization. We, therefore, investigated the clinical outcomes following successful amphilimus-eluting polymer-free stent implantation in long CTOs. A total of 77 consecutive patients who underwent successful revascularization for long CTOs (lesion length ≥30 mm) using Cre8 stents were included. Baseline demographics, periprocedural characteristics, in-hospital events, and post-discharge long-term cardiovascular events were retrospectively screened for all patients. The Japanese CTO score was 1.58 ± 0.96, and the lesion length was 54.0 ± 9.89 mm. All cases were technically successful (n = 77, 100%), while procedural success was obtained in 74 patients (96.1%). Periprocedural complications were contrast-induced nephropathy (n = 4, 5.2%), coronary perforation (n = 3, 3.8%), residual dissection (n = 1, 1.3%), and femoral artery pseudoaneurysm (n = 1, 1.3%). Three patients (3.9%) presented periprocedural myocardial infarction requiring repeat percutaneous coronary intervention. At 25.0 ± 15.8 months follow-up, major adverse cardiac and cerebrovascular events were observed in 14 patients (18.1%). The Cre8 polymer-free drug- eluting stents seems safe and effective for percutaneous revascularization of long CTO lesions with a high success and low adverse event rate.

Intravascular imaging during percutaneous coronary intervention: temporal trends and clinical outcomes in the USA.

Prior trials have demonstrated that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) results in less frequent target lesion revascularization and major adverse cardiovascular events (MACEs) compared with standard angiographic guidance. The uptake and associated outcomes of IVI-guided PCI in contemporary clinical practice in the USA remain unclear. Accordingly, temporal trends and comparative outcomes of IVI-guided PCI relative to PCI with angiographic guidance alone were examined in a broad, unselected population of Medicare beneficiaries. Retrospective cohort study of Medicare beneficiary data from 1 January 2013, through 31 December 2019 to evaluate temporal trends and comparative outcomes of IVI-guided PCI as compared with PCI with angiography guidance alone in both the inpatient and outpatient settings. The primary outcomes were 1 year mortality and MACE, defined as the composite of death, myocardial infarction (MI), repeat PCI, or coronary artery bypass graft surgery. Secondary outcomes were MI or repeat PCI at 1 year. Multivariable Cox regression was used to estimate the adjusted association between IVI guidance and outcomes. Falsification endpoints (hospitalized pneumonia and hip fracture) were used to assess for potential unmeasured confounding. The study population included 1 189 470 patients undergoing PCI (38.0% female, 89.8% White, 65.1% with MI). Overall, IVI was used in 10.5% of the PCIs, increasing from 9.5% in 2013% to 15.4% in 2019. Operator IVI use was variable, with the median operator use of IVI 3.92% (interquartile range 0.36%-12.82%). IVI use during PCI was associated with lower adjusted rates of 1 year mortality [adjusted hazard ratio (aHR) 0.96, 95% confidence interval (CI) 0.94-0.98], MI (aHR 0.97, 95% CI 0.95-0.99), repeat PCI (aHR 0.74, 95% CI 0.73-0.75), and MACE (aHR 0.85, 95% CI 0.84-0.86). There was no association with the falsification endpoint of hospitalized pneumonia (aHR 1.02, 95% CI 0.99-1.04) or hip fracture (aHR 1.02, 95% CI 0.94-1.10). Among Medicare beneficiaries undergoing PCI, use of IVI has increased over the previous decade but remains relatively infrequent. IVI-guided PCI was associated with lower risk-adjusted mortality, acute MI, repeat PCI, and MACE.

The influence of hypothyroidism on the course of coronary artery disease in patients with reduced left ventricular ejection fraction

Background. Thyroid hormones play a fundamental role in the homeostasis of the cardiovascular system. Cardiovascular diseases are among the most common diseases worldwide, causing a significant percentage of mortality, hospitalizations, and disability. The purpose of the study is to evaluate the impact of hypothyroidism on the course of atherosclerotic lesions of coronary arteries and major cardiovascular events in patients with heart failure with reduced left ventricular ejection fraction after myocardial revascularization using percutaneous coronary intervention (PCI). Materials and methods. This prospective observational one-center study included 103 patients with ischemic cardiomyopathy, heart failure with reduced left ventricular ejection fraction, with and without hypothyroidism who underwent PCI. The result of revascularization was evaluated within 2 years. Inclusion criteria: age over 18 years, coronary artery disease, left ventricular ejection fraction less than 40%. Results. Patients with hypothyroidism had a worse lipid profile and, as expected, a higher baseline thyroid-stimulating hormone (TSH). According to echocardiography, patients with hypothyroidism had thickening of the left ventricular myocardium walls, which is indicated by a probable increase in the dimensions of the left ventricular posterior wall (11.40±0.98 mm; p&lt;0.001). In the first group, patients had higher myocardial mass indicators as one of the criteria for left ventricular hypertrophy (172.73±12.72g/m2; p&lt;0.001). After multivariate analysis using Cox proportional hazards regression, an elevated TSH level was still associated with significantly higher rates of cardiovascular mortality (risk ratio (RR) 0.85; 95% confidence interval (CI) 0.75–0.95; p&lt;0.001), repeat PCI (RR 0.75; 95% CI 0.65–0.85; p&lt;0.05) and decompensation due to heart failure (RR 0.88; 95% CI 0.78–0.96; p&lt;0.05). Conclusions. Hypothyroidism is associated with a higher incidence of the primary composite endpoint of repeat PCI, hospitalizations for decompensated heart failure, and the secondary endpoint of cardiovascular mortality compared to euthyroid patients over two years of follow-up. Maintaining adequate control of TSH in patients with coronary artery disease and heart failure with reduced ejection fraction is prognostically important for preventing cardiovascular events.

Design and Rationale of the National Tunisian Registry of Percutaneous Coronary Intervention: Protocol for a Prospective Multicenter Observational Study.

BackgroundCoronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries.ObjectiveThe aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia.MethodsWe will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis.ResultsIn this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022.ConclusionsThis study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region.Trial RegistrationClinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761International Registered Report Identifier (IRRID)RR1-10.2196/24595