SYNTAX Score Research Articles

Quantitative myocardial blood flow distribution derived from CCTA and determination of myocardium at risk in the FAST TRACK CABG trial

Abstract Background In the anatomic SYNTAX score derived from invasive coronary angiography, the ischemic impact of each stenotic coronary segment is weighed with a fixed score based on the severity of luminal diameter narrowing and the theoretical amount of blood flow supplied to the myocardium(1). This method neither accounts for individual variation nor reflects the true extent of myocardium ischemia. Purpose We aim to provide a quantitative CT SYNTAX score derived from coronary computed tomography angiography (CCTA) with customized percent blood flow distribution to the myocardium supplied by each stenotic coronary segment to determine the myocardium at risk of ischemia. Methods Patients with 3VD and/or left main coronary artery disease (CAD) were included in the first-in-human FAST TRACK CABG trial and received surgical revascularization guided solely by CCTA and fractional flow reserve derived from CCTA (FFRCT). The recently reported anatomic CT-SYNTAX score was calculated for all cases. The FFRCT value and percent myocardial blood flow distribution(%MBF) were computed for all 16 SYNTAX score segments using the validated method of Keulards et al(2). On the pre-CABG CCTA, the segments located distal to the site where the FFRCT value dropped below 0.80 were considered at risk of ischemia, and the individual weight point per segment was calculated as 6×%MBF for each segment. The SYNTAX score derived from %MBF is compared to the anatomic and functional CT-SYNTAX score. Results Out of 114 patients enrolled, FFRCT and %MBF were analyzable in 106 patients. After excluding vessels with total occlusion, the coronary flow distribution between the right and left coronary systems was 20.5% vs 79.5%, respectively, similar to the 1:5 ratio in the anatomic SYNTAX score. The anatomic and functional CT-SYNTAX scores were 43.6 and 41.1, respectively. The average total %MBF per patient was 72.0(19.1)%, and the average SYNTAX score derived from %MBF was 38.0. There is a strong correlation between functional SYNTAX score and SYNTAX score derived from %MBF (Peason’s R=0.93). Passing-Bablock regression trends showed that the functional SYNTAX score slightly overestimated the SYNTAX score derived from %MBF (Figure 1). The coronary segment weight varied significantly per individual, especially in the presence of total occlusion. Overall, the fixed weight of the anatomic SYNTAX score is a good surrogate for the individualized weighing based on %MBF (Figure 2). Conclusion CCTA-derived %MBF enabled clinicians to quantify the individualized myocardium at risk of ischemia or injury in patients with severe CAD. Retrospectively, the fixed weight score used in the anatomical SYNTAX score appeared to be a robust surrogate for myocardial blood flow distribution.Figure 1Figure 2

Correlation between LDL/HDL-cholesterol ratio and long term prognosis after acute coronary syndrome and severity of coronary artery disease

Abstract Introduction Dyslipidaemia is an important correctable risk factor for coronary artery disease (CAD). Many studies have confirmed that the lower the low-density lipoprotein cholesterol (LDL-C) levels are, the lower is the CAD morbidity and mortality rates (1). However, many patients who achieved low levels of LDL-C still experience a major adverse cardiovascular event (MACE) because of the other residual risk factors. Therefore, there is a constant need for better stratification of patients who are at higher risk for novel MACE following their first acute coronary syndrome (ACS). Evidence increasingly suggests that the ratio of LDL-C/HDL-C might be a new and better marker of cardiovascular disease, as it simultaneously evaluates the levels of both LDL-C and HDL-C (2). Purpose The aim of this study was to investigate the prediction value of LDL-C/HDL-C ratio for long term prognosis after ACS as well as its correlation with CAD severity. Methods We included patients hospitalized at out centre with ACS from January 2017 to January 2024. Demographic data, data on LDL-C and HDL-C levels on admission and calculated Syntax score were used. Syntax score is a comprehensive angiographic scoring system which determines complexity by using coronary anatomy and lesion characteristics (3). Follow-up data were collected either by clinical follow-up visits or by telephone interviews. The MACE was defined as the composite of cardiovascular death, acute coronary syndrome and need for elective or urgent percutaneous or surgical revascularization. Results This registry-based study included 2471 patients with ACS, median age of 64 (interquartile range 56-73) years, 31% female. Total of 1099 patients (44%) had non-ST elevation ACS and 1372 (54%) had ST elevation myocardial infarction (STEMI). Median Syntax score was 13 (IQR 7-20.5), with 1494 (61%) patients having low Syntax score (≤16), 508 (21%) patients medium (16-22), and 448 (18%) high score (>22), respectively. Median follow up was 17 (3-27) months. LDL-C/HDL-C ratio correlated significantly with cardiovascular death, with weak coefficient (2.94 vs. 2.54 p<0.001; rho=0.102, p<.0001), however did not correlate with MACE (2.88 vs. 2.92, p=0.188, rho=0.06, p=0.77). This remained identical when tested for patients with STEMI and non-STE ACS. In addition, LDL-C/HDL-C ratio did not correlate with CAD severity as assessed with Syntax score (low 2.92 vs. medium 2.83 vs. high 2.86, p=0.597; rho=0.4, p=0.09). Conclusion Our data suggest that LDL-C/HDL-C ratio cannot be used as a relevant predictor of post-ACS long-term MACE or cardiovascular death, nor it can be correlated with CAD severity. Further studies are needed to establish the real value of LDL-C/HDL-C ratio as a post-ACS predictor.

Lipidomics-based deep learning algorithms can enhance prediction of obstructive coronary artery disease

Abstract Background Lipidomics emerge as a promising research field with the potential to help in personalized risk stratification and also improve our understanding on the functional role of individual lipid species in the metabolic perturbations occurring in coronary artery disease (CAD). The existing technological challenges to detect diverse yet structurally similar lipids and their isomers, as well as the need for novel statistical and computational tools to handle the high-dimensional lipidome may be responsible for the reduced clinical translation of the very first lipidomics research outcomes. Methods To that end, this post-hoc analysis of the prospective CorLipid trial aimed to investigate the predictive capability of a lipidomics panel for obstructive CAD risk through an extreme gradient boosting (XGBoost) machine learning (ML) approach. The lipid profiles of 146 individuals with suspected CAD were investigated through liquid chromatography-mass spectrometry. Fasting blood samples were drawn prior to invasive coronary angiography execution. Obstructive CAD was defined as SYNTAX Score (SS) >0 compared to non-obstructive CAD (SS=0). Results Study participants (75.3% male, mean age: 61 ±10.5 years old) were divided into two categories based on the existence of obstructive CAD (54.8% with SS>0 and 45.2% with SS=0). In total, 517 lipid species were identified, from which 290 lipid species were finally quantified in participants’ serum [glycerophospholipids (52.1%), glycerolipids (28.6%) and sphingolipids (19.3%)]. The levels of glycerophospholipid, sphingolipid and glycerolipid classes were significantly different in patients with obstructive CAD. Finally, a ML XGBoost algorithm identified a panel of 17 serum biomarkers (5 sphingolipids, 7 glycerophospholipids, triacylglycerols, galectin-3, glucose, LDL and LDH) as totally sensitive (100% sensitivity, 62.1% specificity and 100% negative predictive value) for the prediction of obstructive CAD. Conclusions These findings provide molecular insights into the role of dysregulated lipid metabolism in the development and progression of CAD while validating the existing body of evidence from similar research studies. Further (ML-based) investigation of lipid metabolism could hold promises for novel therapeutic strategies and improvement of the existing risk stratification schemes.Lipidomics panel importance

Long-term outcome of diabetic patients after unprotected left main percutaneous coronary interventions

Abstract Background Diabetes mellitus (DM) represents an elevated risk in terms of percutaneous coronary intervention (PCI), especially in patients with significant left main (LM) disease. Purpose Our aims were to investigate the 60-month mortality and event-free survival of consecutive patients with DM undergoing unprotected LM PCI at our centre and sought to determine the independent predictors of event-free survival. Methods We included all patients undergoing unprotected LM PCI at our tertiary care centre between 1 January 2007 and 31 December 2014. The primary endpoint was the composite of all-cause mortality, myocardial infarction, and target lesion revascularization at 60 months. Survival curves were constructed using the Kaplan-Meier non-parametric estimator. ROC analysis was used to investigate the predictive power of conventional risk scores (SYNTAX, SYNTAX II, EuroSCORE II, additive and logistic EuroSCORE, ACEF, GRACE 2). Independent predictors were determined by univariate and multivariate analysis. Results A total of 513 patients (mean age 68 ± 12 years, 64% male) underwent unprotected LM PCI during this period, among these 310 (60%) were non-diabetic (non-DM) and 203 (40%) were diabetic (DM). In terms of indication, 157 (31%) elective and 356 (69%) acute LM PCI were performed. There was no significant difference between the non-DM and DM groups in terms of acute indication (218 (70%) vs. 138 (68%), p=0.574). Within the DM group, 135 (67%) were treated with oral antidiabetics (OAD) and 68 (33%) were treated with insulin (IDM). The mean survival (34.6 vs. 39.7 vs. 43.1 months, p=0.003) and event-free survival (29.3 vs. 34.7 vs. 39.3 months, p=0.001) were significantly lower in the IDM and OAD groups compared to non-DM, respectively. Of the risk scores, the SYNTAX score was the most predictive in diabetic patients (AUC=0.767). Based on the SYNTAX score, diabetic patients with a low SYNTAX score (<23) had less events (59% vs. 66%, p=0.043) than those having a moderate/high SYNTAX score (≥23). LVEF (HR 0.976; 95% CI, 0.965-0.987, p<0.001), right coronary artery occlusion (HR 2.031; 95% CI, 1.346-3.064, p=0.001), acute coronary syndrome (HR 1.861; 95% CI, 1.252-2.767, p=0.002), use of FFR (HR 0.481; 95% CI, 0.265-0.871, p=0.016), true bifurcation lesion (HR 1.559; 95% CI, 1.068-2.277, p=0.021) and newer DES generation (HR 0.706; 95% CI, 0.568-0.877, p=0.002) were predictors of event-free survival in diabetics by univariate analysis. Glomerular filtration rate (HR 0.982; 95% CI, 0.973-0.991, p<0.001) emerged as an independent predictor according to multivariate analysis. Conclusion Consecutive diabetic patients with significant unprotected LM stenosis have poor long-term outcome after LM PCI. Anatomical complexity of the lesions is a significant predictor of event-free survival. Careful intervention planning and the use of appropriate tools can improve the outcome in this high-risk population.

Clinical significance of residual ischemia in acute myocardial infarction complicated by cardiogenic shock undergoing VA-ECMO

Abstract Background Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction of residual ischemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischemia in patients undergoing mechanical circulatory supports. Objectives This study aimed to evaluate the effects of residual ischemia on clinical outcomes in AMI patients undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). Methods AMI patients with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischemia evaluated using the residual SYNTAX score (rSS): rSS=0, 0<rSS≤8, and rSS>8. The primary outcome was 1-year all-cause death. Results A total of 408 patients were classified into the rSS=0 (N=100, 24.5%), 0<rSS≤8 (N=136, 33.3%), and rSS>8 (N=172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9% vs. 55.4% vs. 66.1% for rSS=0, 0<rSS≤8, and rSS>8, respectively, overall P<0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (HRadj 1.03, 95% CI 1.01–1.05, P=0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. Conclusions In AMI patients with refractory CS who underwent VA-ECMO, residual ischemia was associated with an increased risk of 1-year mortality. Therefore, revascularization strategies to minimize residual ischemia should be considered in advanced CS, particularly in cases requiring VA-ECMO.

The impact of SYNTAX score on culprit lesion morphology of acute coronary syndrome

Abstract Background The SYNTAX score quantifies the complexity of coronary artery morphology and is useful in determining the indication for CABG (Coronary Artery Bypass Grafting) or PCI (Percutaneous Coronary Intervention), which often reflect coronary artery disease severity. However, how SYNTAX score affects etiology of ACS (Acute Coronary Syndrome) patients observed by OCT (Optical Coherence Tomography) has been unclear. Methods This is a sub study of TACTICS OCT registry (n=702) which include ACS patients who underwent OCT guided PCI. Based on SYNTAX score, patients were divided into low-SYNTAX-group (1-22 points) and high-SYNTAX-group (23 points or higher). ACS culprit lesions were classified into plaque rupture (PR), plaque erosion (PE), and calcified nodule (CN). We compared patient characteristics and culprit lesions in low-group and high-group. Results High-SYNTAX-group was significantly younger with relatively greater prevalence of diabetes and lower body mass index. Peak CK, LVEF, Multi vessel and TIMI grade were also significantly greater in high-SYNTAX-group than low-SYNTAX-group. Although PR and PE were 2 most common etiologies of ACS in both groups, proportion of CN was much greater in high-SYNTAX-group than low-SYNTAX-group. Conclusion High-SYNTAX score was likely to have impact on ACS etiology increasing proportion of CN.

Comparison of the prognosis between complete and incomplete revascularization among moderate to severe chronic kidney disease patients with acute coronary syndrome

Abstract Background Complete revascularization (CR) in acute coronary syndrome patients with multivessel disease (MVD) is recommended in current clinical practice guidelines. However, the benefit of CR in moderate to severe chronic kidney disease (CKD) patients remains controversial. We aimed to compare the clinical outcomes between complete and incomplete revascularization among moderate to severe CKD patients who presented with ACS. Methods Of 1,924 ACS patients who underwent percutaneous coronary intervention (PCI) in our center, 127 patients were CKD. CR was defined as residual SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score ≤ 3. The primary outcome was the patient oriented clinical outcome (POCO) at 1 year, including all-cause death, any myocardial infarction, any revascularization, and heart failure requiring hospitalization. Results The mean age of the patients was 73.89±9.07 years. The median estimated glomerular filtration rate (eGFR) was 32.56±10.68 ml per minute per 1.73 m2. The rate of POCO at 1 year was significantly lower in the CR group (16.3% vs 39.3%; HR 0.36; 95%CI, 0.16-0.81; p=0.014). The primary outcome was mainly driven by 1-year all-cause death which was significantly lower in the CR group (14.0% vs 39.3%; HR 0.32; 95%CI 0.13-0.76; p=0.017). The rate of initiation of renal replacement therapy was comparable (4.7% vs 2.4%; p=0.55). Conclusion CR with a target SYNTAX score ≤ 3 improved 1-year prognosis of POCO and all-cause death in ACS patients with moderate to severe CKD without increasing the rates of renal replacement therapy.1-year POCOPrespecified Subgroup Analysis of POCO

Impact of the distribution of calcification around the left main coronary artery bifurcation on prognosis after percutaneous coronary intervention

Abstract Backgrounds The presence of true bifurcation lesions (TBL) by Medina classification at the left main coronary artery (LMCA) bifurcation is known to be associated with cardiovascular events after percutaneous coronary intervention (PCI). However, the prognostic impact of the distribution of calcification at LMCA bifurcation has not been adequately investigated. Methods This retrospective study consisted of consecutive patients who were implanted with a second or subsequent generation drug-eluting stent for LMCA bifurcation at a single center from 2014 to 2018. We excluded patients with a protected LMCA and those in whom calcification or stenosis of the LMCA bifurcation could not be assessed. With reference to the Medina classification, the region was divided into three segments (LM, LAD, and LCX). Each segment was assigned a value of 0 (for less than moderate calcification) or 1 (for more than moderate calcification) and expressed as calc (X.X.X). Calc (1.1.1), calc (1.0.1), and calc (0.1.1) were defined as true bifurcation calcification (TBC). The primary endpoint was 3-year target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Results Of 498 patients in this analysis, the mean age was 73 years, males accounted for 78% overall, acute coronary syndrome 31% overall, and TBL 42% overall. Moderate or severe calcification at any site around the LMCA bifurcation was observed in 184 (37%). In order of frequency, calc (1.1.0) in 70 (14%), calc (1.1.1) in 58 (12%), calc (0.1.0) in 43 (9%), calc (0.1.1) in 11 (2%), and calc (1.0.1) in 2 (0.4%), while calc (1.0.1) and calc (1. 0.0) were not present. TBC accounted for 14% overall. Patients with TBC at LMCA bifurcation had a higher incidence of 3-year TLF (Log-rank P <0.001; Figure1). Multivariable logistic regression, including age, acute coronary syndrome, maintenance hemodialysis, SYNTAX score ≥33, TBL, and TBC in the model as covariates, TBC was significantly associated with the primary endpoint (adjusted odds ratio 3.4, 95% confidence interval 1.6-7.2, P=0.013). In contrast, a significant association between TBL and the primary endpoint was not observed (adjusted odds ratio 1.5, 95% confidence interval 0.8-2.8, p=0.206). Conclusion Even after adjusting the presence of TBL at LMCA bifurcation, the presence of TBC at LMCA bifurcation was significantly associated with the 3-year TLF.

One-year clinical outcome of aspirin-free prasugrel monotherapy following stent implantation in patients with chronic coronary syndrome: insight from ASET-JAPAN study

Abstract Background Single antiplatelet therapy with a potent P2Y12 inhibitor without aspirin after coronary stent implantation may provide an adequate balance between ischemic and bleeding risks in selected patients. The 3-month follow-up of the Acetyl-Salicylic Elimination Trial (ASET)-Japan pilot study demonstrated the feasibility and safety of Prasugrel monotherapy without aspirin after successful percutaneous coronary intervention (PCI) in selected patients with chronic coronary syndrome (CCS). Purpose The current study aimed to evaluate the 1-year clinical outcome in the ASET-Japan. Methods The ASET-Japan pilot study was designed to demonstrate the feasibility and safety of the approved dose of prasugrel monotherapy in Japan without aspirin after optimal PCI with a platinum-chromium everolimus-eluting stent in CCS population. After successful procedure, all patients were treated with a locally approved maintenance dose of 3.75 mg/day of Prasugrel monotherapy up to 3-month. After 3-month, the choice of antiplatelet therapy was left to the discretion of the investigators. Patients were followed up to 1 year. The target lesion-related endpoint was a composite of cardiac death, spontaneous target-vessel myocardial infarction (MI) >48 h after the index PCI or clinical-driven target lesion revascularisation. Patient-Oriented Composite Endpoint (POCE) was defined as a composite of all cause mortality, any stroke, any MI and any revascularisation. Spontaneous MI was defined according to Forth universal definition. The event rate was estimated by the Kaplan-Meier method. The event was adjudicated by an independent clinical event committee. Results A total of 208 patients were enrolled in the study. The average anatomical SYNTAX score was 7.96 (±4.6). After procedure, prasugrel monotherapy was immediately initiated. After 3-month, Prasugrel monotherapy was continued in 88.6% up to 1-year. Aspirin monotherapy was prescribed to 10 patients (5.0%), while 6 patients (3.0%) were on DAPT at 1-year. All-cause mortality rate was 1.49%, with no occurrence of cardiovascular death. Revascularisation occurred in 4.0% (n=8) with no occurrence of TLR, while one patient (0.5%) underwent a clinical driven target vessel revascularisation. In summary, 7 out of 8 revascularisations were non-target vessel revascularisation (6 clinically-driven non-TVR). Spontaneous non TV-MI occured in 0.5% (n=1) of patients. There was no definite/probable stent thrombosis up to 1 year. The target lesion related endpoint rate at 1-year was 0%, whereas 1-year POCE rate was 7.0% (n=14). Conclusion Discontinuation of Aspirin and Prasugrel monotherapy at a low maintenance dose of 3.75 mg/day following an angiographically successful stent deployment was feasible and safe in selected patients with CCS and low SYNTAX score. This safety profile is confirmed at 1 year while the investigators, in their large majority and at their own discretion, had maintained the prasugrel treatment.

Clinical outcome based on functional complete revascularization in patients with three-vessel coronary artery disease: The FAME 3 Trial

Abstract Background Anatomic complete revascularization after angiography-guided percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. The impact of functional complete revascularization (PCI of all fractional flow reserve (FFR) positive lesions) in patients with 3-vessel coronary artery disease (3VD) amenable to PCI or coronary artery bypass grafting (CABG) is unknown. Purpose To investigate the clinical impact of functional complete revascularization after FFR-guided PCI in the FAME 3 trial Methods The FAME 3 trial is a multicenter, international, randomized study comparing FFR-guided PCI with CABG in patients with angiographic 3VD. This pre-specified sub-study evaluated the impact of functional complete revascularization after PCI on the primary endpoint of death, myocardial infarction (MI), or stroke at 3 years. The degree of functional complete revascularization was quantified by calculating the residual functional SYNTAX score (rFSS), defined as the residual anatomic SYNTAX score based on post-PCI angiography minus any FFR-negative deferred lesions. Results Of the 757 patients treated with FFR-guided PCI, the rFSS could be calculated by the core laboratory in 81% (n=601). Among the angiographically significant lesions, PCI was deferred based on FFR in 17% (51 % of patients had deferral of at least one lesion). The patients were divided into two groups according to acceptable functional complete revascularization: rFSS 0-8 (63%) and functional incomplete revascularization: rFSS>8 (37%). The cumulative incidence of death, MI, or stroke at 3 years was significantly lower in patients with rFSS 0-8 (9% vs. 17%, Hazard ratio[HR]:0.5, 95% confidence interval[CI]:0.3-0.8, p=0.006) compared with rFSS>8. In comparison with the CABG arm, the patients with rFSS 0-8 had similar outcome (HR:0.97, 95%CI:0.6-1.5, p=0.87), while in those with rFSS >8 outcome was worse (HR:1.9, 95%CI: 1.3-2.8, p=0.002) (Figure). There was no difference in death, MI or stroke in CABG patients with or without anatomic complete revascularization. In a multivariate-adjusted model, rFSS>8 showed a significant association with death, MI or stroke at three years (adjusted HR: 1.83, 95% CI: 1.09-3.09, p=0.02). Conclusions Acceptable functional complete revascularization with FFR-guided PCI in patients with 3VD is an independent predictor of death, MI or stroke at three years and can be achieved in 63% of patients resulting in similar outcomes compared with CABG.

Impaired strain in diabetic patients with stable coronary artery disease assessed by cardiac magnetic resonance

Abstract Background Type 2 diabetes mellitus (T2DM) can contribute or lead to myocardial structural derangement by multiple mechanisms, including ischemic cardiomyopathy and, more rarely and of difficult evaluation, diabetic cardiomyopathy. Early stages of myocardial dysfunction can be assessed by strain analysis with cardiac magnetic resonance feature tracking (CMR-FT), however, there is no studies that examined deformation parameters in diabetic patients with stablished coronary artery disease (CAD). Purpose We sought to compare the strain parameters of patients with and without T2DM with stable CAD. Methods Patients with stable multivessel CAD and preserved left ventricular ejection fraction (LVEF), included in the MASS V trial, underwent contrast-enhanced cardiac magnetic resonance before revascularization procedures. Patients were stratified according to T2DM diagnosis at baseline. Feature tracking was performed using short-axis cine images and 2- and 4-chamber long-axis images. The left ventricular endocardial and epicardial contours of the end diastole phase were manually delineated in all images. Automatically tracking contours were performed to calculate left ventricular global longitudinal (LVGLS), circumferential (LVGCS) and radial (LVGRS) strain (FIGURE 1). Results Of 202 patients studied, 88 (44%) were diabetic and 114 (56%) non-diabetic. Baseline characteristics were similar between groups (age 70 ± 10 vs 69 ± 11; 69% vs 68% males; LVEF 65 ± 13 vs 67 ± 9). Mean Syntax score was 21.2 ± 8.5 vs 20.4 ± 8.5 (P=0.52) in diabetic and non-diabetic, respectively. There were no differences in left ventricle volumes, mass and LVEF. Mean LGE mass was 2.3 ± 0.9 vs 1.9 ± 0.9 grams (P=0.32) respectively in T2DM and control groups. Strain values were all reduced in T2DM patients, as shown in FIGURE 2 (LVGLS: -15.5% ± 2.3% vs -17.5% ± 2.7%, P=0.02; LVGCS: -15.4% ± 2.6% vs -17.4% ± 3.0%, P=0.03; LVGCS: 25.9% ± 5.9% vs 29.5% ± 7.2%, P=0.01). Multivariable analyses adjusted for age, sex, BMI, hypertension, Syntax score and LGE mass showed no differences in the results. Conclusion In this study, T2DM was associated with impaired deformation parameters (decreased left ventricular global longitudinal, circumferential, and radial strain). These findings suggest myocardial dysfunction in diabetic patients when compared to control subjects in the setting of stable multivessel CAD.FIGURE 1FIGURE 2

Is there a gender difference in the effects of cardiovascular risk factors on the anatomical localization and severity of obstruction on coronary arteries?

Abstract Background Whether there is a gender difference in the effects of traditional cardiovascular risk factors(CVRF) on the anatomical localization(AL) and severity(AS) of obstruction on coronary arteries(CA) remains unclear. Purpose In our study, we investigated whether there is a gender difference in the relationship between CVRF and obstruction on CA . Methods We included 978 patients(49.9% women, mean age: 61+10.3) with stable chest pain undergoing invasive coronary angiography between 2019-2021 who were recruited from the database of our clinic. We examined the gender difference in hypertension(HT), diabetes mellitus(DM), smoking, hyperlipidemia, previous history of CAD(H.CAD) and family history of premature CAD(F.CAD) and their correlation with the AL and AS of obstruction on CA in both gender. Results Women were older(p<0.001) with higher rates of HT (p=0.001) and DM(p=0.026) and higher TC, LDLC and HDLC levels respectively (rs) as (p=0.001, p=0.001, p=0.001). Whereas H.CAD and smoking rates were higher in men rs as (p=0.001, p=0.009). The incidence of critical stenosis (≥70 obstruction) & intermediate lesions (50-69%) on all CA and Syntax scores were higher in men(p<0,01). In patients with HT, severe CAD was more prominent on circumflex (Cx)(p=0.029) and right coronary artery(RCA)(p=0.002) in women and on the proximal ( p=0.024) and mid portion of left anterior descending artery(LAD) (p=0.045) in men. In patients with DM a statistically significant(ss) correlation was found between the presence of DM and AS in all vessels except for left main coronary artery (LMCA) in women (LAD prox:p=0.001; LAD mid:p=0.001; diagonal artery(Dg):p=0.003; Cx:p=0.001; RCA:p=0.001 ;LMCA:p>0.05). However no such correlation was observed in men(p>0.05). In patients with H.CAD moderate/severe lesions were more common on proximal(p=0.013) and mid portions of LAD(p=0.021), on CX( p=0.006) and on RCA(p=0.016) in men and more common on the proximal portion of LAD(p=0.047), CX(p=0.014) and RCA(p=0.009) in women. For either smoking and F.CAD there was no such correlation in either gender (p>0,05). As for blood lipid levels no correlation was observed between LDLC, HDLC and triglyceride levels and AL&AS in men(p>0,05). However there was a negative, weak correlation between the HDLC levels and obstruction on LAD mid portion(r=-0.140; p=0.003); on Dg(r=-0.100; p=0.034) on CX (r=-0.154; p=0.001) and on RCA (r=-0.151; p=0.001) in women. Conclusion Major traditional CVRFs have a sex specific impact on AL and AS of obstruction on CA. In the era of precisıon medicine we need gender specific risk scoring systems taking these gender differences into account.

Does initial use of large versus small burr size in left main stem bifurcation impact clinical and procedural outcomes?

Abstract Background Coronary calcifications, detected in up to 25% of treated coronary lesions nowadays, has a well-known association with complications during PCI, particularly for left main stem (LMS) interventions. Current guidelines recommend coronary artery bypass grafting for patients with LMS disease, particularly with high SYNTAX score ≥ 33. However, in those with increased surgical risk, PCI can be used particularly with use of rota-ablation (RA). RA is a well-established treatment for heavily calcified disease particularly in non LMS sites. However, data on the safety and efficacy of use of RA in LMS bifurcation management is limited. Current guidelines recommend using a small burr size at the start, with upsizing burrs if required. Whether upfront use of large burr size ≥ 1.75 versus smaller burr size in this context in is safe or effective is unknown. Methods This was a retrospective, single centre, study. Included patients undergoing RA to LMS bifurcation disease. Standard procedures for RA were applied to each case, following current national and international intraprocedural standards. The main study outcomes were overall mortality at 1 year, and a comparison of mortality at 1 and 4 years between groups and repeat target lesion revascularization at 4 years. Results To our knowledge, this is the largest series of LMS rota-ablation cases, with the longest available follow up. Between June 2009 and October 2021, we included 243 patients with a mean age of 74.7±9 years. Males formed 80% of the cases. 51.4% of patients were treated with a large bur size ≥ 1.75mm, with more males being treated with large burr size. Most treated lesions were true bifurcations (85.6%). Treated lesions were complex (Syntax score = 35.3 ± 10.6). Radial access was used in almost two thirds of patients, with size 7F sheath being the most used. Intravascular ultrasound was more commonly used with large burr size (p = 0.017). Upfront 2-stent techniques, predominantly culotte, was employed more often with large burr size. Provisional technique was used more often in the small burr size group. The burr size to vessel size was 0.4 in small burr group versus 0.48 in large burr size using stent size as a surrogate for vessel size. Post dilatation balloons were larger as well as stent size in the large burr group. The overall 1-year mortality for the group was 12.7% similar to international literature. Importantly, procedural complications were not different between groups, and similarly mortality at 1 and 4 years, p = 0.082 and p = 0.384 respectively. There was no difference between groups in terms of repeat vessel revascularization at 4 years p=0.487. Conclusions Upfront use of large burr size ≥ 1.75 is feasible and safe to treat LMS bifurcation disease with no increase in procedural complications or mortality and target lesion revascularization on long term follow up. It is notable that in-hospital mortality for this cohort was low at 1.6% in comparison to previous studies.1 and 4 year mortality KM curves

Optimizing elective high-risk PCI with ECMO support: the value of completely percutaneous use of VA-ECMO

Abstract Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a suitable manner to prevent hemodynamic deterioration during high-risk percutaneous coronary intervention (PCI). VA-ECMO is mainly surgically deployed under general anaesthesia. New developments now facilitate completely percutaneous insertion of VA-ECMO with only local anaesthesia, reducing operating team size and hospital costs. Purpose The aim of this study is to provide data on the outcomes of completely percutaneous use of VA-ECMO during high-risk PCI with local anaesthesia. Methods A retrospective single-centre registry was performed including all patients undergoing ECMO-assisted high-risk PCI, who were rejected for coronary artery bypass graft (CABG) as primary treatment option. Primary endpoint was the incidence of major adverse cardiac events (MACE), assessed during hospital admission and after discharge up to 90 days. Results Between January 2020 and February 2024, 34 patients undergoing ECMO-assisted high-risk PCI were included. The mean age of the population is 71.9 (± 8.4) and 27 (79.4%) patients are male. The mean left ventricular ejection fraction is 28.5 (± 11.1) percent and complexity indices were high, including STS mortality score: 4.1 (± 2.8), SYNTAX score I: 31.7 (± 9.4), SYNTAX score II: (PCI) 54.8 (± 10.8). Femoral artery was used for cannulation in 30 (88.2%) patients, of which one patient required an additional femoral backflow cannula due to prolonged ECMO support. Local anaesthesia in combination with preprocedural oral benzodiazepine was the preferred choice of anaesthesia (85.3%). Closure was predominantly performed with a percutaneous closure device (97.1%). Successful revascularization and procedural success were achieved in all patients. In-hospital MACE occurred in 2 (6.1%) patients. MACE occurred within 90 days in 5 (20.8%) patients after discharge. Conclusion High-risk PCI with completely percutaneous use of VA-ECMO with local anaesthesia is a novel concept, providing a suitable alternative to the standard surgical use of VA-ECMO with general anaesthesia.

Impact of waist circumference and abdominal fat distribution on coronary artery disease severity stratified by computed tomography-derived SYNTAX score

Abstract Background Waist circumference (WC) is the most convenient anthropometric measure of obesity. Recently, abdominal fat distribution (AFD) has been identified as a more important risk factor for coronary artery disease (CAD) than the absolute amount of adipose tissue. However, studies examining the impact of body composition indicators (BCIs) on CAD severity are lacking. The computed tomography (CT)-derived SYNTAX score (CT-SXscore) is a feasible method for grading CAD severity based on coronary CT angiography (CTA) findings. Purpose This study was aimed to evaluate the association between BCI and CAD severity using the CT-SXscore. Methods We enrolled consecutive patients with suspected CAD who underwent CTA using a 320-row multidetector CT scanner between October 2014 and March 2020. Plain abdominal CT was also performed at the umbilical level to measure the visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) areas. The total adipose tissue (TAT) area was calculated as the sum of VAT and SAT. To assess the AFD, the VAT/SAT (V/S) ratios were also calculated as the VAT area divided by the SAT area in each case. WC was measured by tracing the body contour at the umbilical level in CT images. The severity of coronary artery stenosis was assessed using CTA. Significant stenosis was defined as a stenosis diameter of ≥50%. The CT-SXscore was calculated in patients with more than one significant stenoses. Each stenotic lesion was evaluated to calculate the CT-SXscore in the same manner as the invasive coronary angiography assessment. We assessed the effects of BCI [i.e., WC, body mass index (BMI), each adipose tissue area, and V/S ratios] on the CT-SXscores. Results 308 eligible patients (mean age, 70.9 ± 10.6 years; 69.5% males) were evaluated. The median values of WC, BMI, TAT, SAT, VAT, and V/S ratio were 84.8 cm, 23.6 kg/m2, 198.2 cm2, 111.8 cm2, 81.0 cm2, and 0.67, respectively. Although WC showed a significant correlation with BMI, TAT, SAT, and VAT area, no correlation was observed between WC and V/S ratio (Figure1). The CT-SXscore showed no association with WC, BMI, and TAT area; however, it exhibited a weak negative correlation with the SAT area and a weak positive correlation with the VAT area. Additionally, a strong correlation was observed between the CT-SXscore and V/S ratio. In the multivariate regression analysis, WC, BMI, TAT, SAT, and VAT were no longer associated with the CT-SXscore after adjusting for traditional coronary risk factors, whereas the V/S ratio remained as the only independent predictor of CAD severity based on the CT-SXscore (Figure2). Conclusions WC was strongly correlated with other BCIs, except for the V/S ratio; however, it could not be identified as a predictive factor of CAD severity. Among the BCIs, only the V/S ratio was an independent predictor of CAD severity, indicating that the AFD revealed by the V/S ratio may be a more important risk factor for progression of CAD than other BCIs.Figure1Figure2

Comparative characteristics and invasive management in patients with non-ST elevation acute coronary syndromes in two high-volume hospitals from Romania and Germany

Abstract Introduction Cardiovascular disease (CVD) carries the highest mortality burden across Europe, acute coronary syndromes (ACS) being responsible for most CVD-related deaths. However, significant regional differences in ACS management have been reported. Purpose To describe the characteristics and management of patients with higher-risk non-ST elevation ACS (NSTE-ACS) in 2 high-volume hospitals from 2 European countries with different prevalence of CVD and different income (Germany – GER and Romania – RO). Methods All consecutive invasively managed high and very-high risk NSTE-ACS patients admitted in 2022 in two high-volume hospitals from GER and RO were identified. Patient clinical profiles, coronary anatomy, revascularization strategies, and in-hospital outcomes were compared. Results were adjusted for age and gender. Results 707 patients (345 GER, 66.7% male; 362 RO, 71.5% male; p>0.05) were included. RO patients were younger (65.5 vs. 70.1 years), with higher rates of hypertension (88.7% vs. 82.0%), dyslipidemia (95.6% vs. 81.7%), diabetes (46.1% vs. 34.5%), and active smoking (37.3% vs. 23.5%) (all p<0.05); whereas GER patients had higher rates of atrial fibrillation (36.2% vs. 23.2%), chronic respiratory disease (24.6% vs. 10.5%), sleep apnoea (9.0% vs. 1.4%), thyroid disorders (24.1% vs. 6.4%), and prior revascularization by percutaneous coronary interventions (PCI) (36.5% vs. 20.2%) or coronary artery bypass grafting (CABG) (15.7% vs. 3.0%) (all p<0.05). Mean left ventricular ejection fraction (LVEF) was lower in the RO cohort (43.4% vs. 48%, p<0.001). Rates of myocardial infarction diagnosed by high-sensitivity troponin I assays (88.7% GER, 87.6% RO), and median diagnosis-to-cathlab intervals (12.8 hours GER, 15.5 hours RO) were similar (all p>0.05). In the obstructive coronary artery disease (CAD) group (80.3% GER, 84.3% RO), no differences were found in multivessel disease rates (67.1% GER, 69.8% RO) or mean SYNTAX score (18.6 GER, 16.9 RO) (all p>0.05). For type 1 NSTE-ACS (67% GER vs. 79% RO, p<0.001), PCI represented the main revascularization method (88.3% GER vs. 78.3% RO, p<0.05). Excluding patients with prior CABG undergoing PCI, complete revascularization (residual SYNTAX score ≤8), was reported in 77.1% GER and 84.4% RO of the PCI cases (p>0.05). Intravascular imaging was used in 28.4% of PCIs in GER, and in none in RO. In-hospital mortality (7.0% GER, 6.8% RO), and rates of major adverse cardiovascular events, defined as a composite of death, myocardial infarction, and stroke (8.1% GER, 9.1% RO), were similar (all p>0.05). Conclusions Higher-risk NSTE-ACS patient profiles mirror overall country CVD risk patterns. Compared to Germany, patients in Romania are younger, with a higher CVD risk factor burden, lower LVEF, underdiagnosis of major non-CVD comorbidities, and delayed CAD diagnosis. Despite similar guideline-directed management and in-hospital outcomes in both centres, these aspects may influence the long-term prognosis.

Assessment of surgical revascularization completeness with quantitative myocardial blood flow distribution derived from CCTA in severe coronary artery disease

Abstract Background Complete revascularization remained the "holy grail" in the treatment of patients with severe coronary artery disease (CAD). However, there is no universally accepted definition of complete revascularization after coronary bypass graft surgery (CABG). The current assessment methods are visual, categorical, and biased by the operator's intention. Moreover, no method to date provides an individualized quantification of residual ischemia burden. Purpose We aim to provide an individualized method to assess the completeness of surgical revascularization through quantitative myocardial blood flow distribution derived from coronary computed tomography angiography (CCTA) that could reflect the actual functional ischemia burden after CABG. Methods Patients with 3VD and/or left main CAD were enrolled in the first-in-human FAST TRACK CABG trial for surgical revascularization guided solely by CCTA and fractional flow reserve derived from CCTA (FFRCT). Following CABG, the study protocol mandated a 30-day follow-up CCTA, which provides graft patency and topographical adequacy of the bypass graft anastomoses. The pre- and post-CABG CCTA were analyzed. The FFRCT value and percent myocardial blood flow distribution (%MBF) were computed for all 16 SYNTAX score segments using the validated method of Keulards et al(1). On pre-CABG CCTA, the myocardium located distal to the site where the FFRCT value dropped below 0.80 on the vessel centerline was considered ischemic, and the %MBF of the subtended myocardium was summed into the total percent ischemic myocardium (Figure 1). Following CABG, the segment was considered adequately revascularized when a non-narrowed graft was anastomosed distally to the site of FFRCT≤0.8 on the pre-operative CCTA. The change in percent ischemic myocardium and the residual ischemic burden were calculated for each patient (Figure 2). Results CCTA, FFRCT, and %MBF were obtained pre- and post-CABG in 96 patients, and the percent ischemic myocardium was computed per patient. At baseline, the average percent ischemic myocardium was 72.0(19.1)%. Post-CABG, the residual percent ischemic myocardium was 13.6(15.1)%. Residual percent ischemic myocardium <10% was achieved in 44 patients (44.8%). The first diagonal branch(n=13), distal LCX(n=12), and the first obtuse marginal branch(n=10) were the most frequent segments not revascularized, which subtended an average MBF of 12.2(3.5)%, 16.7(8.4)%, and 11.3(7.3)%, respectively. The main reason for inadequate revascularization was surgical deferral, with graft occlusion accounting for only 13.6% of the residual ischemic segments. Conclusion Percent ischemic myocardium and the completeness of surgical revascularization can be assessed with CCTA-derived %MBF. This novel method allows clinicians to assess the individualized ischemia burden and the completeness of revascularization that could be incorporated into personalized CABG planning.Figure 1Figure 2

Segmental post-PCI physiological gradients using ultrasonic or optical flow ratio

Abstract Background Segmental pressure gradients post percutaneous coronary intervention (PCI) may detect residual disease and potential targets for optimization. Ultrasonic flow ratio (UFR) or optical flow ratio (OFR) provide simultaneous physiological and morphological data using a single imaging catheter. Notably, both have been validated against wire based FFR Objectives To evaluate the utility of UFR and OFR to identify residual disease post-PCI. Methods The present study is a sub analysis of the ASET (Acetyl Salicylic Elimination Trial) JAPAN pilot study Phase I which showed the feasibility and safety of low dose prasugrel monotherapy following PCI in Japanese patients presenting with chronic coronary syndrome and an anatomical SYNTAX score <23. Patients with complete intra-vascular imaging pullback data were included with UFR/OFR acquired in all patients post-PCI. Quantitative and qualitative assessment of IVUS or OCT pullbacks was performed by automatically delineating vessel, lumen, and stent contours every 0.5 mm using QCU-CMS (version 4.69, Division of Image Processing, Leiden University Medical Centre). UFR or OFR was calculated using the respective IvusPlus or OctPlus software, Pulse Medical, Shanghai, China.(13)(15) All UFR and OFR tracings, and IVUS and OCT pullbacks were analyzed at the CORRIB Core lab, Galway, Ireland by two analysts blinded to clinical and procedural data. Anatomically focal lesions distal and proximal to the stent were evaluated in segments ≥5mm long. UFR/OFR virtual pullback curves were used to calculate intra-stent pressure gradients and physiologically define lesions as focal or diffuse by segmental pressure drops ≥0.05 over lengths <10mm or ≥10mm, respectively. Results The median post-PCI UFR/OFR was 0.93 (0.88-0.96) with 69/195 vessels (35.4%) having a UFR/OFR≤0.90. There were significantly more focal anatomical and physiological lesions proximal and distal to the stent in vessels with a UFR/OFR≤0.90 versus >0.90. In vessels with a UFR/OFR≤0.90 there was moderate agreement (weighted kappa=0.553, p<0.001) between anatomical and physiological focal lesions proximal to the stent, whilst it was fair (weighted kappa=0.219, p=0.002) distally. In-stent gradient had poor discriminative ability to detect significant stent under-expansion. The performance of a proximal or distal virtual FFR gradient to detect proximal or distal anatomically focal disease was good (AUC–0.835 and 0.877, respectively) Conclusions UFR/OFR enables suboptimal vessel physiology post-PCI to be detected and helps identify the precise anatomical location with corroboration from intra-vascular imaging. Adequately powered physiology optimization trials using UFR/OFR will determine the role of combined morphology and physiological evaluation post PCI in improving clinical outcomes.

Clinical prediction model of main adverse cardiovascular and cerebrovascular events for elderly patients with acute coronary syndrome

Abstract Background Age is an independent factor for adverse outcomes in acute coronary syndrome (ACS). With the accelerated aging process, there is an increasing incidence of ACS in the elderly; however, research on this population is underrepresented. Due to the unique presence of multiple diseases and organ changes in the elderly, specialized risk assessment tools are required. Purpose To explore the risk factors for poor prognosis of elderly patients with ACS and establishing a risk stratification tool. Methods The derivation cohort consisted of 1674 elderly ACS patients consecutively enrolled in a single center from January 2013 to December 2013. The validation cohort included 2333 elderly ACS patients consecutively enrolled in nine medical centers from January 2015 to May 2019. All patients were followed up for 2 years, and the study endpoint was defined as major adverse cardiovascular and cerebrovascular events (MACCE). Model selection was performed using Cox regression and the Akaike Information Criterion (AIC) to construct the final risk assessment model. The performance of the predictive model was evaluated in the derivation and validation cohorts using the c-index, receiver operating characteristic (ROC) curves, and calibration curves. Results A total of 1,674 elderly ACS patients (70.97±4.68 years, 23.24% female) were included in the derivation cohort, and 210 cases (12.54%) of MACCE were recorded during the 2-year follow-up period. In the validation cohort, there were 2,333 elderly ACS patients (72.13±5.82 years, 35.83% female), with 364 cases (15.60%) of MACCE documented during the 2-year follow-up. Initially, 25 variables were preliminarily selected based on the results of univariate Cox regression and the clinical importance of these variables. Subsequently, these variables were included in a multivariable Cox model, and model selection was performed based on the AIC, resulting in the final selection of 10 variables (including age, cardiac insufficiency, current smoker, DAPT use, history of PCI or CABG, IABP use, number of lesions, residual SYNTAX score, preoperative HGB, and preoperative PLT). Then we developed and validated a nomogram to predict the 2-year MACCE in elderly ACS patients based on the assessment of 10 clinically easily obtainable variables during hospitalization. In both the derivation and validation cohorts, the nomogram demonstrated good discriminative ability (AUC of 0.723 and 0.699, c-index of 0.727 and 0.661, respectively) and calibration (calibration curves closely approximating the 45-degree diagonal line). The Kaplan-Meier analysis reveals significant differences in MACCE incidence rates between groups stratified by the median predicted probability (p<0.001). Conclusion Our study developed and validated a practical nomogram for predicting the 2-year risk of MACCE in elderly patients with ACS.

Prognostic role of post-percutaneous coronary intervention quantitative flow ratio

Abstract Background/Introduction Accumulated evidence supports the prognostic value of post–percutaneous coronary intervention (PCI) physiological measurement. Quantitative Flow Ratio (QFR) is a well-studied angiography-based method for functional assessment. Purpose To investigate the possible prognostic implications of post-PCI QFR in patients undergoing revascularization. Methods We performed offline QFR analysis in all-comers undergoing PCI in a single center. A cut-off value of 0.8 was used to classify patients in high post-PCI QFR group (>0.8) and low post-PCI QFR group (≤0.8). Patients with at least one vessel with post-PCI QFR ≤0.8 were classified in the low post-PCI QFR group. Primary endpoint was the composite outcome of death, myocardial infraction, ischemia-driven revascularization, and heart failure-related hospitalization. Results We included 297 patients in the study. Mean age was 64 (±11) years and 81% of patients were male. Number of patients presented with chronic coronary syndrome was comparable to that of patients presented with acute coronary syndrome (52.9 vs 47.1 %, respectively). Patients in the low post-PCI QFR group had more often diabetes mellitus, lower left ventricular ejection fraction (LVEF) and higher SYNTAX score compared to patients in the high post-PCI QFR group. Median follow-up period was 29 (26-34) months. After adjusting for covariates, low post-PCI QFR was independently associated with higher rate of the composite outcome (HR: 2.22 95% CI 1.01-4.88, p=0.047). Conclusions In our study, patients with lower post-PCI value were independently associated with higher risk of cardiovascular adverse events.