Revascularization Treatment Research Articles

Retrospective analysis of a tertiary care centre of sex differences in risk factors, aetiology and short-term clinical outcome after revascularization treatment in young adults’ ischemic stroke

Retrospective analysis of a tertiary care centre of sex differences in risk factors, aetiology and short-term clinical outcome after revascularization treatment in young adults’ ischemic stroke

LDHA exacerbates myocardial ischemia-reperfusion injury through inducing NLRP3 lactylation.

Myocardial ischemia-reperfusion (I/R) injury caused by revascularization treatment is the leading cause of cardiac damage aggravation in ischemic heart disease. Increasing evidence has unraveled the crucial role of pyroptosis in myocardial I/R injury. Of note, lactylation has been validated to be participated in modulating pyroptosis. Hence, this study was aimed to elaborate the potential and mechanism of lactylation in myocardial I/R damage. We established the cell model of I/R through inducing hypoxia/reoxygenation (H/R) of H9c2 cells. It was uncovered that H/R stimulation drove cardiomyocyte pyroptosis and upregulated total lactylation level. Further, we demonstrated that promoting lactylation contributed to H/R-evoked pyroptosis, whereas silencing LDHA led to the opposite results. More than that, LDHA was confirmed to facilitate lactylation of NLRP3 at K245 site and increase its protein stability. Our findings indicated that activation of NLRP3 abolished the function of LDHA deficiency in H/R-treated H9c2 cells. In concert with the aforementioned outcomes, knockout of LDHA attenuated the infarct size and myocardial damage in I/R mice and upregulation of NLRP3 counteracted the effects of LDHA knockout on I/R-evoked injury in vivo. To summarize, the current research provided persuasive evidence that LDHA promoted myocardial I/R damage via enhancing NLRP3 lactylation to induce cardiomyocyte pyroptosis.

Prognostic significance of serum inflammatory markers in patients with acute ischemic stroke undergoing revascularization therapy.

This study aimed to evaluate the prognostic significance of serum inflammatory factor levels in patients with acute ischemic stroke undergoing revascularization therapy. The study included 94 patients with acute ischemic stroke who underwent revascularization therapy at our hospital. The primary outcome was the modified Rankin scale (mRS) score assessed three months post-treatment. Patients were categorized into two groups: those with a poor prognosis (mRS score > 2) and those with a good prognosis (mRS score≤2). The patients were divided into two groups based on the type of revascularization treatment received: thrombus extraction or intravenous thrombolysis. Logistic regression analysis was used to identify independent risk factors associated with the prognosis of patients treated with recanalization for acute ischemic stroke. Among the 94 patients, 59 had a good prognosis, and 35 had a poor prognosis. At admission, the patients in the good prognosis group exhibited lower NIHSS scores, shorter hospital stays, fewer previous cardiac events, lower LDL levels, fasting glucose, IL-6, and TNF-a compared to those in the poor prognosis group (all P < 0.05). Logistic regression analysis identified TNF-a (odd ratio (OD), 1.623; 95% confidence interval (CI), 1.282-1.933; P = 0.035) and IL-6 (OD, 1.055; 95% CI, 1.024-1.088, P = 0.023) as independent risk factors for poor prognosis in patients after revascularization. Additionally, pre-hospital NIHSS scores, IL-6, and TNF-a levels were significantly lower in the good prognosis group compared to the poor prognosis group, with these differences being statistically significant. IL-6 and TNF-α may serve as prognostic markers for outcomes following revascularization therapy in patients with acute ischemic stroke, including those receiving intravenous thrombolysis.

Abstract 4132742: Fractional flow reserve guided complete revascularization versus Culprit-only percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. A meta-analysis of randomized controlled trials

Background: Data comparing the efficacy and safety of fractional flow reserve (FFR)-guided complete revascularization (CR) to culprit-only percutaneous coronary artery intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease are limited. Method: Pubmed, Embase and Cochrane were searched for randomized controlled trails (RCTs) comparing FFR-guided CR to Culprit-only PCI in patients with STEMI and multivessel CAD. A meta-analysis was performed on primary outcomes of major adverse cardiac events (MACE) and all-cause mortality. Heterogeneity was examined with I 2 statistics. A random-effects model was used for outcomes with high heterogeneity. Results: We included 4 RCTs with 3173 patients comparing FFR-guided CR with culprit-only PCI in patients with STEMI and multivessel coronary artery diseases. The pooled results of the 4 RCTs showed that MACE (RR=0.66; 95% CI [0.45, 0.99]; p=0.01; 16.8% vs 24.1%), PCI revascularization (RR=0.50; 95% CI [0.37, 0.67]; p&lt;0.00001; 13.1% vs 24.9%) and unplanned revascularization (RR=0.66; 95% CI [0.44, 0.99]; p=0.04; 8.7% vs 12.9%) were significantly reduced in the FFR-guided complete revascularization group compared to culprit-only PCI group. However, all-cause mortality (RR=1.09; 95% CI [0.84, 1.42]; p=0.53; 7.2% vs 6.0%), stroke (RR=1.02; 95% CI [0.38, 2.75]; p =0.97; 2.0% vs 1.8%), major bleeding (RR=0.95; 95% CI [0.54, 1.67]; p=0.87; 1.7% vs 1.7%), death from cardiovascular causes (RR=0.82; 95% CI [0.55, 1.21]; p=0.31; 3.1% vs 3.4%), MI (RR=1.09; 95% CI [0.60, 1.95]; p=0.78; 6.7% vs 6.4%), rehospitalization for HF (RR=0.72; 95% CI [0.44, 1.15]; p=0.17; 3.4% vs 5.3%), death from any cause or MI (RR=1.02; 95% CI [0.61, 1.71]; p=0.95; 14.9% vs 13.6%), any stent thrombosis (RR=1.42; 95% CI [0.35, 5.72]; p=0.62; 2.2% vs 1.4%), contrast induced nephropathy (RR=0.25; 95% CI [0.02, 2.79]; p=0.26), and CABG revascularization (RR=1.25; 95% CI [0.30, 5.15]; p=0.76) were not statistically different between groups. Conclusion: Our meta-analysis suggests that FFR-guided CR is safe and has superior efficacy to Culprit-only PCI in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease with significantly lowered incidence of MACE, PCI revascularization as well as unplanned or urgent revascularization. However, FFR-guided CR showed no beneficial effect on all-cause mortality, stroke, major bleeding and myocardial infarction.

Cortistatin exerts an immunomodulatory and neuroprotective role in a preclinical model of ischemic stroke

Ischemic stroke is the result of a permanent or transient occlusion of a brain artery, leading to irreversible tissue injury and long-term sequelae. Despite ongoing advancements in revascularization techniques, stroke remains the second leading cause of death worldwide. A comprehensive understanding of the complex and interconnected mechanisms, along with the endogenous mediators that modulate stroke responses is essential for the development of effective interventions. Our study investigates cortistatin, a neuropeptide extensively distributed in the immune and central nervous systems, known for its immunomodulatory properties. With neuroinflammation and peripheral immune deregulation as key pathological features of brain ischemia, cortistatin emerges as a promising therapeutic candidate. To this aim, we evaluated its potential effect in a well-established middle cerebral artery occlusion (MCAO) preclinical stroke model. Our findings indicate that the peripheral administration of cortistatin at 24h post-stroke significantly reduces neurological damage and enhances recovery. Importantly, cortistatin-induced neuroprotection was multitargeted, as it modulated the glial reactivity and astrocytic scar formation, facilitated blood-brain barrier recovery, and regulated local and systemic immune dysfunction. Surprisingly, administration of cortistatin at immediate and early post-stroke time points proved to be not beneficial and even detrimental. These results emphasize the importance of understanding the spatio-temporal dynamics of stroke pathology to develop innovative therapeutic strategies with appropriate time windows. Premature interruption of certain neuroinflammatory processes might inadvertently compromise neuroprotective mechanisms. In summary, our study highlights cortistatin as a novel pleiotropic therapeutic approach against ischemic stroke, offering new treatment options for patients for whom early revascularization intervention is unsuccessful.

Percutaneous coronary intervention versus coronary arterial bypass grafting in patients with left main coronary artery disease and chronic kidney disease: a systematic review and meta-analysis

Abstract Background Left main coronary artery disease (LMCAD), defined as a stenosis of &amp;gt;50%, is a potentially lethal condition that should be treated intensively by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) depending on the anatomy. The presence of chronic kidney disease (CKD) complicates LMCAD, acting as a potential worsening factor for this group of patients, as well as impairing the effectiveness and outcomes of both revascularization treatments. Purpose This systematic review and meta-analysis aims to comprehensively compare the outcomes of PCI and CABG in patients with LMCAD and CKD. Methods A systematic search of the available literature was conducted in PubMed, Embase, and CENTRAL. Studies that compared PCI versus CABG in patients with LMCAD and CKD were included. The primary endpoints comprised major adverse cardiac and cerebrovascular events (MACCE) and all-cause death, while secondary endpoints included components of MACCE, such as myocardial infarction (MI), stroke and new revascularization events. The results were qualitatively and quantitatively synthesized and pooled hazard ratios (HR) were calculated. The statistical analysis was conducted in R. Results A total of 767 titles were initially retrieved, with five studies finally included in the analysis (n = 2,337 patients). The pooled analysis revealed that patients treated with PCI experienced more MACCE (HR: 1.50, 95% CI: 1.26-1.78, p &amp;lt; 0.001), an outcome primarily driven by MI (HR: 1.75, 95% CI: 1.17-2.62, p = 0.01) and revascularization rates (Hazard Ratio: 3.66, 95% CI: 1.84-7.30, p &amp;lt; 0.001), while no significant difference was shown in stroke rates (HR: 0.70, 95% CI: 0.40-1.22, p = 0.21). A trend towards increased all-cause death was observed for the PCI group, although this outcome slightly failed to reach statistical significance (HR: 1.30, 95% CI: 1.00-1.68, p = 0.05). Conclusion The present systematic review and meta-analysis indicated that PCI appears inferior to CABG in patients with LMCAD and CKD, with respect to most long-term outcomes. This includes higher rates of MACCE, and particularly MI and new events of revascularization for patients undergoing PCI, while all-cause death was marginally higher for this group. Further randomized controlled trials are needed to provide more robust evidence for guiding revascularization strategies in this high-risk population.

Impact of coronary revascularization on clinical outcomes of post-acute myocardial infarction patients with left ventricular thrombus

Abstract Background Left ventricular thrombus (LVT) is an uncommon, but dangerous complication seen in post-acute myocardial infarction (AMI). With advances in percutaneous coronary intervention (PCI) techniques, the incidence of post-AMI LVT has declined in the contemporary era. However, a minority of patients do not undergo coronary revascularisation due to medical contraindications or patient preference. This study aimed to evaluate the clinical characteristics and outcomes of post-AMI LVT patients treated with and without coronary revascularisation. Methods This was a retrospective study of 263 consecutive post-AMI patients diagnosed with LVT from November 2012 to January 2021, retrieved from a echocardiography database. Patients were stratified by the presence or absence of revascularisation treatment. Baseline clinical characteristics, treatment and outcomes data were collected and analysed. Results The median follow-up duration was 2.9 years (IQR: 0.9 – 4.7). A majority of post-AMI LVT patients underwent revascularisation via PCI (71.5%, n = 188), CABG (4.2%, n = 11) or thrombolysis (0.4%, n = 1). Unrevascularised patients (24.0%, n = 63) were older (p &amp;lt;0.001), more likely to be female (p &amp;lt;0.001), and had more co-morbidities such as previous stroke (p &amp;lt;0.001), heart failure (p = 0.001), chronic kidney disease (p = 0.020), and malignancy (p = 0.021). More unrevascularised patient had NSTEMI (p &amp;lt; 0.001), and significantly fewer were treated with triple therapy (p &amp;lt; 0.001). Incidence of LVT resolution was lower (p &amp;lt; 0.001) while all-cause mortality was higher (p &amp;lt; 0.001) for unrevascularised patients on univariate survival analyses. On multivariable Cox regression, revascularisation status was not an independent predictor of LVT resolution, bleeding, stroke, or all-cause mortality outcomes. Conclusion While unrevascularised post-AMI LVT patients had poorer outcomes compared to revascularised patients overall, revascularisation status itself was not independently associated with poorer clinical outcomes. Optimising medical therapy such as triple therapy remains a key treatment goal for post-AMI LVT patients.

Impact of CT attenuation correction on viable myocardium detection in combined SPECT and PET/CT: A retrospective cohort study.

The influence of computed tomography attenuation correction (CTAC) on the accuracy of diagnosing viable myocardium using Tc-99m-MIBI dedicated cardiac cadmium-zinc-telluride (CZT) single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) combined with F-18-FDG Positron Emission Tomography/Computed Tomography (PET/CT) metabolic imaging, compared with conventional SPECT MPI, remains to be fully elucidated. To evaluate the impact of CTAC on the accuracy of diagnosing viable myocardium using Tc-99m-MIBI dedicated cardiac CZT SPECT MPI combined with F-18-FDG PET/CT, compared to conventional SPECT MPI. 193 patients underwent CZT SPECT and F-18-FDG PET/CT imaging, while 39 patients underwent conventional SPECT and F-18-FDG PET/CT imaging, with both groups utilizing CT for attenuation correction. The injured myocardium (hibernating and scarring) was quantified using the Q.PET software. After CTAC, both groups showed significant improvements in perfusion of the injured myocardial areas, particularly in the inferior wall (INF). The reduction in perfusion was more notable in the CZT SPECT group than that in the conventional group, particularly in the inferior and lateral walls. Among patients with large cardiac chambers, those undergoing MPI with CZT, with normal weights, or males, hibernating myocardium (HM) and scar post-CTAC reductions were particularly significant in the INF. If HM ≥ 10% is considered an indicator for recommended revascularization, among the 87 patients without prior cardiac bypass, 25 (28.7%) might not require revascularization treatment. Dedicated cardiac CZT SPECT and conventional SPECT MPI combined with F-18-FDG PET/CT significantly influenced the assessment of viable myocardium. The impact of CTAC was more profound in dedicated cardiac CZT SPECT, particularly in the INF region. CTAC significantly enhances the accuracy of viable myocardial assessment and may influence clinical decisions regarding revascularization therapy. Therefore, CTAC should be routinely used in dedicated cardiac CZT SPECT MPI combined with F-18-FDG PET/CT for myocardial viability diagnosis.

Mesenchymal stromal cell therapy (REGENACIP®), a promising treatment option in chronic limb threatening ischemia - a narrative review.

Chronic Limb Threatening Ischemia (CLTI) is a challenging clinical problem associated with high morbidity and mortality. Endovascular interventions have been the cornerstone of treatment whenever possible. It is estimated that CLTI represents < 10% of all Peripheral Artery Disease patients, yet 50% of the patients end up either with a major amputation of the lower limbs or die of cardiovascular causes within one year period, especially in those with unsuccessful revascularization or "no-option" CLTI. Cell-based therapeutics, especially bone marrow-derived mesenchymal stromal cells have emerged as a potential, promising, and novel alternate therapeutic modality in the management of CLTI, bolstered with positive results in numerous research, including randomized and nonrandomized trials. REGENACIP® is one such BM-MSC therapy approved by Central Drugs Standard Control Organization in India for the management of "no-option" Atherosclerotic Peripheral Arterial disease / Buerger's disease patients with established critical limb ischemia in Rutherford Grade III-5 or III-6, not eligible for or have failed traditional revascularization treatment, with rest pain and / or ulcers in the affected limb. The current review aims to deliberate upon the various aspects of CLTI and clinical benefits of REGENACIP® therein.

Vein bypass first vs. best endovascular treatment first revascularisation strategy for chronic limb-threatening ischaemia due to infra-popliteal disease: the BASIL-2 RCT.

Chronic limb-threatening ischaemia with ischaemic pain and/or tissue loss. To examine the clinical and cost-effectiveness of a vein bypass-first compared to a best endovascular treatment-first revascularisation strategy in preventing major amputation or death. Superiority, open, pragmatic, multicentre, phase III randomised trial. Thirty-nine vascular surgery units in the United Kingdom, and one each in Sweden and Denmark. Patients with chronic limb-threatening ischaemia due to atherosclerotic peripheral arterial disease who required an infra-popliteal revascularisation, with or without an additional more proximal infra-inguinal revascularisation procedure, to restore limb perfusion. A vein bypass-first or a best endovascular treatment-first infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation strategy. The primary outcome was amputation-free survival. Secondary outcomes included overall survival, major amputation, further revascularisation interventions, major adverse limb event, health-related quality of life and serious adverse events. Participants were randomised to a vein bypass-first or a best endovascular treatment-first revascularisation strategy. The original sample size of 600 participants (247 events) was based on a hazard ratio of 0.66 with amputation-free survival rates of 0.72, 0.62, 0.53, 0.47 and 0.35 in years 1-5 in the best endovascular treatment-first group with 90% power and alpha at p = 0.05. The sample size was revised to an event-based approach as a result of increased follow-up time due to slower than anticipated recruitment rates. Participants were followed up for a minimum of 2 years. A cost-effectiveness analysis was employed to estimate differences in total hospital costs and amputation-free survival between the groups. Additionally, a cost-utility analysis was carried out and the total cost and quality-adjusted life-years, 2 and 3 years after randomisation were used. Between 22 July 2014 and 30 November 2020, 345 participants were randomised, 172 to vein bypass-first and 173 to best endovascular treatment-first. Non-amputation-free survival occurred in 108 (63%) of 172 patients in the vein bypass-first group and 92 (53%) of 173 patients in the best endovascular treatment-first group [adjusted hazard ratio 1.35 (95% confidence interval 1.02 to 1.80); p = 0.037]. Ninety-one (53%) of 172 patients in the vein bypass-first group and 77 (45%) of 173 patients in the best endovascular treatment-first group died [adjusted hazard ratio 1.37 (95% confidence interval 1.00 to 1.87)]. Over follow-up, the economic evaluation discounted results showed that best endovascular treatment-first was associated with £1690 less hospital costs compared to vein bypass-first. The cost utility analysis showed that compared to vein bypass-first, best endovascular treatment-first was associated with £224 and £2233 less discounted hospital costs and 0.016 and 0.085 discounted quality-adjusted life-year gain after 2 and 3 years from randomisation. Recruiting patients to the Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 trial was difficult and the target number of events was not achieved. A best endovascular treatment-first revascularisation strategy was associated with better amputation-free survival, which was largely driven by fewer deaths. Overall, the economic evaluation results suggest that best endovascular treatment-first dominates vein bypass-first in the cost-effectiveness analysis and cost-utility analysis as it was less costly and more effective than a vein bypass-first strategy. The Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 investigators have a data sharing agreement with the BEst Surgical Therapy in patients with Chronic Limb threatening Ischaemia investigators. One output of this collaboration will be an individual patient data meta-analysis. Current Controlled Trials ISRCTN27728689. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/35/45) and is published in full in Health Technology Assessment; Vol. 28, No. 65. See the NIHR Funding and Awards website for further award information.

Racial Differences in Adoption and Outcomes of Transcarotid Artery Revascularization among High-Risk Adults with Carotid Artery Stenosis

Differential access to new technologies may contribute to racial disparities in surgical outcomes but has not been well-studied in the treatment of carotid artery stenosis. We examined race-based differences in adoption and outcomes of transcarotid artery revascularization (TCAR) among high-risk non-Hispanic (NH) NH Black and NH white adults undergoing carotid revascularization. We conducted a retrospective analysis of TCAR, transfemoral carotid artery stenting (TF-CAS), and carotid endarterectomy (CEA) procedures performed for carotid artery stenosis from 1/2015 to 7/2023 in the Vascular Quality Initiative. NH Black and NH white adults were included if they met Centers for Medicare & Medicaid Services high-risk criteria. Hospitals and physicians were categorized as TCAR-capable if they had previously performed at least one TCAR prior to the time of a given procedure. We fit logistic and linear regressions, adjusted a priori for common demographic, clinical, and disease characteristics, to estimate associations of race with receipt of TCAR (versus CEA or TF-CAS), and to explore associations between race, hospital and physician characteristics, and perioperative composite stroke/death/myocardial infarction. Of 159,471 high-risk patients undergoing revascularization for carotid artery stenosis (mean age 72 years, 38.5% female, 5.3% NH Black), 28,722 (18.0%) received TCAR, including 16.9% of NH Black adults and 18.1% of NH white adults (P<0.001). After controlling for patient and disease characteristics, NH Black patients were less likely than NH white patients to receive TCAR (aOR 0.92, 95% CI 0.87 to 0.99). The use of TCAR did not vary by race among patients treated at TCAR-capable hospitals (aOR 0.98, 95% CI 0.91 to 1.05) or by TCAR-capable physicians (aOR 1.01, 95% CI 0.93 to 1.10); however, NH Black race was associated with lower odds of receiving treatment in these settings (TCAR-capable hospital: aOR 0.93 [0.88 to 0.98]; TCAR-capable physician: aOR 0.92 [0.87 to 0.98]). NH Black race was associated with higher odds of stroke/death/MI in the full cohort (aOR 1.18, 95% CI 1.03 to 1.36), but not in the subgroup of patients who received TCAR (aOR 0.87, 95% CI 0.56 to 1.34). TCAR attenuated racial disparities in perioperative morbidity and mortality associated with carotid revascularization, but NH Black adults were less likely than NH white adults to receive TCAR. Relatively worse access for NH Black adults to technologically-advanced treatment settings may partially explain the broader persistence of race-based differences in carotid revascularization treatment patterns and outcomes.

Cost-effectiveness of MLC601 in post-stroke functional recovery compared with placebo - the CHIMES & CHIMES-E studies

BackgroundDespite progress in stroke therapy (e.g., revascularisation interventions by thrombolysis and/or thrombectomy, organised stroke care), many stroke survivors will have impairment of neurological function. We aimed to compare the cost-effectiveness of an oral natural formulation, MLC601, versus placebo in functional recovery among subjects receiving standard of care after an ischemic stroke of intermediate severity assessed with NIH Stroke Scale at baseline (b-NIHSS 8–14).MethodsA Markov cohort model with a 2-year time horizon was developed to simulate patients from a published randomised placebo-controlled clinical trial of MLC601 in their post-stroke functional recovery assessed by modified Rankin Score (mRS), from a health system perspective. Transition probabilities were derived from a multi-centre clinical trial in South East Asia. As cost and utility data were not collected in the trial, therefore we extracted them from the published literature. The main outcomes were incremental cost, incremental quality-adjusted life-year (QALY) gained, and incremental cost-effectiveness ratio (ICER). Besides base-case and sensitivity analyses, we performed subgroup analyses to explore the heterogeneity of patients with poor-prognosis factors (b-NIHSS 10–14, stroke onset to treatment time > 48 h, rehabilitation during first 3 month). All costs are expressed in 2022 Euro and USD, with an annual discount rate of 3% applied to costs and QALYs.ResultsBase-case analysis showed that MLC601 was cost-effective compared with placebo, with €5,080 saved and 0.45 QALY gained, resulting in an ICER of -€11,352.50 per QALY gained. Similarly, results from subgroup analyses indicated that the use of MLC601 was a dominant strategy in all subgroups with poor-prognosis factors. Sensitivity analyses revealed the results were robust.ConclusionCompared with placebo on top of standard stroke care, MLC601 was cost-effective in post-stroke functional recovery over two years. Due to the lack of cost and utility data from the study population, the results might not be generalizable to other settings. Further studies with country-specific data are needed to confirm the results of this study.Trial registrationURL http://www.clinicaltrials.gov. Unique identifier NCT00554723 November 7, 2007.

The use of perioperative Impella 5.5 support in high-risk cardiac surgery: a retrospective cohort study.

Although the Impella device has an established role in high-risk percutaneous intervention and cardiogenic shock, its role in open cardiac surgery remains unclear. We undertook this study to better understand the role of Impella support in cardiac surgical intervention. This is a retrospective cohort study of consecutive patients who underwent cardiac surgery with surgically placed Impella 5.5 device support from October 2020 through June 2023. Patient charts were identified and systematically reviewed for relevant information. The primary outcome for this study was patient survival to discharge. Secondary outcomes included intraoperative survival, 30-day survival and 1-year survival. From 2020-2023, ten patients underwent open cardiac surgery with Impella 5.5 support. Five patients were male and the median age was 56.5 years [interquartile range (IQR), 52-63.8 years]. Three patients (30%) presented for isolated revascularization, 3 patients (30%) presented for single valve surgical intervention, 3 patients (30%) presented for revascularization and valve intervention, and 1 patient (10%) presented for multivalve intervention. The median ejection fraction (EF) of patients was 25% (IQR, 21.25-32.5%), the median Society of Thoracic Surgeons risk score was 4.32% (IQR, 1.73-11.06%). Of the patients, 40% underwent axillary cannulation while 60% had central cannulation. Intraoperative survival was 100%, survival to discharge was 90% and 30-day survival was 80%. Our study suggests the use of surgical Impella in high-risk cardiac surgical patients is associated with acceptable survival regardless of site or timing of cannulation. However, Impella usage is associated with significant morbidity. Further investigation is warranted to better understand which patients benefit perioperative Impella support.

Temporalis muscle thickness as a predictor of functional outcome after reperfusion therapies for acute ischemic stroke: a retrospective, cohort study.

Sarcopenia, defined as the loss of skeletal muscle mass, has been associated with a worse functional outcome after stroke. Measurement of temporal muscle thickness (TMT) has been introduced as an easily obtainable surrogate marker to identify patients with sarcopenia. Our study aims to investigate the correlation between pre-stroke sarcopenia, measured by TMT assessment, and functional outcome in patients treated with revascularization procedures for acute ischemic stroke. We included consecutive adult patients who underwent thrombolysis, endovascular thrombectomy or both for acute ischemic stroke at our Centre from January 2020 to June 2022. Besides collecting baseline clinical and neuroradiological features, TMT was measured on brain computed tomography scans according to a standardized protocol. Modified Rankin Scale (mRS) scores at 3months represented the main endpoint of functional outcome. A total of 261 patients were available for the analysis. In univariate models, patients with excellent outcomes (mRS = 0-1) were younger, had higher TMT values and lower pre-event disability and stroke severity. In multivariate models higher TMT values resulted independently associated with reduced mortality (Odds Ratio 0.708, 95% Confidence Interval 0.538-0.930, p = 0.013). Age, diabetes, brain bleeding events and stroke severity were found to be predictors of mortality, too. Our retrospective analysis shows that in patients who underwent revascularization treatments for ischemic stroke TMT is as an independent predictor of survival easily obtainable from the baseline CT scan. Further investigation is required to confirm the role of sarcopenia assessment and TMT measurement in the prognostication toolkit of this disease.

Racial and ethnic differences in access to care and treatment in patients with suspected acute stroke: A retrospective, observational, cohort study

BackgroundData regarding unequal diagnostic and therapeutic access in patients with acute stroke based on ethnicity and race are inconclusive in Europeans. The objectives of our study were to evaluate the effect of race/ethnicity on access to acute stroke care and treatments and outcomes. MethodsIn this retrospective cohort study, we enrolled adult patients admitted to the emergency department of a comprehensive stroke center for suspected stroke. Based on race/ethnicity, patients were divided into two main groups: Western European Whites (WEW) and non-Western European Whites (nWEW). We also divided the nWEW group into four subgroups based on the Office of Management and Budget classification of human races and ethnicities (White-Others, Hispanic, Asian, Black). Univariate comparisons and logistic regression analyses were also performed. Results9167 patients were enrolled in the study: 582 in the nWEW and 8585 in the WEW group. Patients with ischemic stroke in the nWEW group were significantly younger than those in the other group (p < 0.001). Once adjusted for possible confounders, belonging to the nWEW group was found to be an independent predictor of a lower likelihood of receiving revascularization treatments (p = 0.006), regardless similar onset-to-door times. There were no differences in stroke outcomes and prevalence of stroke mimic diagnosis between the groups. ConclusionsRacial/ethnic disparities in healthcare represent a challenging issue, even in universal healthcare systems, that should be addressed promptly through education campaigns of healthcare personnel and implementation measures, such as integrating readily available interpreter staff for medical emergencies.

Integrated deep learning model for automatic detection and classification of stenosis in coronary angiography

Coronary artery disease poses a significant threat to human health. In clinical settings, coronary angiography remains the gold standard for diagnosing coronary heart disease. A crucial aspect of this diagnosis involves detecting arterial narrowings. Categorizing these narrowings can provide insight into whether patients should receive vascular revascularization treatment. The majority of current deep learning methods for analyzing coronary angiography are mostly confined to the theoretical research domain, with limited studies offering direct practical support to clinical practitioners. This paper proposes an integrated deep-learning model for the localization and classification of narrowings in coronary angiography images. The experimentation employed 1606 coronary angiography images obtained from 132 patients, resulting in an accuracy of 88.9 %, a recall rate of 85.4 %, an F1 score of 0.871, and a MAP value of 0.875 for vascular stenosis detection. Furthermore, we developed the "Hemadostenosis" web platform (http://bioinfor.imu.edu.cn/hemadostenosis) using Django, a highly mature HTTP framework. Users are able to submit coronary angiography image data for assessment via a visual interface. Subsequently, the system sends the images to a trained convolutional neural network model to localize and categorize the narrowings. Finally, the visualized outcomes are displayed to users and are downloadable. Our proposed approach pioneers the recognition and categorization of arterial narrowings in vascular angiography, offering practical support to clinical practitioners in their learning and diagnostic processes.

Omics Science and Social Aspects in Detecting Biomarkers for Diagnosis, Risk Prediction, and Outcomes of Carotid Stenosis.

Carotid stenosis is characterized by the progressive narrowing of the carotid arteries due to the formation of atherosclerotic plaque, which can lead to stroke and death as major complications. Numerous biomarkers allow for its study and characterization, particularly those related to "omics" sciences. Through the most common research databases, we report representative studies about carotid stenosis biomarkers based on genomics, transcriptomics, proteomics, and metabolomics in a narrative review. To establish a priority among studies based on their internal validity, we used a quality assessment tool, the Scale for the Assessment of Narrative Review Articles (SANRA). Genes, transcriptomes, proteins, and metabolites can diagnose the disease, define plaque connotations, predict consequences after revascularization interventions, and associate carotid stenosis with other patient comorbidities. It also emerged that many aspects determining the patient's psychological and social sphere are implicated in carotid disease. In conclusion, when taking the multidisciplinary approach that combines human sciences with biological sciences, it is possible to comprehensively define a patient's health and thus improve their clinical management through precision medicine.

Effect of dexmedetomidine on ncRNA and mRNA profiles of cerebral ischemia-reperfusion injury in transient middle cerebral artery occlusion rats model.

Ischemic stroke poses a significant global health burden, with rapid revascularization treatments being crucial but often insufficient to mitigate ischemia-reperfusion (I/R) injury. Dexmedetomidine (DEX) has shown promise in reducing cerebral I/R injury, but its potential molecular mechanism, particularly its interaction with non-coding RNAs (ncRNAs), remains unclear. This study investigates DEX's therapeutic effect and potential molecular mechanisms in reducing cerebral I/R injury. A transient middle cerebral artery obstruction (tMACO) model was established to simulate cerebral I/R injury in adult rats. DEX was administered pre-ischemia and post-reperfusion. RNA sequencing and bioinformatic analyses were performed on the ischemic cerebral cortex to identify differentially expressed non-coding RNAs (ncRNAs) and mRNAs. The sequencing results showed 6,494 differentially expressed (DE) mRNA and 2698 DE circRNA between the sham and tMCAO (I/R) groups. Additionally, 1809 DE lncRNA, 763 DE mRNA, and 2795 DE circRNA were identified between the I/R group and tMCAO + DEX (I/R + DEX) groups. Gene ontology (GO) analysis indicated significant enrichment in multicellular biogenesis, plasma membrane components, and protein binding. KEGG analysis further highlighted the potential mechanism of DEX action in reducing cerebral I/R injury, with hub genes involved in inflammatory pathways. This study demonstrates DEX's efficacy in reducing cerebral I/R injury and offers insights into its brain-protective effects, especially in ischemic stroke. Further research is warranted to fully understand DEX's neuroprotective mechanisms and its clinical applications.

Revascularization Therapies for Ischemic Stroke and Association With Risk of Epilepsy: A Danish Nationwide Register-Based Study.

The association between stroke revascularization therapies and poststroke epilepsy is only sparsely investigated, and results are conflicting. The aim of this study is to investigate whether stroke revascularization therapies are associated with different risks of poststroke epilepsy. We conducted a nationwide, register-based, propensity score-matched cohort study. We identified 40 816 patients admitted with a first ischemic stroke and no prior history of epilepsy in Denmark between January 1, 2011, and December 16, 2018. Of these, 6541 were treated with thrombolysis, 379 with thrombectomy, and 1005 with both thrombolysis and thrombectomy. The 3 treatment groups were each matched 1:1 to patients with stroke not treated with revascularization. Exact matching was done for sex, while propensity scores included information on stroke severity, cortical involvement, age, comorbidities, and socioeconomic parameters. Outcome was any diagnosis of epilepsy. We used Cox regressions to estimate adjusted hazard ratios (HRs) of epilepsy after ischemic stroke. Compared with matched patients with ischemic stroke not receiving revascularization treatment, patients who received thrombolysis alone had 32% lower risk of epilepsy (adjusted HR, 0.68 [95% CI, 0.57-0.81]) and patients who received thrombolysis and thrombectomy had 45% lower risk of epilepsy (adjusted HR, 0.55 [95% CI, 0.41-0.73]). Thrombectomy alone was not associated with significantly lower risk of epilepsy compared with matched patients with ischemic stroke not receiving revascularization therapy (adjusted HR, 0.78 [95% CI, 0.57-1.29]). Thrombolysis alone and in combination with thrombectomy in ischemic stroke was associated with lower risk of epilepsy, whereas thrombectomy alone was not associated with lower risk of epilepsy.

The Effect of Revascularization on Lower Limb Circulation Parameters in Symptomatic Peripheral Arterial Disease.

Background: The prevalence of peripheral arterial disease and the number of revascularization procedures performed in symptomatic patients are steadily increasing. However, uncertainties remain regarding hemodynamic monitoring after revascularization and the prediction of clinical outcomes. This study aimed to investigate hemodynamic parameters with a focus on the microvasculature. Methods: This prospective, single-center study included 29 patients (15 with intermittent claudication [IC] and 14 with chronic limb-threatening ischemia [CLTI]). Before and after the revascularization procedure, in addition to the ankle-brachial index (ABI), microperfusion parameters, including microvascular blood flow, capillary oxygen saturation (SO2), and relative hemoglobin content (rHb), were assessed with lightguide spectrophotometry combined with laser Doppler flowmetry using an oxygen-to-see (O2C) device in the horizontal and elevated leg positions. Results: At baseline, SO2 in the elevated leg position was significantly lower in patients with CLTI than in those with IC (p = 0.0189), whereas the other microcirculatory parameters and ABI values were not significantly different. Patients with diabetes mellitus had a higher flow rate than those without in the horizontal leg position (p = 0.0162) but not in the elevated leg position. After successful revascularization, the flow increased immediately and significantly in both positions, whereas SO2, rHb, and the ABI did not. Conclusions: Elevated leg SO2 was significantly lower in CLTI than in clinically compensated peripheral arterial disease, whereas microvascular flow was a suitable surrogate parameter indicating successful revascularization. In studies using surgical or interventional revascularization procedures, noninvasive hemodynamic monitoring of the microcirculation at the foot level might be beneficial.