Target Coronary Artery Research Articles

Transatlantic Telerobotic Coronary Angiography: A Pre-clinical Feasibility Study

Patients in many underserved geographies lack access to invasive coronary angiography (ICA). This preclinical study explored the feasibility of telerobotic ICA between separate continents. Using a novel robotic system, attempts were made to navigate a magnetic guidewire and diagnostic catheter from the aortic arch into a target coronary artery ostium in a fluid-filled cardiac model. The model and robotic system were located in Zürich, Switzerland. The operating physician was either "onsite" in the laboratory in Zürich or "transatlantic," in which the physician remotely controlled the robot from Grand Rapids, Michigan, USA. An onsite control group of 40 manual catheterization cases was made for comparison. The primary endpoint was technical success (catheter engagement into target ostium without conversion to manual). A secondary endpoint was engagement time (time from initial robotic manipulation to engagement in target ostium). In 260 consecutive attempts, of which 40 (15.4%) were "onsite" and 220 (84.6%) were "transatlantic," technical success was 97.5% onsite and 100% in the transatlantic group (P=0.154). Median engagement times were 33.2 seconds (25th, 75th percentile: 24.9, 45.0 seconds) onsite and 26.7 seconds (25th, 75th percentile: 21.7, 35.5 seconds) transatlantic (P=0.003). Median engagement time was faster for manual cases (17.1 seconds [25th, 75th percentile: 12.2, 23.2 seconds]) compared to both robotic groups (P<0.001). In this preclinical study, the proof-of-concept for telerobotic ICA was successfully demonstrated. Furthermore, the current limits of telerobotic capabilities were tested by conducting ICA between separate continents and showing that transatlantic telerobotic navigation of endovascular devices is now technically possible.

Medium and long-term patency results of distal anastomosis connectors: a meta-analysis.

The difficulty of suturing perfect anastomoses in limited-access conditions prevents the transition of traditional coronary artery bypass grafting (CABG) to sternal-sparing approaches, even in the robotic era. Automated coronary anastomotic connector technologies may address these difficulties, but to date, none have achieved broad adoption. Besides versatility, ease-of-use and cost-effectiveness, the key performance parameter of such technology is anastomotic patency. In this meta-analysis, we aim to evaluate published connector devices by examining their patency outcomes in distal anastomoses. The literature was systematically searched for studies comparing the angiographic patency of connector constructed coronary anastomoses to handsewn (HS) connections in adult patients undergoing CABG. The primary outcome was anastomosis patency across early (<30 days), mid-term (30 days to 1 year) and long-term (>1 year) follow-up. Random-effects meta-analyses were employed to analyze and compare patency using pooled risk ratios (RR) with 95% confidence intervals (CI). The search yielded 14 studies concerning eight connector devices. In 4,311 patients, a total of 4,328 anastomoses were constructed, 674 with connector devices and 3,654 with a HS technique. The pooled device patency over all timeframes was non-inferior to the HS technique (RR 0.90, 95% CI: 0.56-1.44). Technologies having a relatively large blood-exposed non-intimal surface area (BENIS, >15 mm2) performed acceptably when applied to large target vessels [>2.0-2.5 mm inner diameter (ID)]. A tiny anastomotic orifice area (AOA, < ca. 4 mm2) appeared to adversely affect results. Technologies realizing a generous AOA in combination with a limited BENIS showed superior results and applicability by performing well across the entire range of target coronary artery diameters (>1.0-1.5 mm ID). The overall results suggest that connectors yield at least non-inferior anastomosis patency outcomes compared to HS techniques in all observed timeframes. Optimizing device characteristics like BENIS and AOA appear fundamental for broad applicability.

Robot-Assisted Minimally Invasive Multivessel Coronary Bypass Guided by Computerized Tomography.

Robot-assisted minimally invasive coronary bypass surgery is one of the least invasive approaches that offers multivessel revascularization and accelerated recovery. We investigated the benefits of computed tomography angiography (CTA) guidance in robotic coronary bypass (RCAB) by analyzing perioperative outcomes. Between April 2022 and April 2023, 60 consecutive patients who underwent RCAB under preoperative CTA guidance were included. The intercostal space of the minithoractomy incision was determined based on the distance from the thoracotomy site to the midsection of the left anterior descending artery (LAD) on preoperative CTA. Peripheral vascular findings on preoperative CTA guided the decision for the cannulation site. Perioperative parameters and early outcomes were evaluated. The mean age of the patients was 62.3 ± 10.5 years, and 51 patients were male (85.0%). The mean number of revascularized vessels was 2.9 ± 1.1. Left thoracotomy guided by CTA measurements was performed in the fourth intercostal space in 37 patients (61.7%) and in the third intercostal space in the remaining patients. Axillary cannulation was performed in 28 (46.7%) patients because of prohibitive findings in the iliac vessels and aorta. All target coronary arteries with an indication for bypass were revascularized with CTA-guided RCAB. The left internal mammary artery (LIMA) was anastomosed to the LAD in all patients, and the LIMA was anastomosed sequentially to the diagonal artery in 17 patients (28.3%). No operative mortality or cerebrovascular event was observed. One patient underwent reoperation due to bleeding. Robot-assisted minimally invasive multiple-vessel coronary bypass under preoperative CTA guidance is safe and can be performed with excellent results.

Highly Inflamed Non-Calcified Coronary Plaques Sealed with Stents in Patients with Zero Calcium Score – a Case Series and Review of the Literature

Abstract The modern management of coronary artery disease (CAD) uses coronary computed tomography angiography (CCTA) to enhance plaque evaluation and cardiovascular risk assessment. CCTA identifies high-risk plaques, and the latest CT technologies based on calculation of fat attenuation index (FAI) allow assessment of inflammation at the level of the target coronary artery. We present a series of case studies with chest pain and positive CCTA, in whom a significant stenosis was detected in the left anterior descendent coronary artery, and the existence of high-risk, inflamed plaques was documented even in the context of a zero calcium score. A severe narrowing of the left anterior descending artery, exhibiting the pattern of high-risk anatomy, was associated with a very high inflammation depicted by FAI analysis in all three cases, an association that may be extremely dangerous. In this case series, CCTA examination led to immediate stenting of the obstructive stenosis, sealing the dangerous plaque.

Radial artery graft in coronary artery bypass surgery 1 week to 1 year postoperation.

The actual patency rate of the radial artery (RA) grafts 1 week and 1 year after coronary artery bypass grafting (CABG) has not been extensively reported on. We used coronary computed tomography angiography (CCTA) to evaluate the patency rate of RA grafts and compared it with that of saphenous vein (SV) grafts. In this observational cohort study, 80 patients who underwent urgent or elective CABG with RA and SV grafts at Ruijin Hospital from August 2019 to June 2021 were included. Follow-up CCTA scans were completed about 1 year postoperation in the out-patient clinic. We graded the grafts into four classes: A, excellent; B, graft diameter <50% of target coronary artery; O, occluded; and S, string sign. Both S and O were defined as graft failure. The patients' mean age was 58.48±8.06 years, and 87.5% (70/80) of the patients were male. The 1-week patency rate of the left internal mammary artery (LIMA), RA, and SV grafts were 98.7% (75/76), 76.3% (61/80), and 93.8% (75/80), respectively. At 1 year, the patency rate of the LIMA, RA, and SV grafts were 97.4% (74/76), 80.0% (64/80), and 81.3% (65/80), respectively. The RA graft patency rate was lower than was the SV graft patency rate perioperatively [relative risk (RR): 0.918; 95% confidence interval (CI): 0.852-0.990; P=0.007]. Moreover, 63.6% (7/11) of RA grafts graded S and 25.0% (2/8) of RA grafts graded O were defined as patent (graded A or B) at 1 year postoperation. Compared with SV grafts, more RA grafts improved (RA: 12/80, 15.0%; SV: 0%) and fewer RA grafts deteriorated (RV: 10/80, 12.5%; SV: 19/80, 23.8%) from 1 week to 1 year (P=0.001). The patency rate of the 2 types of grafts became similar at 1 year postoperation (RR: 0.560; 95% CI: 0.113-2.781; P>0.99). RA grafts had a lower patency rate than did SV grafts 1 week after operation. However, because of the "revival" phenomena and lower attrition rate, the patency rate of the two kinds of grafts did not show any significant difference at 1 year.

Transit-time flowmetry measurement features of coronary bypass grafts after multiple percutaneous coronary interventions

The functionality of coronary bypass grafts after surgical myocardial revascularization in patients with coronary heart disease directly depends on the state of the target coronary arteries. In the presence of widespread and diff use atherosclerotic lesions or microcirculatory dysfunctions, a high frequency of coronary bypass dysfunctions is noted in the near future. In some cases, shunt dysfunction can lead to severe hemodynamic instability, accompanied by acute circulatory disorders.Aim: To assess the function of coronary bypass grafts during myocardial revascularization using the method of ultrasonic flowmetry in patients with and without a history of multiple percutaneous coronary interventions (PCI).Material and methods. The retrospective study included 47 patients who underwent coronary artery bypass surgery. A total of 145 coronary bypass grafts were performed. All patients were divided into 2 groups. Group 1 (PCI group) included patients after multiple previous PCI (n = 25; 74 coronary bypass grafts), group 2 (without PCI) included patients without previous PCI (n = 22; 71 coronary bypass grafts). All patients underwent intraoperative ultrasonic flowmetry of coronary bypass grafts using the VeriQ system (Medistim, Norway).Results. When analyzing the status of coronary bypass grafts in patients after multiple PCI, a significantly low mean volumetric blood flow rate was noted (29.5 ± 8.3 ml/min and 48.2 ± 11.6 ml/min, respectively, p = 0.0001) and lower diastolic filling (55.2 ± 8.2% and 71.9 ± 7.1%, p = 0.0001). Also in the group of patients after multiple PCI, there were 2 (2.7%) cases of revision of the distal anastomosis due to a high pulsatile index and low volumetric blood flow velocity. However, no such events were noted in the group without PCI.Conclusions. Previous percutaneous coronary interventions are compromising factors for the state of the coronary bed, which reduces the functional status of coronary bypass grafts and may increase the perioperative risk of surgical myocardial revascularization.

The Null technique as a novel, potential first-line method of device delivery for complicated lesions during percutaneous coronary intervention

AimDuring percutaneous coronary intervention (PCI), complicated lesions in the target coronary artery often hinder device delivery. Fluid lubricants have commonly been used to reduce friction between adjacent solid materials in manufacturing, thus achieving smoother action. This ex vivo experimental study examined whether a contrast medium could function as a fluid lubricant during PCI. Methods and resultsWe used two different coronary artery lesion models with distinct complexities made from silicon. Each model was fit into the ex vivo PCI-simulation system. This ex vivo laboratory equipment consisted of ordinary PCI instruments and an aorta model from the Valsalva sinus to the descending aorta. A Wolverine™ cutting balloon catheter was advanced through each lesion model via a guide catheter set into the system. The maximum force required to push the catheter through the lesion models was measured while the vessel system was filled with either normal saline or contrast medium. The maximum force required was significantly lower with the contrast medium (1.38 ± 0.21 N in the normal-saline condition vs. 0.92 ± 0.05 N in the contrast-medium condition in the lesion model A, p < 0.001; 1.30 ± 0.07 N in the normal-saline condition vs. 1.14 ± 0.04 N in the contrast-medium condition in the lesion model B, p < 0.001). ConclusionsThe contrast medium for vessel system filling reduced the force required to push the devices through the lesion models. This contrast medium represents a potential candidate for a liquid lubricant to facilitate device delivery for complicated coronary lesions.

Patch repair for the seagull deformity of a sequential diamond-shaped coronary anastomosis

Seagull deformity (Figure 1, A) is the most frequent and feared complication of sequential diamond-shaped coronary anastomoses.1 Its threat is a turbulence flow that may trigger clot formation within the graft. The main cause of the seagull deformity is too-long incision of a target coronary artery, which leads to the transverse tension of the graft with its flattening and kinking at the anastomosis. In addition, the position of the target coronary artery deep in the myocardium and stiffness of its wall may amplify the impact of the excessive incision length.

Safety and efficacy of the expressman extension system for complex coronary lesions during percutaneous coronary intervention.

Safety and efficacy of the expressman extension system for complex coronary lesions during percutaneous coronary intervention.

Optical coherence tomography as a method for assessing the conduit-anastomosis-artery system in patients after coronary artery bypass grafting

Background. Coronary artery bypass grafting (CABG) remains the most common cardiac surgery in the world. In the long-term follow-up period after surgery, graft failure occurs in a substantial proportion of CABG conduits and is a complex pathomorphological process. Optical coherence tomography (OCT) is a high-resolution intravascular imaging modality that allows to assess in-vivo endothelial integrity.Aim. To substantiate the efficacy and safety of OCT assessment of the conduitanastomosis-artery system in CABG patients.Methods. The prospective observational cohort study included 21 patients with chronic coronary artery disease who underwent CABG. 3–5 days after CABG, patients underwent OCT and angiography of arterial and vein grafts, including distal anastomosis and nearby segment of the target coronary artery. At 12-month follow-up, all patients underwent repeated OCT and angiography of the conduitanastomosis-artery system to assess the changes. The primary endpoint of the study was graft failure; secondary endpoints of the study included unplanned repeat myocardial revascularization, cardiac death, and myocardial infarction due to graft failure.Results. At 12-month follow-up, 14.3% of graft failure and 9.5% of cases of unplanned repeated myocardial revascularization were registered. In most cases of graft failure, primary OCT revealed pronounced changes in the conduit and the native coronary artery (conduit/artery diameter ratio was more than 2 mm), whereas the diameter of the coronary artery anastomosis was less than 2.5 mm. Myocardial infarctions and death within 12 months were not registered.Conclusion. Thus, OCT is an effective and safe intravascular imaging technique for assessing coronary arteries and the conduit-anastomosis-artery system. OCT makes it possible to identify morphological changes in coronary bypass grafts, which can predict their early failure. The conduit/artery diameter ratio greater than 2 and target coronary artery diameter less than 2.5 mm was associated with graft failure within 12 months after CABG.

Comparison between the diagnostic performance of vessel fractional flow reserve and nonhyperemic pressure ratio for functionally significant coronary stenosis severity as assessed by fractional flow reserve.

Fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs) have been widely used to assess the functional severity of coronary stenosis. However, their measurement requires using a pressure wire, making their use in all patients difficult. The recently developed vessel fractional flow reserve (vFFR), derived from three-dimensional quantitative coronary angiography, is expected to serve as a surrogate for pressure wire assessment. This retrospective study was conducted on patients with intermediate coronary stenosis who underwent FFR and NHPR measurements. The vFFR and NHPR values were compared for diagnosing coronary stenosis as defined by an FFR of ≤0.80, and the number of patients not requiring wire-based assessment was estimated. In a total of 90 lesions from 74 patients (median [SD] age 75 [12] years; men 80%), the median FFR was 0.78 (0.72-0.84), and 57% of these lesions (N = 51) exhibited an FFR of ≤0.80. vFFR provided high discrimination for coronary stenosis (area under the curve 0.80, 95% confidence interval0.70-0.90), which was comparable to that of NHPRs (p = 0.42). High diagnostic accuracy was consistently observed across a variety of clinical presentations (i.e., old age, diabetes, target coronary artery, and left ventricular hypertrophy) (pinteraction > 0.05). In total, 55 lesions (61%) demonstrated positive or negative likelihood of coronary stenosis when vFFR was <0.73 (specificity 90%) or >0.87 (sensitivity 88%), respectively. vFFR demonstrated excellent diagnostic performance for detecting functionally significant coronary stenosis as evaluated by FFR. vFFR may be used as a surrogate for pressure wire assessment.

Relation of quantitative flow ratio with transit time coronary artery bypass graft flow measurement.

BackgroundQuantitative flow ratio (QFR) is a new functional index to assess the functional significance of coronary stenosis. While whether there is an association between QFR and transit-time flow measurement (TTFM) parameters of the target coronary artery has not been well addressed.MethodsA total of 89 patients receiving the in situ left internal thoracic artery (LITA) grafts to the left anterior descending artery (LAD), and 19 patients undergoing the saphenous vein grafts (SVG) were enrolled in this retrospective study. The QFR value of the LAD was evaluated preoperatively. According to the QFR values, patients with the LITA to the LAD bypass grafts were divided into two groups (group A1: QFR < 0.75, group A2: QFR ≥ 0.75), and SVG patients were divided into two groups (V1 group: QFR < 0.75, V2 group: QFR ≥ 0.75).ResultsIn groups A1 and A2, respectively, median graft flow (Qm) was 44 (34) mL/minute and 26.5 (30.0) ml/minute; median pulsatility index (PI) was 2.00 (1.00) and 2.65 (0.90). Significant differences were observed in Qm (P = 0.034) and PI (P = 0.030). And the correlation coefficients of the TTFM variables with QFR were Qm: r = r = −0.226, (P = 0.036), PI: r = 0.265 (P = 0.012) among the LITA to LAD population.ConclusionTTFM variables, especially the PI, of the LITA in situ graft to the LAD during Coronary artery bypass grafting (CABG) are strongly affected by preoperative QFR values. Moreover, in functionally mild coronary stenosis, the chance of competitive flow increases.

Results of CABG Using Microsurgical Technique and Endarterectomy for Diffuse Lesions of the Coronary Arteries

Background. The number of patients (pts) with diffuse lesions among coronary artery bypass grafting (CABG) candidates has increased; they are expected to have worse results. Complex reconstructions, such as coronary endarterectomy (CEAE) and prolonged anastomoses with arteries less than 1.5mm in diameter, are being used more often. There is no sufficient evidence data and accepted guidelines for surgical treatment of this most complicated category of pts. Aim to evaluate the effectiveness of CABG with and without endarterectomy in pts with diffuse lesion and compare it with standard CABG in pts with local lesion. Materials and methods. In 20102017 CABG were performed in 2.927 pts. 1276 had diffuse coronary artery disease and in 154 cases the surgeon was forced to perform CEAE. After excluding 38 pts with comorbidities, the study group was formed (group 1, n = 116). We selected 2 equally large control groups with propensity score matching: from pts with diffuse lesion operated without CEAE (group 2, n = 116) and pts with local lesion operated as standard (group 3, n = 116). Cardiopulmonary bypass and microsurgical techniques were used. Hospital and long-term (up to 8 years; median follow-up of 60 (42; 74) months results were compared. The endpoints were all-cause and cardiac mortality, myocardial infarction (MI), angina recurrence and repeated revascularization. Results. In group 1 the frequency of perioperative MI was significantly higher compared to groups 2 and 3 (6.9% vs 0.7 and 0.7% resp, p 0.05) Hospital mortality was comparable in groups (p = 0.444). In the long-term period, the angina recurrence frequency was insignificantly lower in both control groups compared with the study group (p = 0.418). Autovenous grafts had significantly more dysfunctions compared with the internal thoracic artery grafts in symptomatic pts (57.5 versus 12.1%, p 0.05; odds ratio OR = 9.82; 95% CI: 3.2429.79). Also the severity of the target coronary artery lesion 4 points scaled by the diffuse lesion index were more frequent cause of graft dysfunction in this group (60.9 versus 41.6%; p 0.05; OR = 2.13; 95% CI: 1.134.24). Conclusion. Coronary endarterectomy is related to the high risk of perioperative myocardial infraction, while do not significantly increase the hospital mortality and adverse events in the long-term period. It should be considered to use coronary endarterectomy when there is no other option for surgery. The using of other adjunctive techniques demonstrate high efficiency in patients with diffuse lesions of the coronary arteries, comparable to surgery in patients with local lesion.

Initial clinical experience with a new sheathless guiding catheter designed for direct insertion

Abstract Funding Acknowledgements Type of funding sources: None. Background Radial access for percutaneous coronary intervention (PCI) is growing rapidly as this approach has been shown to improve patient comfort and reduce complications. Use of a sheathless guiding catheter for transradial PCI has the potential reduce trauma to the radial artery and to further expand the type of cases where this approach can be utilised. The new Sheathless Hyperion system allows direct insertion of the Sheathless Hyperion guiding catheter using a 20 G needle or IV cannula, a 0.25" Silverway wire and a custom dilator. Purpose We report the first clinical experience with the new Sheathless Hyperion guiding catheter designed for direct insertion. Methods We prospectively evaluated outcomes in consecutive patients who underwent PCI using the Sheathless Hyperion catheter at our institution between June 2020 and March 2021. All procedures were performed via radial access. There were no exclusion criteria. Results Eighty one patients were included with 99 lesion being treated using 85 Sheathless Hyperion catheters. Mean age 67.7 ± 11.8 years, 77.8% male, 22.2% diabetic and 38.8% had acute coronary syndromes. The Sheathless Hyperion was inserted directly into the radial artery in 46 (54.1%) cases with 100% success rate and inserted following initial sheath insertion for the remaining 39 (45.9%). Of the Sheathless Hyperion catheters used 30 (35.3%) were 6F in 55 (64.7%) were 7F. The Sheathless Hyperion was passed into the ascending aorta successfully in all cases. The target coronary artery was successfully engaged in 85 (98.8%). In one case the coronary could not be engaged because of excessive brachiocephalic tortuosity and conversion to femoral access occurred. In 4 cases the Sheathless Hyperion catheter had to be exchanged for one with a small curve. The majority of lesions were complex: 18.2% CTO, 39.4% heavily calcified, 44.4% long lesions and 31.3% bifurcation lesions. Adjunctive devices included rotational atherectomy (12.1%), intravascular lithotripsy 14.1%, IVUS (56.6%) and OCT (28.3%). Angiographic success was achieved in 100%. Peri-procedural non-ST-elevation myocardial infarctions defined by the 4th Universal definition occurred in 3 (3.7%) patients. No patient meet the SCAI criteria for periprocedural MI. There was no in-hospital target vessel revascularisation or death. Radial artery occlusion was infrequent occurring in one patient. No major haematomas or vascular complications occurred. Conclusion First clinical experience with the Sheathless Hyperion demonstrates that direct insertion is safe and effective and that it allows complex interventions to be undertaken transradially with a high success rate.

Intraoperative transit time flow measurement in patients with diffuse coronary artery disease in the prevention of aortocoronary bypass graft occlusion

Aim. To study the parameters of transit time flow measurement (TTFM) for coronary bypass grafts in patients with diffuse lesions with different diameter of target coronary arteries.Material and methods. The study included 150 patients with diffuse coronary artery disease. All patients underwent microscope-assisted coronary artery bypass grafting (CABG), during which the TTFM parameters were evaluated. Depending on the diameter of target coronary arteries, patients were divided into 3 groups: group 1 included grafts to arteries ≤1 mm (n=101), group 2 — 1-1,5 mm (n=138), group 3 — ≥1,5 mm (n=308). Comparative analysis of TTFM parameters was performed.Results. Mostly participants were male (76%); mean age was 62,9±7,6 years. During hospitalization, we recorded 1 death, 2 perioperative myocardial infarctions (1,3%) and 1 cerebrovascular accident (0,7%). TTFM analysis showed the worst hemodynamic parameters and a higher rate of suboptimal function in group 1; blood flow parameters were comparable in groups 2 and 3. The additional analysis in group 1 and combined groups 2 and 3 allows us to make an opinion about the negative impact of coronary artery diameter less than 1 mm on optimal blood flow through the grafts (odds ratio=2,1, 95% confidence interval, 1,2-3,8, p=0,011).Conclusion. Diffuse coronary atherosclerosis with a diameter of target coronary arteries less than 1 mm significantly increase the risk of suboptimal graft function that requires considering more aggressive secondary prevention. TTFM demonstrate high effectiveness of microscope-assisted CABG in target coronary artery diameter of 1-1,5 mm and higher.

The RAGE Trial (Radial Arterial Graft in the Elderly)- A Pilot Study

Use of radial artery (RA) as a second arterial conduit in Coronary Artery Bypass Grafting (CABG) is well established and appreciated for its higher long-term patency rate compared to vein grafts. This study tends to investigate if there are any detrimental consequences when it is used in elderly (aged 60 and above) population of Bangladesh. A total of 71 patients who received RA grafts at elective, isolated CABG operation were consecutively enrolled in this study from May 2018 to September 2019. 31 patients were in the Elderly group and 40 patients were in the Non-elderly group. The groups were compared for baseline characteristics and co-morbidities; preoperative techniques, findings, events and procedures; and postoperative outcomes or end-point variables inclusive of local complications related to RA harvesting wound. Elderly and Non-elderly groups had statistically different age (p=0.000) and Society of Thoracic Surgery (STS) Score predicted mortality (p=0.000). Operative techniques, events, findings and procedures were similar. Clinical outcomes were found to be similar with no statistical difference between the groups. Number of deaths also was not statistically different. There were no local complications related to RA harvesting wound in either of the two groups. Harvesting and grafting of radial artery in suitable patients, using meticulous "no-touch" technique and for ideal target coronary artery stenosis is as safe in the elderly patients as in the younger ones.&#x0D; CBMJ 2020 July: Vol. 09 No. 02 P: 08-13

Biodegradable polymer drug eluting stents versus durable polymer drug eluting stents for percutaneous coronary intervention

Abstract Background Invasive angiography with subsequent revascularization is a widely used treatment method in patients with coronary heart disease. Although biodegradable polymer drug eluting stents (BP-DES) have been used for almost a decade now, clinical trials regarding their long-term outcomes are both sparse and inconsistent. We aimed to compare the long-term outcomes of patients undergoing percutaneous coronary intervention (PCI) with BP-DES versus durable polymer drug eluting stents (DP-DES). Methods Among 11,517 PCIs with second generation drug eluting stents preformed in our institution between 2007 and 2019, we identified 8042 procedures performed using DP-DES and 3475 using BP-DES. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (re-MI), target vessel revascularization (TVR) and coronary artery bypass grafting (CABG). Propensity score matching was used to create a well-balanced cohort. Results Mean follow up was 4.8 years. Of the 3,413 matched pairs, 21% were females, and the mean age was 66. At one year, the primary outcome occurred in 9.6% patients versus 8.3% (p=0.05), and TVR rate was 4.1% versus 3% (p=0.005) in patients with DP-DES and BP-DES respectively. Within 5 years, the primary outcome occurred in in 24.9% versus 24.8% (p=0.83), and the rate of TVR was 9.8% versus 9.1% (p=0.07) in patients with DP-DES and BP-DES respectively. Conclusions Similar rates of the composite outcome were observed throughout the entire follow-up. TVR rates were lower in the DP-DES group at 1-year but equalized within 5 years. Funding Acknowledgement Type of funding sources: None.

Reopening of the occluded saphenous vein composite grafts after coronary artery bypass grafting.

We have observed reopening of the occluded "no-touch" saphenous vein (NT SV) composite grafts on follow-up angiograms in patients who underwent coronary artery bypass graftings (CABGs). Between 2008 and 2018, 1283 patients received NT SV conduits without or with surrounding pedicle tissue as composite grafts based on the in situ left internal thoracic artery (ITA) for CABG and underwent early postoperative angiographies. Among the 1283 patients, 53 patients showed 55 occluded SV conduit anastomoses, and 46 patients who had 48 occluded SV anastomoses were re-evaluated by 1-year postoperative angiographies. Early postoperative angiographies in 1283 patients demonstrated overall occlusion rates of 1.2% (56/4518); occlusion rates of the ITA and SV were 0.08% (1/1259) and 1.7% (55/3260), respectively. One-year angiograms demonstrated that 14 occluded SV anastomoses (29.2% [14/48 occluded SV]) of 14 patients became patent. Reopening of occluded SV conduits occurred more frequently in NT SV with pedicle tissue than in NT SV without pedicle tissue (45.0% [9/20] vs. 17.9% [5/28]; p = .057). When we examined the preoperative and 1-year postoperative angiograms, reopening of the occluded SV conduits was not related with progression (p = .258) or preoperative reversibility score (p = .115) of native target coronary artery disease. More than a quarter of the occluded SV composite grafts on early postoperative angiograms were patent in the 1-year angiograms. The reopening rates were higher in patients who had received NT SV conduits with pedicle tissue than those who had received NT SV conduits without pedicle tissue.

Impact of target coronary artery stenosis severity measured by instantaneous wave-free ratio on to bypassed graft patency

Background: This study aimed to assess the impact of the measurement of the degree of target coronary artery stenosis using the instantaneous wave-free ratio (iFR) on patency of attached grafts. Materials and Methods: A total of 86 grafts were assessed by computed tomography angiography (CTA) after coronary artery bypass grafting (CABG) in 24 patients with multivessel coronary artery disease (CAD). The iFR was evaluated for all target coronary arteries. The coronary artery stenoses were divided into three groups based on the iFR value: iFR < 0.86 (group 1); iFR 0.86–0.90 (group 2); and iFR > 0.90 (group 3). Results: CTA was performed at 192 ± 44 days (range: 80–318 days). The correlation coefficient (r) between iFR and failed grafts was 0.332 (p = 0.035). Graft failure was detected in three grafts (8.1%) for group 1, in two grafts (8.3 %) for group 2, and in four grafts (16%, all arterial grafts) for group 3. Statistically significant differences were found between groups 1 and 3 (p = 0.041) and between groups 2 and 3 (p = 0.044). No significant differences were found between groups 1 and 2 (p = 0.228). Conclusions: The degree of coronary artery stenosis measured by iFR is a risk factor for attached graft failure. In a coronary artery where the iFR was haemodynamically non-significant, a higher rate of graft failure was detected.

Trends in ST-elevation myocardial infarction.

Despite recent progress in coronary artery disease treatment, ST-segment elevation myocardial infarction (STEMI) remains a very high-risk medical condition. Whether recent patients' outcomes, following implementation of the 2012 European Society of Cardiology (ESC) STEMI guidelines have improved, is yet unclear. The study was based on a prospective detailed registry of 2004 consecutive patients with STEMI treated with primary percutaneous coronary intervention (pPCI). We compared trends during two different time periods (2006-2012 vs. 2012-2018). Endpoints included mortality and major adverse cardiac events (MACE: death, repeat myocardial infarction, target vessel revascularization and coronary artery bypass surgery) at 1 month, 1 and 2 years. Rates of transradial interventions have risen significantly (67.3 vs. 42.0%; P < 0.01), as have rates of prasugrel administration (69.8 vs. 4.5%; P < 0.01) and use of drug eluting stents (75.5 vs. 56.5%; P < 0.01). Both at 1 and at 2 years, MACE was significantly lower in the later period (11.6 vs. 20.9%; P < 0.01 and 18.9 vs. 25.4%; P < 0.01 respectively), whereas mortality was only significantly lower after 1 year (5.8 vs. 8.6%; P = 0.02). Cox regression identified the later period (2012-2018) to independently and favorably impact MACE (hazard ratio, -0.69; 95% CI, 0.56-0.85; P < 0.01) but not mortality (hazard ratio, -0.76; 95% CI, 0.54-1.05; P = 0.09). Among patients treated with pPCI for STEMI, adoption of the contemporary evidence-based treatments is associated with better MACE derived outcomes, following the inception of the 2012 ESC guidelines. Nonetheless, the long-term mortality was marginally (but not significantly) lower, which indicates an unmet need for further improvement.