Setting Of Percutaneous Coronary Intervention Research Articles

The Incidence of Contrast-Induced Nephropathy in Patients on Sodium-Glucose Cotransporter-2 Inhibitors Following Percutaneous Coronary Intervention: An Observational Analysis.

The purpose of this study is to compare the incidence of contrast-induced nephropathy (CIN) following percutaneous coronary intervention (PCI) in patients on sodium-glucose cotransporter-2 (SGLT-2) inhibitors prior to the procedure with a matched cohort of patients not receiving sodium-glucose cotransporter-2 inhibitor therapy. In this retrospective observational study, patients were eligible for inclusion if they underwent PCI at any of the included study centers within the study time period. Patients were assigned to either the SGLT-2 inhibitor group or control group depending on the documentation of receiving any SGLT-2 inhibitors within 24h prior to PCI. Propensity matching was utilized to determine the final subjects to include for comparison. The primary outcome was the incidence of CIN. A total of 192 patients (96 in each group) were matched after exclusion criteria were applied. The incidence of contrast-induced nephropathy was similar between groups, occurring in 8 (8.3%) patients in the SGLT-2 inhibitor group and 6 (6.3%) patients in the comparator group (p = 0.58). There was also no difference between groups in the change in serum creatinine following PCI. Based on our analysis, we did not identify any risk of CIN associated with SGLT-2 inhibitor use prior to PCI. Based on these results and in conjunction with previously published literature, the use of SGLT-2 inhibitors appears safe prior to PCI. These results still warrant further investigation with prospective adequately powered studies to evaluate the incidence of CIN with SGLT-2 inhibitor use in the setting of PCI.

A race against time – an evaluation of lifesaving treatment pathways for patients following cardiac arrest in a non-hospital setting.

BackgroundCardiac arrest occurs when the heart ceases pumping blood around the body. Most take place outside hospital. A sequence of effective interventions (a “chain of survival”) is essential for patient survival and recovery of organ function. Out of Hospital Cardiac Arrest (OHCA) requires prompt recognition and call for help, proficient CPR, early defibrillation and conveyance by the emergency services to an appropriate hospital. If initial resuscitation is successful, effective post-resuscitation care is required, delivered usually in the intensive care unit (ICU). New patient pathways were introduced following an update to national guidelines, which recommend conveyance of patients to centres with percutaneous coronary intervention (PCI) services where possible. ObjectiveWe have evaluated outcomes for patients, comparing those conveyed to PCI settings and those conveyed elsewhere to quantify the effect of the new patient pathway on mortality, survival and length of hospital stay. ApproachWe have linked electronic health records from emergency departments, acute hospital settings, ICUs and the national deaths register for OHCA patients living in Wales, UK. We have undertaken temporal analysis and time to event analysis to compare patient subgroups. ResultsVariation in patient pathways will be described using characteristics of conveyance method, the type of treating hospital and transfers between PCI and non-PCI settings adjusted for individual patient level confounders such as age, sex and comorbidities. ConclusionThis work is important to evaluate efficacy of operational procedures and inform national policies which aim to improve survival following OHCA and save lives.

Temporal trends and outcomes of acute ischaemic strokes in patients hospitalised for percutaneous coronary intervention.

Acute ischaemic stroke (AIS) after percutaneous coronary intervention (PCI) is a rare, but debilitating, complication. However, contemporary data from real-world unselected patients are scarce. We aimed to explore the temporal trends, outcomes and variables associated with AIS as well as in-hospital all-cause mortality in a nationwide cohort. A retrospective analysis of healthcare records from 2006-2021 was implemented. Patients were stratified according to the occurrence of AIS in the setting of PCI. The temporal trends of AIS were analysed. A stepwise regression model was used to identify variables associated with AIS and in-hospital all-cause mortality. A total of 4,910,430 PCIs were included for the current analysis. AIS occurred in 4,098 cases (0.08%). An incremental increase in the incidence of AIS after PCI from 0.03% to 0.14% per year was observed from 2006-2021. The strongest associations with AIS after PCI included carotid artery disease, medical history of stroke, atrial fibrillation, presentation with an ST-segment elevation myocardial infarction (STEMI) or non-STEMI and coronary thrombectomy. For patients with AIS, a higher in-hospital all-cause mortality (18.11% vs 3.29%; p<0.001) was documented. With regard to all-cause mortality, the strongest correlations in the stroke cohort were found for cardiogenic shock, dialysis and clinical presentation with a STEMI. In an unselected nationwide cohort of patients hospitalised for PCI, a gradual increase in AIS incidence was noted. We identified several variables associated with AIS as well as with in-hospital mortality. Hereby, clinicians might identify the patient population at risk for a peri-interventional AIS as well as those at risk for an adverse in-hospital outcome after PCI.

C-74 | Coronary perforation occurring in the setting of percutaneous coronary intervention is associated with high inpatients mortality and complication.

C-74 | Coronary perforation occurring in the setting of percutaneous coronary intervention is associated with high inpatients mortality and complication.

A-57 | Coronary perforation occurring in the setting of percutaneous coronary intervention is associated with high inpatients mortality and complication

A-57 | Coronary perforation occurring in the setting of percutaneous coronary intervention is associated with high inpatients mortality and complication

Development of a routine bedside CYP2C19 genotype assessment programfor antiplatelet therapy guidance in a community hospital catheterization laboratory.

Genotype based personalized antiplatelet therapy in the setting of percutaneous coronary intervention (PCI) has been studied in clinical trials. Despite the demonstrated risk associated with CYP2C19 loss-of-function (LoF) carriage in clopidogrel-treated PCI patients, real-world implementation of genotyping for PCI has been low. The goal of the current study was to provide CYP2C19 genotype information to the interventionalist prior to the completion of the catheterization to facilitate immediate personalized antiplatelet therapy. Routine personalization of P2Y12 inhibitor therapy for PCI in a community hospital cardiac catheterization laboratory by POC genotyping with the SpartanRx system was first offered in February 2017. A best practice advisory (BPA) based on the Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 genotype and clopidogrel therapy was placed in the electronic health record prescription medication ordering system. By December 2019, 1,052 patients had CYP2C19 genotype testing, 429 patients underwent PCI with genotype guided antiplatelet therapy, and 250 patients underwent PCI without genotype testing and received antiplatelet therapy at the discretion of the treating physician. BPA compliance was 93. 87% of LoF allele carriers were prescribed ticagrelor or prasugrel whereas 96% of non-LoF allele carriers were prescribed clopidogrel. The genotyping results were available within 1h and made immediately available for decision making by the interventional cardiologist. POC CYP2C19 genotyping is feasible in a community hospital catheterization laboratory and is associated with high rate of best practice compliance.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03040622.

The first septal perforating artery in the setting of percutaneous coronary interventions: More than just a side branch.

The first septal perforating artery in the setting of percutaneous coronary interventions: More than just a side branch.

Post-contrast Acute Kidney Injury After Emergent and Elective Percutaneous Coronary Intervention (from the CREDO-Kyoto PCI/CABG Registry Cohort 3)

Post-contrast acute kidney injury (PC-AKI) is a common complication after percutaneous coronary intervention (PCI). However, it is unclear whether or not the effects of PC-AKI on long-term clinical outcomes were different between emergent and elective procedures. Among patients enrolled in the CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Grafting) registry cohort 3, we identified 10,822 patients treated using PCI (emergent PCI stratum: n=5,022 [46%] and elective PCI stratum: n=5,860 [54%]). PC-AKI was defined as ≥0.3mg/100ml absolute or 1.5-fold relative increase of serum creatinine within 72hours after PCI. The incidence of PC-AKI was significantly higher after emergent PCI than after elective PCI (10.5% vs 3.7%, p <0.001). In the multivariable logistic regression model, emergent PCI was the strongest independent risk factor for PC-AKI in the entire study population. The excess adjusted risk of patients with PC-AKI relative to those without remained significant for all-cause death in both the emergent and elective PCI strata (hazard ratio 1.87, 95% confidence interval 1.59 to 2.21, p <0.001 and hazard ratio 1.31, 95% confidence interval 1.03 to 1.68, p=0.03, respectively). There was a significant interaction between the PCI setting (emergent and elective) and the effect of PC-AKI on all-cause death, with a greater magnitude of effect in the emergent PCI stratum than in the elective PCI stratum (p for interaction=0.01). In conclusion, the incidence of PC-AKI was 2.8 times higher after emergent PCI than after elective PCI. The excess mortality risk of PC-AKI relative to no PC-AKI was greater after emergent PCI than after elective PCI.

A-41 | Percutaneous Coronary Intervention With Procedural Unfractionated Heparin Without Activated Clotting Time Guidance: A Unique Opportunity to Assess Thrombotic and Bleeding Events

Rates of major bleeding and intraprocedural thrombotic events (IPTE) in the setting of percutaneous coronary intervention (PCI) using weight-adjusted unfractionated heparin (UFH) without activated clotting time (ACT) monitoring are not known. We reviewed 2748 consecutive patients who underwent coronary angiography at our tertiary care university hospital between January 2017 and December 2020. All patients who underwent PCI with weight-adjusted UFH without ACT guidance were considered for further analysis. Major bleeding complications occurring within 48 hours of PCI were collected from patients’ medical records. IPTE were collected independently by two interventional Cardiologist after review of coronary angiograms. There were 718 patients included in the analysis (65.4±12.2 years old; 81.3% male). In total, 45 patients (7.8%) experienced a major bleed or IPTE. The most common IPTE were slow/no reflow (1.5%) and coronary artery dissection with decreased flow (1.1%). Other IPTE occurred in <1% of cases. Major bleeding occurred in 11 patients (1.5%), of whom 8 required blood transfusion and 3 required vascular intervention. Bleeding complications were more common with femoral compared with radial access (6.6% vs 0.2%, P<0.001). Weight-adjusted UFH use during PCI without ACT monitoring was related to low rates of major bleeding or IPTE.

TCTAP A-042 An Umbrella Review of the Meta Analyses About Risk and Protective Factors for Post-discharge Bleeding Events in Percutaneous Coronary Intervention Setting

TCTAP A-042 An Umbrella Review of the Meta Analyses About Risk and Protective Factors for Post-discharge Bleeding Events in Percutaneous Coronary Intervention Setting

A glimpse into the future of the percutaneous treatment of coronary chronic total occlusions.

Percutaneous coronary intervention (PCI) of coronary chronic total occlusion (CTO PCI) is one of the most challenging but rewarding procedures in the portfolio of interventional cardiologists. Several challenges, however, still must be overcome and many questions need to be answered. After coronary artery bypass graft (CABG), disease of the conduits and concomitant progression of atherosclerotic disease to CTO of the subtended native coronary vessels are common and associated with onset of new anginal symptoms and worsening of the prognosis. Which is the best strategy for these post-CABG CTOs? Furthermore, what is the role of physiology in the setting of CTO PCI? In the last decades, many researchers tried to demystify the complex maze but technical limitations and the demanding procedure itself, for both the patient and the operator, do not allow extensive investigation of its impact on clinical practice. Can we enhance periprocedural planning of CTO PCI with a more tailored and multidimensional evaluation? Analysis of coronary computed tomography angiography (CCTA) scans is getting more and more incorporated into the clinical routine and training of interventional cardiologists but mainly focuses on structural valvular disease. Nevertheless, with the appropriate expertise, a lot of information can be derived for coronary intervention to improve procedural planning and potentially outcomes. Finally, in the era of drug-eluting stent, is there a place for strategies that minimize metal implantation in the coronaries to further reduce late-onset adverse events in CTO PCI? This approach could be attractive in CTOs due to the higher risk of target vessel failure and revascularization shown in literature but, at the same time, more challenging due to the histological and anatomical complexity of the disease. In this review, we aim to tackle these questions and concomitantly provide a vision of potential future application of new techniques and technology in CTO PCI that could allow further advancement in this field.

Pharmacogenetics of P2Y12 receptor inhibitors.

Oral P2Y12 inhibitors are commonly prescribed for cardiovascular disease and include clopidogrel, prasugrel, and ticagrelor. Each of these drugs has its strengths and weaknesses. Prasugrel and ticagrelor are more potent inhibitors of platelet aggregation and were shown to be superior to clopidogrel in preventing major adverse cardiovascular events after an acute coronary syndrome and percutaneous coronary intervention (PCI) in the absence of genotyping. However, both are associated with an increased risk for non-coronary artery bypass-related bleeding. Clopidogrel is a prodrug requiring bioactivation, primarily via the CYP2C19 enzyme. Approximately 30% of individuals have a CYP2C19 no function allele and decreased or no CYP2C19 enzyme activity. Clopidogrel-treated carriers of a CYP2C19 no function allele have decreased exposure to the clopidogrel active metabolite and lesser inhibition of platelet aggregation, which likely contributed to reduced clopidogrel efficacy in clinical trials. The pharmacogenetic data for clopidogrel are most robust in the setting of PCI, but evidence is accumulating for other indications. Guidance is available from expert consensus groups and regulatory agencies to assist with integrating genetic information into P2Y12 inhibitor prescribing decisions, and CYP2C19 genotype-guided antiplatelet therapy after PCI is one of the most common examples of clinical pharmacogenetic implementation. Herein, we review the evidence for pharmacogenetic associations with clopidogrel response and outcomes with genotype-guided P2Y12 inhibitor selection and describe guidance to assist with pharmacogenetic implementation. We also describe processes for applying genotype data for P2Y12 inhibitor therapy selection and remaining gaps in the field. Ultimately, consideration of both clinical and genetic factors may guide selection of P2Y12 inhibitor therapy that optimally balances the atherothrombotic and bleeding risks.

Balloon Shaft Fracture: A Nightmare Scenario in the Setting of Percutaneous Coronary Intervention

Balloon Shaft Fracture: A Nightmare Scenario in the Setting of Percutaneous Coronary Intervention

997 ACUTE AND LATE GASTROINTESTINAL BLEEDING EVENTS AFTER LEFT VENTRICULAR MECHANICAL SUPPORT IMPLANTATION: THE ISMETT REGISTRY

Abstract Background The number of patients with end stage heart failure (HF) which requires a ventricular assist devices (VADs) implantation is constantly increasing. Gastrointestinal bleeding (GIB) represents one of the most common complications that occur in this patient population. GIB risk assessment could have important implications for candidate selection and postimplant therapeutic strategies. A recent model, called UTAH bleeding risk score (UBRS), was created with the aim of predicting the risk of GIB during LVAD support, but its use does not yet have a worldwide validation. The two most popular bleeding risk (BR) scores available, the ARC-HBR and the HAS-BLED scores, have been validated respectively in the setting of percutaneous coronary intervention and atrial fibrillation but their use in VAD patients is limited. Aims to describe clinical outcome and gastrointestinal bleeding complications of patients underwent LVAD implantation at a single tertiary referral hospital for heart transplant. Furthermore, to explore possible correlation among clinical, echocardiographic, hemodynamic parameters and the development of gastrointestinal bleeding complications has been evaluated. Finally, to evaluate the predictive value of UBRS, ARC-HBR and HAS-BLED scores in this population and to propose possible new parameters capable of predicting the risk of GIB in VAD patients. Methods Between November 2010 and December 2021, 75 consecutive patients with end stage heart failure who underwent LVAD implantation have been enrolled in this monocentric retrospective registry. Univariable and multivariable Cox regression analysis were performed to identify factors independently associated with GI bleeding in the study population. Results Patient's mean age was 57,8 ± 8,8 years. Thirty-six patients (48%) died at mean time of 579 ± 481 days after implant of VAD. The overall patient survival was 66,6% at two years. To the mean follow-up time of 737 ± 593 days, a total of 44 bleeding (incidence of 58,7%) occurred in 30 patients. Nineteen patients (25%) experienced 21 GIB events. Mean time to first GIB was 469 ± 520 days and only one event occurred within 30 days.The patient survival at two years did not differ significantly between patients who experienced GIB and those who did not (58% vs 69,6%; p=0,3). While, considering the total bleedings, overall mortality was significantly higher in patients who developed any bleeding event, than in those who did not bleed (67 vs 35%; p= 0,008).The clinical characteristics of patient with and without gastrointestinal bleeding were similar with regard to age, INTERMACS profile, etiology of heart failure and VAD implant indication.The subgroup analysis demonstrated that low cardiac output (P&amp;lt; 0,001), right ventricular disfunction (P=0,01) and severe mitral regurgitation (P= 0,01) were all associated with increased risk of GIB. In our population, high risk profile UBRS was shown to be related to a higher percentage of GIB, compared to patients with a low risk profile UBRS, in which patients without GIB prevailed (p&amp;lt; 0,001). Instead, ARC-HBR and HAS-BLED scores, didn't prove to be effective in predicting the GIB risk of VAD patient population. Conclusions High gastrointestinal bleeding rates associated with LVAD implantation do not impact negatively with patient survival. Total bleedings are correlated with higher mortality. Reduced cardiac output, right ventricular disfunction and severe mitral regurgitation are independent GIB risk factors. UBRS was able to stratify risk, in order to predict GIB, in the population tested, while ARC-HBR and HAS-BLED did not.

What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention?

Interest in the use of percutaneous left ventricular assist devices (p-LVADs) for patients undergoing high-risk percutaneous coronary intervention (PCI) is growing rapidly. The Impella™ (Abiomed Inc.) is a catheter-based continuous micro-axial flow pump that preserves haemodynamic support during high-risk PCI. Anticoagulation is required to counteract the activation of the coagulation system by the patient's procoagulant state and the foreign-body surface of the pump. Excessive anticoagulation and the effect of dual antiplatelet therapy (DAPT) increase the risk of bleeding. Inadequate anticoagulation leads to thrombus formation and device dysfunction. The precarious balance between bleeding and thrombosis in patients with p-LVAD support is often the primary reason that patients' outcomes are jeopardized. In this chapter, we will discuss anticoagulation strategies and anticoagulant management in the setting of protected PCI. This includes anticoagulant therapy with unfractionated heparin, direct thrombin inhibitors, DAPT, purge blockage prevention by bicarbonate-based purge solution, and monitoring by activated clotting time, partial thromboplastin time, as well as anti-factor Xa levels. Here, we provide a standardized approach to the management of peri-interventional anticoagulation in patients undergoing protected PCI.

Impact of biomarker type on periprocedural myocardial infarction in patients undergoing elective PCI.

Periprocedural myocardial infarction (MI) according to the Society for Cardiovascular Angiography and Interventions (SCAI) criteria has prognostic relevance among patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether the type of cardiac biomarker used for the diagnosis of periprocedural MI plays a role in terms of event frequency and outcomes. To compare the characteristics of SCAI periprocedural MI based on creatine kinase-myocardial band fraction (CK-MB) vs. high-sensitivity cardiac troponin (hs-cTn) in patients undergoing elective PCI. Between 2017 and 2021, periprocedural MI was assessed in a prospective study. The primary clinical outcome of interest was all-cause death at 1-year follow-up. A total of 1010 patients undergoing elective PCI were included. SCAI periprocedural MI based on CK-MB vs. hs-cTnI occurred in 1.8 and 13.5% of patients, respectively. hs-cTnI periprocedural MI in the absence of concomitant CK-MB criteria was associated with lower rates of ancillary criteria, including angiographic, ECG, and cardiac imaging criteria. At 1-year follow-up, periprocedural MI defined by CK-MB (adjusted hazard ratio, HR, 4.27, 95% confidence intervals, CI, 1.23-14.8; P=0.022) but not hs-cTnI (adjusted HR 2.04, 95% CI 0.94-4.45; P=0.072) was associated with a higher risk of all-cause death. Hs-cTnI periprocedural MI was not predictive of death unless accompanied by CK-MB criteria (adjusted HR 4.64, 95% CI 1.32-16.31; P=0.017). In the setting of elective PCI, using hs-cTn instead of CK-MB resulted in a substantial increase in SCAI periprocedural MI events, which were not prognostically relevant in the absence of concurrent CK-MB elevations.

Abstract 15578: A Rare Case of Anomalous Left Main Coronary Artery Origin Presenting as ST Elevation Myocardial Infarction

Background: ST-segment elevation myocardial infarctions (STEMI) are uncommon presentations of coronary artery anomalies and pose challenges in the emergent setting of percutaneous coronary interventions. We describe an extremely rare case of left main coronary artery (LMCA) originating off the right coronary artery (RCA) in a patient who presents with STEMI and was found to have Medina 1,1,1 lesion at the origin of the anomalous (LMCA). Case Presentation: An 81-year old male, with a past medical history significant for aortic stenosis and hyperlipidemia, presents to the emergency room for substernal non-radiating chest pressure. His electrocardiogram showed ST segment elevations in inferior and anterior leads. He was taken emergently to the cardiac cath lab. Coronary angiogram revealed a single right coronary ostium with an anomalous LMCA to mid left anterior descending (LAD) artery via dual insertion within a myocardial bridge. There was severe 90% Medina 1,1,1 bifurcating proximal RCA stenosis and 90% proximal LMCA stenosis. The entire left coronary system was fed by the anomalous LMCA, which was inserted into the mid-LAD in a dual insertion, between which there was a myocardial bridge. Cardiothoracic surgery team was consulted, and decision was made to pursue coronary artery bypass grafting (CABG). An intra-aortic balloon pump was placed via right femoral artery and patient was taken for emergent surgery, where he underwent 3 vessel CABG (left internal mammary artery to LAD, saphenous venous graft to obtuse marginal branch and posterior descending artery). Discussion: A broad spectrum of coronary anomalies have been reported, but their incidence in STEMI is rare. We discuss a very rare anomaly in which the entire left coronary system branches off the RCA, and culprit lesion was found to be a Medina 1,1,1 lesion. We aim to add to the sparce data pool of STEMI management in patients with anomalous coronary arteries.

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

TIMI flow and myocardial blushing after rescue PCI and cardiac magnetic resonance: Results from the Myocardial Salvage After Rescue Angioplasty: Evaluation by Magnetic Resonance (SAVE-ME) study

IntroductionThrombolysis is currently reserved for ST-elevation myocardial infarction (STEMI) patients who cannot access timely percutaneous coronary intervention (PCI). In case of failed thrombolysis, rescue PCI is a viable option. Substantial data concerning the outcomes in terms of infarct size and myocardial function after rescue PCI are lacking. MethodsForty patients treated with rescue PCI underwent serial contrast-enhanced cardiac magnetic resonance imaging (CMR) at 1 week, 3 months and 6 months from the index STEMI. Angiographic images were reviewed to assess Thrombolysis in Myocardial Infarction (TIMI) blood flow and TIMI Myocardial Blush Grade (TMBG) in the infarct related artery after PCI. ResultsPatients with lower TMBG at the end of procedure, but not patients with worse TIMI flow, had lower left ventricular ejection fraction (LVEF) and higher volume of late gadolinium enhancement (LGE) on baseline CMR (44 ± 13% vs 52 ± 9%, p = 0.026, and 41 ± 21 ml vs 26 ± 12, p = 0.030, respectively). Patients with lower TMBG remained with significantly lower LVEF at 6 months follow up (48 ± 16% vs 59 ± 14, p = 0.049). ConclusionTMBG after rescue PCI is associated with reduced LVEF and increased LGE burden. As TMBG is a known marker of microvascular damage after STEMI, novel strategies aimed at improving microvascular function in the setting of rescue PCI are needed to improve the outcomes in this patient population.

Glycaemic Control in Patients Undergoing Percutaneous Coronary Intervention: What Is the Role for the Novel Antidiabetic Agents? A Comprehensive Review of Basic Science and Clinical Data.

Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality worldwide, and revascularization through percutaneous coronary interventions (PCI) significantly improves survival. In this setting, poor glycaemic control, regardless of diabetes, has been associated with increased incidence of peri-procedural and long-term complications and worse prognosis. Novel antidiabetic agents have represented a paradigm shift in managing patients with diabetes and cardiovascular diseases. However, limited data are reported so far in patients undergoing coronary stenting. This review intends to provide an overview of the biological mechanisms underlying hyperglycaemia-induced vascular damage and the contrasting actions of new antidiabetic drugs. We summarize existing evidence on the effects of these drugs in the setting of PCI, addressing pre-clinical and clinical studies and drug-drug interactions with antiplatelet agents, thus highlighting new opportunities for optimal long-term management of these patients.