Subsequent Percutaneous Coronary Intervention Research Articles

Abstract 4122710: Impact of cigarette smoking on long-term clinical outcomes in patients with coronary chronic total occlusion lesions

Cigarette smoking is a significant risk factor for coronary artery disease (CAD). However, evidence regarding on the long-term clinical effects of smoking in the Asian population with chronic total coronary occlusion (CTO) is insufficient. This study aimed to assess the effects of smoking on 5-year (median follow-up period 4.2 ± 1.5 years, interquartile range 4.06-5.0 years) clinical outcomes in patients with CTO lesions who had undergone percutaneous coronary intervention (PCI) or medical treatment (MT). We enrolled 681 consecutive patients with CTO who had undergone diagnostic coronary angiography and subsequent PCI or MT. Patients were categorized into smokers (n = 304) and non-smokers (n = 377). The primary endpoint encompassed major adverse cardiovascular events (MACE), including a composite of all-cause death, myocardial infarction (MI), and revascularization over a 5-year period. Propensity score matching (PSM) analysis was used to adjust for potential baseline confounders. After PSM analysis, two propensity-matched groups (200 pairs, n = 400) were generated, and the baseline characteristics of both groups were balanced. The smokers exhibited a higher cardiovascular risk of MACE (29.5% vs. 18.5%, p = 0.010) and non-target vessel revascularization (17.5 vs. 10.5%, p = 0.044) than those of the non-smokers(Table 1). In a landmark analysis using Kaplan-Meier (KM) curvesat the 1-year, the smokers had significantly higher rate of MACE in early period (up to 1-year) (18.8% and 9.2%, p=0.008) compared with non-smokers(Figure 1). Cox hazard regression analysis by propensity score-adjustedwith , revealed that smoking was independently associated with an increased risk of MACE. The findings indicate that smoking is a strong cardiovascular risk factor in patients with CTO, regardless of treatment strategies (PCI or MT) (Figure 2). In addition, in a subgroup analysis, the risk of MACE was most prominently elevated in the group of smokers who underwent PCI.

Patients with STEMI after Revascularization: Is There a Relationship Between Coronary Artery Lesion and Renal Function?

The aim. To establish the relationship between coronary bed lesions and glomerular filtration rate (GFR) calculated on the basis of creatinine, cystatin C and urine albumin-creatinine ratio in patients with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention. Materials and methods. We examined 286 patients with STEMI, aged 39 to 87 years (mean age 62.8 ± 9.8, median age 64, interquartile range 56 to 71 years), 202 (70.6%) were men and 84 (29.4%) were women. All the patients underwent general clinical tests, coronary angiography with subsequent percutaneous coronary intervention, and echocardiography. Results. The most frequent infarct-related coronary artery (CA) was the anterior interventricular branch of the left coronary artery in the proximal and middle segments, and the right coronary artery in the proximal segment. In general, there was no significant difference in the number of affected CAs among the examined patients. The division of patients into groups according to the level of GFR, determined both on the basis of creatinine and cystatin C, did not reveal significant differences in the distribution of infarct-related CAs. At the same time, the number of patients with multivessel lesions significantly increases with decreased GFR. Depending on the level of the urinary albumin-to-creatinine ratio, a significant increase in the number of patients with two- and multivessel lesions of the CAs was noted. Conclusions. Close correlations between multivessel lesions of CAs and gender, age, urinary albumin-to-creatinine ratio, GFR, left and right atrial size, duration of history of hypertension and diabetes mellitus, presence of II-III degree atrioventricular block and mortality were established.

Injury to the sinus nodal artery during radiofrequency ablation of atrial fibrillation and atrial tachycardia: its prevalence and treatment with percutaneous coronary intervention

Abstract Background/Introduction Injury to the sinus node artery (SNA) leading to SN dysfunction during radiofrequency catheter ablation (RFCA) of atrial Fibrillation (AF) and atrial tachycardia (AT) has been reported. Purpose The purpose of this study was to elucidate the prevalence and clinical course of SNA injuries during RFCA of AF/AT and examine the efficacy of the percutaneous coronary intervention (PCI) to restore SN function. Methods We retrospectively analyzed data from 6,906 consecutive patients (pts) who underwent RFCA of AF/AT (6,379 pts with AF ablation and 527 pts with AT ablation) in two institutions between January 2013 and December 2022. Results Among 6,906 pts, 9 (0.13%) pts developed SN dysfunction due to SNA injury during RFCA (8 with AF, 1 with AT). Acute SNA injury (total occlusion or severe narrowing of the SNA) was confirmed by coronary angiography (CAG) during the RFCA session in 8/9 pts. In the remaining patient, SNA injury was suspected based on the CT angiography. The culprit sites of the SNA injury were located at the septal site of the superior vena cava-right atrium junction in 4 pts (44%), on the left atrial appendage ridge in 3 (33%), on the roof of the left atrium adjacent to the right superior pulmonary vein in 1 (11%), and in the persistent left superior vena cava in 1 (11%). PCI to the occluded SNA was performed in 8 of the 9 pts: 1) coronary blood flow of the SNA was restored by a 0.014" guidewire advancement into the occluded artery using a micro-catheter followed by direct nitroprusside injection in 4 pts; 2) the direct balloon angioplasty using 0.75-1.5 mm diameter balloons was required to maintain the blood flow of SNA in 3 pts; and 3) CAG revealed spontaneous recovery of the blood flow of SNA in one pt. The remaining patient did not receive the CAG/PCI. All 8 pts who underwent the PCI resulted in restoration of normal sinus rhythm. During a median of 44 months follow-up, all 8 pts who received the PCI maintained normal sinus rhythm, while one patient without PCI demonstrated persistent SN dysfunction. Conclusions SNA injury during RFCA is a rare but critical complication. Prompt recognition by CAG and subsequent PCI effectively restores SN function in pts with unexpected SN dysfunction during RFCA procedures.

Spontaneous coronary artery dissection in a young patient with antiphospholipid syndrome

A 28-year-old man diagnosed with triple positive antiphospholipid syndrome (APS) and undergoing warfarin experienced three separate admissions to the cardiac ward within a one-month period due to escalating chest pain. While the initial two admissions revealed normal results in cardiological investigations, such as blood tests, electrocardiogram, and echocardiography, the third admission unveiled signs of ST-elevation myocardial infarction (STEMI), despite the patient maintaining an INR (International Normalized Ratio) of 4. Subsequent percutaneous coronary intervention (PCI) exposed spontaneous coronary artery dissection (SCAD) of type 3. Faced with hemodynamic instability and worsening symptoms, the patient underwent stenting and was prescribed dual antiplatelet therapy in addition to warfarin. A follow-up evaluation one month later indicated a normalization of his condition.

Impact of Preloading Strategy With Ticagrelor on Periprocedural Myocardial Injury in Patients With Non-ST Elevation Myocardial Infarction Undergoing Early Invasive Strategy.

Pretreatment with an oral P2Y12 receptor blocker (before coronary angiography) versus treatment in the catheterization laboratory has been a matter of debate in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI). The primary aim of this study was to assess the impact of an immediate preloading strategy with ticagrelor on periprocedural myocardial injury in patients with NSTEMI treated with an early invasive strategy. NSTEMI patients who underwent coronary angiography and subsequent percutaneous coronary intervention (PCI) within 24 hours after hospital admission were divided into 2 groups: the first group (pretreatment group) included patients who received ticagrelor pretreatment as soon as possible after admission and the second group (no pretreatment group) included patients who received a loading dose of ticagrelor after coronary angiography. The pretreatment group included 232 patients, and the no pretreatment group included 87 patients. Male patients represented the majority of the patients. The 2 groups were similar in baseline characteristics, except for a greater incidence of hypertension ( P = 0.014) and higher hemoglobin levels ( P = 0.01) in the pretreatment group in comparison with the no pretreatment group. Patients in the ticagrelor pretreatment group had less myocardial injury until coronary angiography based on troponin measurements collected at 12 hours after admission ( P = 0.025). Patients in the ticagrelor pretreatment group also had fewer periprocedural myocardial injuries based on troponin measurements taken between 12 and 24 hours after the PCI ( P = 0.026 and P = 0.022, respectively). Our findings suggested that ticagrelor pretreatment reduces periprocedural myocardial injury in NSTEMI patients who underwent PCI within 24 hours after admission.

His bundle pacing in a patient with atrioventricular conduction abnormalities, persistent atrial flutter at high thromboembolic and bleeding risk after hybrid coronary revascularization and left atrial appendage closure - case report

We present a case of a 78-year-old patient with persistent atrial fl utter, history of atrial fi brillation and atrioventricular conduction disturbances, including fi rst-degree atrioventricular block (AVB) and paroxysmal complete AVB. Echocardiography revealed mildly reduced left ventricular ejection fraction (LVEF, 44%). The patient had high thromboembolic risk, had previous ischemic stroke, suffered from chronic coronary artery disease treated with hybrid coronary revascularization (minimally invasive direct coronary artery bypass grafting and subsequent percutaneous coronary intervention) as well as left atrial appendage closure. Because of high bleeding risk, double antiplatelet therapy (acetylsalicylic acid and clopidogrel) combined with low dose of low-molecular-weight heparin after cardiac surgery were introduced. Due to persistent atrial fl utter, complete AVB, lack of intraventricular conduction abnormalities, mildly reduced LVEF and expected high right ventricle pacing burden, the patient was referred for dual-chamber pacemaker implantation using conduction system pacing (CSP), preferentially His bundle pacing (HBP). The procedure was performed with good outcome and CSP was utilized via HBP. After reassessment of thromboembolic and bleeding risk, the patient was discharged home on reduced dose of dabigatran. Short-term follow-up showed stable HBP parameters along with no additional symptoms. Despite good short-term outcomes and no complications in studied patient, large randomized controlled trials are needed to verify long-term safety and effi cacy of HBP to optimize clinical care of patients with atrioventricular conduction abnormalities using a personalized approach. 

Impact of cigarette smoking on long-term clinical outcomes in patients with coronary chronic total occlusion lesions.

Cigarette smoking is a significant risk factor for coronary artery disease. However, there is insufficient evidence regarding the long-term clinical effects of smoking in Asian populations with chronic total occlusion (CTO). This study aimed to assess the effects of smoking on 5-year (median follow-up period, 4.2 ± 1.5 [interquartile range, 4.06-5.0] years) clinical outcomes in patients with CTO lesions who underwent percutaneous coronary intervention (PCI) or medical treatment (MT). We enrolled 681 consecutive patients with CTO who underwent diagnostic coronary angiography and subsequent PCI or MT. The patients were categorized into smokers (n = 304) and nonsmokers (n = 377). The primary endpoint was major adverse cardiovascular events (MACE), including a composite of all-cause death, myocardial infarction, and revascularization over a 5-year period. Propensity score matching (PSM) analysis was performed to adjust for potential baseline confounders. After PSM analysis, two propensity-matched groups (200 pairs, n = 400) were generated, and the baseline characteristics of both groups were balanced. The smokers exhibited a higher cardiovascular risk of MACE (29.5% vs. 18.5%, p = 0.010) and non-TVR (17.5 vs. 10.5%, p = 0.044) than the nonsmokers. In a landmark analysis using Kaplan-Meier curves at 1 year, the smokers had a significantly higher rate of MACE in the early period (up to 1 year) (18.8% and 9.2%, respectively; p = 0.008) compared with the nonsmokers. The Cox hazard regression analysis with propensity score adjustment revealed that smoking was independently associated with an increased risk of MACE. These findings indicate that smoking is a strong cardiovascular risk factor in patients with CTO, regardless of the treatment strategy (PCI or MT). In addition, in the subgroup analysis, the risk of MACE was most prominently elevated in the group of smokers who underwent PCI.

Comparison of Robot-Assisted Multivessel Minimally Invasive Direct Coronary Artery Bypass and Hybrid Revascularization

BackgroundThis study compares 2 minimally invasive coronary revascularization approaches: robot-assisted multivessel minimally invasive direct coronary artery bypass (MIDCAB) and the hybrid approach combining MIDCAB with subsequent percutaneous coronary intervention. MethodsA retrospective review was conducted on cases of robotic MIDCAB performed at our institution between 2012 and 2022. Two groups of patients were analyzed: the surgery group (undergoing robotic multivessel MIDCAB) and the hybrid group. Surgical procedures included robotic left internal mammary artery harvest and anastomosis, with percutaneous coronary intervention performed within 30 days in the hybrid group. ResultsThere were 105 patients in the surgery group and 81 patients in the hybrid group. Both groups had similar characteristics, except that the surgery group had older patients. There were no mortalities in either group. Postoperative atrial fibrillation rates were higher in the surgery group. Length of stay and other postoperative complications did not differ significantly between the groups. ConclusionsMultivessel robotic MIDCAB can be safely performed with comparable outcomes to the hybrid approach. The hybrid technique, being less demanding, is the preferred in most centers. However, multivessel robotic MIDCAB offers the advantage of complete revascularization and potentially more durable results. Patients with complex non–left anterior descending lesions may not be suitable for the hybrid approach.

Effectiveness, safety, and patient reported outcomes of a planned investment procedure in higher-risk chronic total occlusion percutaneous coronary intervention:Rationale and design of the invest-CTO study.

The anatomical complexity of a chronic total occlusion (CTO) correlates with procedural failure and complication rates. CTO modification after unsuccessful crossing has been associated with subsequent higher technical success rates, but complication rates remain high with this approach. While successful CTO percutaneous coronary intervention (PCI) has been associated with improved angina and quality of life (QOL) this has not been demonstrated in anatomically high-risk CTOs. Whether a planned CTO modification procedure, hereafter named Investment procedure, could improve patient outcomes has never been investigated. Invest-CTO is a prospective, single-arm, international, multicenter study, evaluating the effectiveness and safety of a planned investment procedure, with a subsequent completion CTO PCI (at 8-12 weeks), in anatomically high-risk CTOs. We will enroll 200 patients with CTOs defined as high-risk according to our Invest CTO criteria at centers in Norway and United Kingdom.Patients with aorto-ostial lesions, occlusion within a previous stent, or a prior attempt at target vessel CTO PCI within 6 months will be excluded. The co-primary endpoints are cumulative procedural success (%) after both procedures, and a composite safety endpoint at 30 days after completion CTO PCI. Patient reported outcomes (PROs), treatment satisfaction, and clinical endpoints will be reported. This study will prospectively evaluate the effectiveness and safety of a planned two staged PCI procedure in the treatment of high-risk CTOs and may have the potential to change current clinical practice.

Single antiplatelet therapy directly after percutaneous coronary intervention in non-ST-segment elevation acute coronary syndrome patients: the OPTICA study.

Early P2Y12 inhibitor monotherapy has emerged as a promising alternative to 12 months of dual antiplatelet therapy following percutaneous coronary intervention (PCI). In this single-arm pilot study, we evaluated the feasibility and safety of ticagrelor or prasugrel monotherapy directly following PCI in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Patients received a loading dose of ticagrelor or prasugrel before undergoing platelet function testing and subsequent PCI using new-generation drug-eluting stents. The stent result was adjudicated with optical coherence tomography in the first 35 patients. Ticagrelor or prasugrel monotherapy was continued for 12 months. The primary ischaemic endpoint was the composite of all-cause mortality, myocardial infarction, definite or probable stent thrombosis or stroke within 6 months. The primary bleeding endpoint was Bleeding Academic Research Consortium type 2, 3 or 5 bleeding within 6 months. From March 2021 to March 2022, 125 patients were enrolled, of whom 75 ultimately met all in- and exclusion criteria (mean age 64.5 years, 29.3% women). Overall, 70 out of 75 (93.3%) patients were treated with ticagrelor or prasugrel monotherapy directly following PCI. The primary ischaemic endpoint occurred in 3 (4.0%) patients within 6 months. No cases of stent thrombosis or spontaneous myocardial infarction occurred. The primary bleeding endpoint occurred in 7 (9.3%) patients within 6 months. This study provides first-in-human evidence that P2Y12 inhibitor monotherapy directly following PCI for NSTE-ACS is feasible, without any overt safety concerns, and highlights the need for randomised controlled trials comparing direct P2Y12 inhibitor monotherapy with the current standard of care.

Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach.

Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.

Meta-Analysis on the Impact of Coronary Bypass Graft Markers on Angiographic Procedural Outcomes

Utilization of radio-opaque coronary artery bypass graft markers is known to decrease the amount of contrast dye required to complete the procedure. Thepractice of marking bypass grafts varies significantly among surgeons. Limited data exist comparing the outcomes of percutaneous coronary intervention with and without coronary artery bypass graft (CABG) markers. We sought to explore the impact of proximal radio-opaque markers placed during CABG in subsequent percutaneous coronary intervention procedural risks. In our understanding of the current literature, this is the first meta-analysis conducted to evaluate the association between procedural angiographic metrics and CABG radio-opaque markers.We performed a query of MEDLINE and Scopus databases through August 2022 to identify relevant studies evaluating procedural metrics among patients with previous CABG with and without radio-opaque markers who underwent angiography. The primary outcomes of interest were fluoroscopy time, amount of contrast, and duration of angiography.We identified a total of 4 studies with 2,046 patients with CABG (CABG with markers n=688, CABG without markers n=1,518).2-5 Total fluoroscopy time was significantly reduced among patients with CABG markers compared with those with no markers (odds ratio [OR] -3.63, p <0.0001).The duration of angiography (OR -36.39, p >0.10) was reduced, although the result was not statistically significant. However, the amount of contrast utilization was significantly reduced (OR -33.41, p <0.0001).In patients who underwent CABG with radio-opaque markers, angiographic procedural metrics were improved, including reduced fluoroscopic time and the amount of contrast agent required compared with no markers.

Prognostic value of neutrophil-lymphocyte ratio in out-of-hospital cardiac arrest patients receiving targeted temperature management: An observational cohort study

Out-hospital cardiac arrest (OHCA) is a major cause of mortality and morbidity worldwide. The magnitude of the post-resuscitation inflammatory response is closely related to the severity of the circulatory dysfunction. Currently, targeted temperature management (TTM) has become an essential part of the post-resuscitation care for unconscious OHCA survivors. Some novel prognostic inflammatory markers may help predict outcomes of OHCA patients after TTM. A retrospective observational cohort study of 65 OHCA patients treated with TTM was conducted in a tertiary hospital in Taiwan. The primary outcome measure was in-hospital mortality. Baseline and post-TTM neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte (PLR), and the systemic immune inflammation index (SII) were identified as potential predictors. These patients had a mean age of 62.2±17.0 years. Among the total sample, 53.8% had an initial shockable rhythm and 61.5% had a presumed cardiac etiology. The median resuscitation duration was 20min (IQR 13.5-28.5) and 60% received subsequent percutaneous coronary intervention. The mean baseline NLR, PLR and SII were 7.5±16.7, 118±207, 1395±3004, and the mean post-TTM NLR, PLR and SII were 15.0±11.6, 206±124, 2369±2569, respectively. Using multiple logistic regression analysis, post-TTM NLR was one of the independent factors which predicted in-hospital mortality (adjusted odds ratio (aOR): 1.249, 95% confidence interval (CI): 1.040-1.501, p=0.017). Post-TTM NLR is a predictor of in-hospital mortality in OHCA patients who underwent TTM.

Characteristics of Radial Artery Coronary Bypass Graft Failure and Outcomes Following Subsequent Percutaneous Coronary Intervention

BackgroundWhen patients with prior coronary artery bypass grafting (CABG) undergo percutaneous coronary intervention (PCI), targeting the native vessel is preferred. Studies informing such recommendations are based predominantly on saphenous vein graft (SVG) PCI. There are few data regarding arterial graft intervention, particularly to a radial artery (RA) graft. ObjectivesThe aim of this study was to report the characteristics of arterial graft stenoses and evaluate the feasibility of RA PCI. MethodsThis study included 2,780 consecutive patients with prior CABG undergoing PCI between 2005 and 2018 who were prospectively enrolled in the MIG (Melbourne Interventional Group) registry. Data were stratified by PCI target vessel. RA graft PCI was compared with both native vessel (native PCI) and SVG PCI. Internal mammary graft PCI data were reported. The primary outcome was 3-year mortality. ResultsOverall, 1,928 patients (69.4%) underwent native PCI, 716 (25.6%) SVG PCI, 86 (3.1%) RA PCI, and 50 (1.8%) internal mammary graft PCI. Compared with SVG PCI, the RA PCI cohort presented earlier after CABG, less frequently had acute coronary syndrome, and more commonly had ostial or distal anastomosis intervention (P < 0.005 for all). Compared with patients who underwent native PCI, those who underwent RA PCI were more likely to have diabetes and peripheral vascular disease (P < 0.001 for both) and to present with non–ST-segment elevation myocardial infarction (P = 0.010). The RA PCI group had no perforations or in-hospital myocardial infarctions, though no significant difference was found in periprocedural outcomes compared with either native or SVG PCI. No differences were found between RA PCI and either native or SVG PCI in 30-day outcomes or 3-year mortality. ConclusionsPresenting and lesion characteristics differed between patients undergoing arterial compared with SVG PCI, implying a varied pathogenesis of graft stenosis. RA PCI appears feasible, safe, and where anatomically suitable, may be a viable alternative to native PCI.

289 DIAGNOSTIC PATHWAY OF PATIENTS WITH CHRONIC CORONARY SYNDROME AFTER THE ISCHEMIA TRIAL PUBLICATION

Abstract Introduction Patients with chronic coronary syndrome (CCS) can initially undergo an invasive (i.e., early referral to invasive coronary angiography [ICA]) or a conservative (i.e., anatomical or functional testing before ICA) management. The ISCHEMIA trial showed no difference between these two strategies in CCS patients with moderate-to-severe ischemia. The aim of our study was to assess whether the results of the ISCHEMIA trial impacted on the management of CCS patients. Methods Trends in the management of patients with CCS in our centre, according to the ISCHEMIA trial publication date, were analyzed and patients categorized into pre-ISCHEMIA (before March 2020) and post-ISCHEMIA (from July 2020 to February 2022) groups, with an in-between blanking period of three months. The primary outcome was incidence of referral to ICA by coronary computed tomography angiography (CCTA). Secondary objectives included the incidence ischemia test-referred ICA, incidence of CCTA-referred ICA and subsequent percutaneous coronary intervention (PCI), incidence of ischemia test-referred ICA and subsequent PCI and incidence of CCTA-referred ICA without subsequent PCI. Differences between the pre-specified subpopulations (age ≥75 years, diabetes, chronic kidney disease [CKD], peripheral arterial disease [PAD], gender male, unstable angina, active smoking status, body mass index [BMI] &amp;gt;30, hypertension, family history of coronary artery disease [CAD], atrial fibrillation [AF], prior percutaneous coronary intervention [PCI], prior coronary artery bypass grafting [CABG]) and the general population of the study were tested using a regression analysis. Results A total of 2,365 patients were included, 487 (20.6%) and 1,878 (79.4%) in the pre-ISCHEMIA and post-ISCHEMIA groups, respectively. There were no notable between-group differences in baseline characteristics. The primary outcome occurred more frequently in the post-ISCHEMIA group (73.5% vs. 32.5%; p&amp;lt;0.01). Compared to pre-ISCHEMIA, the post-ISCHEMIA group displayed less referrals to ICA by ischemia testing (31.6% vs. 52.5%; p&amp;lt;0.01) and more ICA referrals by CCTA with subsequent PCI (8.3% vs. 12.0%; p&amp;lt;0.01). There were no within-group differences in ischemia test-referred ICA and PCI, and CCTA-referred ICA without subsequent PCI. A regression analysis between the primary endpoint incidence in the general population compared to the incidence in the pre-specified subpopulations showed no significant difference in the p values for interaction. Conclusions In the first two years from publication, the ISCHEMIA trial significantly impacted on the decision-making algorithm for patients with CCS, increasing referral to ICA by CCTA and diminishing ICAs indicated by an ischemia test.

76 INSIDE VEIN GRAFT FAILURE: A WORK FOR OCT

Abstract An 84-years-old woman with prior history of triple coronary artery bypass graft and subsequent percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) for right coronary artery (RCA) was admitted for non-ST-elevation myocardial infarction and newly diagnosed atrial fibrillation. Coronary angiography showed chronic occlusion of native vessels and good flow in all grafts, in absence of critical stenoses. However, SVG for RCA presented a small filling defect of non-univocal interpretation (atherothrombosis, thromboembolus, venous valve). Optical coherence tomography (OCT) was performed for better assessment of the lesion, which was found to be a red thrombus, overlying a ruptured thin-cap fibroatheroma. To reduce the risk of distal embolization, a well-known complication of SVG PCI, direct stenting with conservative stent sizing was performed: everolimus-eluting stent diameter (3,5 mm) was chosen according to mean reference lumen diameter, while length (18 mm) was determined to obtain complete plaque coverage. Repeated OCT showed proximal stent malapposition and underexpansion at the mid portion. The stent was post-dilated with 4,0×12 mm non-compliant balloon and final OCT showed correction of both malapposition and underexpansion. The presented case offers an example of the advantages of intravascular imaging in diagnosis and treatment of SVG lesions. Venous grafts have high failure rate: up to 12% of graft are occluded before hospital discharge and up to 60% after 10 years. While in the first year graft occlusion is mainly caused by neointimal hyperplasia, after this period neoatherosclerosis is the leading cause of failure, as exemplified in the case. Intravascular imaging, and particularly OCT, may help to elucidate graft failure mechanism, with important implications for treatment strategy. Moreover, SVG interventions have higher incidence procedural complications, particularly no-reflow and periprocedural myocardial infarction, due to high plaque burden and friable atheromatous material. Proposed strategies to mitigate procedural risk include use of embolic protection devices, direct stenting and use of undersized stents. In this complex setting, intravascular imaging can guide stent sizing and optimization, thus reducing procedural complications and long-term lesion failure.

Safety and Feasibility of Retrograde Recanalization of Radial Artery Occlusion in Patients with Need for Repeated Wrist Procedures

AIM: The purpose of the study was to present a new technique of retrograde recanalization of radial artery (RA) occlusion (RAO) in patients with need for repeated wrist access percutaneous angiographic procedures. MATERIALS AND METHODS: During a 10-year period from March 2011–May 2021, 53 000 patients were referred for percutaneous coronary intervention (PCI) in a high-volume transradial center. RAO on angiography was documented in 1165 patients. Retrograde recanalization of RAO was attempted in 70 patients. The selected patients were with multiple previous bilateral wrist interventions (n = 3–9). Ipsilateral ulnar artery was usually rudimented or occluded and contralateral wrist approach could not be used. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and procedural success of retrograde recanalization of RAO. Visual analog scale (VAS) score forearm pain assessment was performed after procedure. Technique: All patients had palpable pulse distal of previous puncture site due to collaterals from ipsilateral ulnar and interosseous artery. The RA was punctured with an inner metallic needle with a plastic cannula. Using retrograde radial angiography performed by injecting contrast through the plastic cannula, the occluded segment was visualized and crossed with different types of hydrophilic chronic total occlusion guide wires. After sheath insertion, balloon dilatation of the occluded RA segment, successful catheterization, and/or percutaneous coronary intervention was performed. Final RA angiography was performed on all patients. RESULTS: Successful retrograde opening of RAO was achieved in 65 out of 70 patients (92%). PCI was performed in 56% of patients through the opened RAO and 5 patients underwent CAS. Procedural success through opened RA was achieved in all 65 patients. Forearm pain during procedure was present in all cases (VAS score 3 ± 2.1). Access site bleeding EASY score 3 and 4 occurred in 6 patients (8.5%). One patient had discharge of embolic material up the arm without clinical consequences. In one patient, we observed dissection of the interosseous artery. Clinical and duplex long-term follow-up with a median of 4.1 years showed patent RA in only 20 patients. There were no registered cases of hand ischemia. About 61% of patients underwent subsequent PCIs, through other alternative access sites. CONCLUSION: Retrograde recanalization of RAO is successful and safe in patients with need of repeated coronary angiography procedures and inability to use other wrist access sites. Puncturing the collateral and performing retrograde radial angiography through the cannula is a key factor in successful opening of the RAO.

Abstract 157: Diagnostic Test Accuracy Of The ST-segment Elevation Myocardial Infarction Equivalents In Electrocardiogram After Return Of Spontaneous Circulation Among Out-of-hospital Cardiac Arrest Patients Without ST-segment Elevation

Background: Out-of-hospital cardiac arrest (OHCA) patients with acute coronary syndrome (ACS) needs emergent coronary angiography and subsequent percutaneous coronary intervention to improve their outcomes. ‘STEMI equivalents’ in electrocardiogram (ECG) are known to help the diagnosis of ACS. However, these findings have not been sufficiently evaluated among OHCA patients. This study aimed to evaluate the diagnostic test accuracy (DTA) of ‘STEMI equivalents’ to identify ACS among OHCA patients without ST-segment elevation. Methods/Results: Nine emergency medical departments among the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan collected the patients' first 12 leads ECGs after return of spontaneous circulation (ROSC) from 2012 to 2017. Patients with non-traumatic OHCA aged &gt;=18 years old with ventricular fibrillation / pulseless ventricular tachycardia as first documented rhythm or rhythm at hospital arrival were included. Of them, patients without ST-segment elevation nor complete left bundle branch block were extracted. The DTAs; sensitivity, specificity, positive likelihood ratio (LR+), and negative and likelihood ratio (LR-) of STEMI equivalents (i.e., Isolated T-wave inversion, Wellens signs) for the diagnosis of the ACS were evaluated. ACS was diagnosed by the physicians in each hospital based on the coronary angiography. Results: A total of 143 cases were included in the analysis and 79 patients were diagnosed as ACS. Isolated T-wave inversion was found in 7 (3.2%) patients in the ACS group and 3 (8.8%) in the non-ACS group. The Wellens signs was present in 5 (6.3%) and 5 (7.8%) patients, respectively. The isolated T-wave inversion and the Wellens signs had high specificity with 0.95 (95% CI: 0.87-0.99) and 0.92 (95% CI: 0.82-0.97), whereas these findings had low LR+ with wide range of 95% CI with 1.89 (95% CI: 0.51-7.02), and 0.81 (95% CI: 0.25-2.68), respectively. Conclusion: In this study, the DTA of STEMI equivalents of single 12 leads ECG alone were not sufficient for the diagnosis of ACS after ROSC among OHCA patients without ST-segment elevation. Further investigation of the DTA evaluation considering the measurement timing and the change of the ECG is needed.

Right versus left coronary artery involvement in patients with type A acute aortic dissection

BackgroundType A acute aortic dissection (AAD) complicated by coronary malperfusion is a life-threatening disease. In the present study, we compared the clinical characteristics and prognostic impact of treatment strategies including surgical treatment and percutaneous coronary intervention (PCI) in type A AAD patients with RCA and LCA involvement. MethodsThis multicenter registry included 220 patients with type A AAD and either RCA or LCA involvement. Treatment strategies were left to treating physicians. The primary endpoint was in-hospital death. ResultsOf 220 patients, 115 (52.3%) and 105 (47.7%) had RCA and LCA involvement. Patients with LCA involvement were more1 likely to present with Killip class IV on admission than those with RCA involvement. Coronary angiography was performed in 52 of 220 (23.6%) patients, among whom 39 (75.0%) underwent subsequent PCI. During the hospitalization, 93 (42.3%) patients died. Patients with LCA involvement had an increased risk of in-hospital mortality compared to those with RCA involvement (54.3% vs. 31.3%, p < 0.001). In patients with RCA involvement, multivariable analysis identified Killip class IV and no surgical treatment as predictors of in-hospital death, while PCI and surgical treatment were indicated as factors associated with lower in-hospital mortality in patients with LCA involvement. ConclusionsThe rates of RCA and LCA involvement were similar in type A AAD. Immediate PCI as a bridge to subsequent surgical treatment might improve survival in patients with type A AAD complicated by coronary malperfusion, especially in those with LCA involvement.

Multi-institutional distributed data networks for real-world evidence about medical devices: building unique device identifiers into longitudinal data (BUILD).

ObjectivesTo support development of a robust postmarket device evaluation system using real-world data (RWD) from electronic health records (EHRs) and other sources, employing unique device identifiers (UDIs) to link to device information.MethodsTo create consistent device-related EHR RWD across 3 institutions, we established a distributed data network and created UDI-enriched research databases (UDIRs) employing a common data model comprised of 24 tables and 472 fields. To test the system, patients receiving coronary stents between 2010 and 2019 were loaded into each institution’s UDIR to support distributed queries without sharing identifiable patient information. The ability of the system to execute queries was tested with 3 quality assurance checks. To demonstrate face validity of the data, a retrospective survival study of patients receiving zotarolimus or everolimus stents from 2012 to 2017 was performed using distributed analysis. Propensity score matching was used to compare risk of 6 cardiovascular outcomes within 12 months postimplantation.ResultsThe test queries established network functionality. In the analysis, we identified 9141 patients (Mercy = 4905, Geisinger = 4109, Intermountain = 127); mean age 65 ± 12 years, 69% males, 23% zotarolimus. Separate matched analyses at the 3 institutions showed hazard ratio estimates (zotarolimus vs everolimus) of 0.85–1.59 for subsequent percutaneous coronary intervention (P = .14–.52), 1.06–2.03 for death (P = .16–.78) and 0.94–1.40 for the composite endpoint (P = .16–.62).DiscussionThe analysis results are consistent with clinical studies comparing these devices.ConclusionThis project shows that multi-institutional data networks can provide clinically relevant real-world evidence via distributed analysis while maintaining data privacy.