Coronary Total Occlusion Research Articles

Pancreatitis as a Potential Trigger for Severe Accelerated Cardiac Allograft Vasculopathy Early Post Heart Transplant: A Case Report

We present a case of severe accelerated cardiac allograft vasculopathy (CAV), an infrequent finding usually related to dismal prognosis, in a heart recipient with recurrent episodes of acute pancreatitis. A 38-year-old male was transplanted owing to advanced heart failure related to nonischemic dilated cardiomyopathy. On the fifth day after transplantation, a nonbiliary acute ischemic pancreatitis occurred. Recurrent relapses ensued within the following year requiring hospital readmissions for both supportive and pain management. The patient developed graft dysfunction by the 18th month post-transplant with severe multivessel CAV. A trial of bortezomib and percutaneous coronary interventions with drug-eluting stents at coronary arteries were attempted but the patient died suddenly, before the scheduled staged percutaneous coronary intervention for the coronary total occlusion was performed. The causal mechanisms of aggressive accelerated CAV are unclear, but it is suggested that important inflammatory and/or humoral responses may play a pivotal role in this life-threatening disease pathogenesis. Increased levels of biomarkers have been linked to advanced CAV, as well as pancreatitis pathogenesis, related to cytokine activation with remarkable systemic inflammatory response. Some of those inflammatory mediators have been reported as central in both pancreatitis and CAV, more specifically interleukin-6. A pro-inflammatory state due to recurrent acute pancreatitis early after transplantation may have contributed to severely accelerated CAV development in the presented case. Comprehensive evaluation of risk factors may assist in close surveillance and targeted therapies in the management of this challenging post-heart transplant scenario.

Abstract 14158: Impact of Gender Differences on Changes in Myocardial Perfusion Following Percutaneous Coronary Intervention of Chronic Total Coronary Occlusions

Introduction. Data on gender differences in chronic total coronary occlusion (CTO) percutaneous coronary intervention (PCI) are scarce. Prior studies have demonstrated CTO PCI to reduce ischemia, however female patients are less likely to undergo revascularization. This study sought to investigate the impact of gender on myocardial perfusion changes following CTO PCI as measured by [ 15 O]H 2 O positon-emission tomography (PET) perfusion imaging. Methods. A total of 212 patients were prospectively enrolled in a single-center CTO registry and underwent single-vessel CTO PCI, combined with [ 15 O]H 2 O PET imaging at baseline and three months follow-up. Baseline and follow-up resting myocardial blood flow (MBF), hyperemic MBF and coronary flow reserve (CFR) allocated to the CTO territory were quantitatively assessed. The presence of residual ischemia was defined as hMBF ≤2.3 mL·min -1 ·g -1 in the CTO area at follow-up. Results. This study comprised 34 (16%) females and (84%) males. Mean age in females was higher compared to males (68 ± 9 vs. 61 ± 10 years, p<0.01). In women, resting MBF at baseline was more elevated than in men (1.02 ± 0.24 vs. 0.84 ± 0.21 mL·min -1 ·g -1 , p<0.01). Similarly, baseline hMBF was found to be higher in females (1.81 ± 0.53 vs. 1.64 ± 0.53 mL·min -1 ·g -1 , p=0.03), and showed a higher increase after CTO PCI (Δ1.06 ± 0.71 vs. Δ0.71 ± 0.66 mL·min -1 ·g -1 , p=0.01). Improvement in CFR after CTO PCI was more evident in female patients (Δ1.17 ± 1.04 vs. Δ0.82 ± 0.89, p=0.04). At three months follow-up, the proportion of patients with residual ischemia was lower in women versus men (9 (27%) vs. 91 (51%), p=0.01). Conclusions. We found a higher increase in hyperemic MBF and CFR following CTO PCI in women compared to men, as measured by serial [ 15 O]H 2 O PET imaging. In addition, lower rates of residual ischemia were observed in women. This study suggests the potential benefit of a lower threshold for CTO PCI in female patients.

Differentially hypomethylated cell-free DNA and coronary collateral circulation

BackgroundThe factors affecting cardioprotective collateral circulation are still incompletely understood. Recently, characteristics, such as CpG methylation of cell-free DNA (cfDNA), have been reported as markers with clinical utility. The aim of this study was to evaluate whether cfDNA methylation patterns are associated with the grade of coronary collateral circulation (CCC).ResultIn this case–control study, clinical and angiographic data were obtained from 143 patients (mean age, 58 years, male 71%) with chronic total coronary occlusion. Enzymatic methyl-sequencing (EM-seq) libraries were prepared using the cfDNA extracted from the plasma. Data were processed to obtain the average methylation fraction (AMF) tables of genomic regions from which blacklisted regions were removed. Unsupervised analysis of the obtained AMF values showed that some of the changes in methylation were due to CCC. Through random forest preparation process, 256 differentially methylated region (DMR) candidates showing strong association with CCC were selected. A random forest classifier was then constructed, and the area under the curve of the receiver operating characteristic curve indicated an appropriate predictive function for CCC. Finally, 20 DMRs were identified to have significantly different AMF values between the good and poor CCC groups. Particularly, the good CCC group exhibited hypomethylated DMRs. Pathway analysis revealed five pathways, including TGF-beta signaling, to be associated with good CCC.ConclusionThese data have demonstrated that differential hypomethylation was identified in dozens of cfDNA regions in patients with good CCC. Our results support the clinical utility of noninvasively obtained epigenetic signatures for predicting collateral circulation in patients with vascular diseases.

The relationship between mean platelet volume lymphocyte ratio and collateral circulation in patients with chronic total coronary occlusion.

To correlate mean platelet volume lymphocyte ratio (MPVLR) and coronary collateral circulation (CCC) in patients with chronic total occlusion (CTO). A total of 643 patients who were hospitalized at a single large academic medical center from January 2020 to October 2021 and had CTO lesions in at least one major coronary artery confirmed by coronary angiography were retrospectively analyzed. Patients were divided according to the Rentrop criteria into poorly formed CCC (Rentrop grade 0-1, n = 235) and well-formed CCC (Rentrop grade 2-3, n = 408) groups. Mean platelet volume lymphocyte ratio (MPVLR) was calculated from routine laboratory data (MPV divided by lymphocyte count). The clinical data of the two groups were compared, and relationships between MPVLR and CCC formation were analyzed. The MPVLR of patients with poorly formed CCC was significantly higher than that of patients with well-formed CCC (7.82 ± 3.80 vs. 4.84 ± 1.42, P < 0.01). The prevalence of diabetes mellitus and C-reactive protein levels were significantly higher in the poor CCC group than in the good CCC group (P < 0.01), while the proportions of patients with CTO or multivessel lesions in the right coronary artery were significantly lower in the poor CCC group than in the good CCC group (P < 0.01). Multivariate logistic regression analysis identified MPVLR (OR: 2.101, 95% CI: 1.840-2.399, P < 0.01), C-reactive protein level (OR: 1.036, 95% CI: 1.008-1.064, P < 0.05), a history of diabetes mellitus (OR: 2.355, 95% CI: 1.532-3.621, P < 0.01), and right coronary CTO ratio (OR: 0.313, 95% CI: 0.202-0.485, P < 0.01) as independent risk factors for CCC formation. The area under the ROC curve of MPVLR for predicting poorly formed CCC was 0.82 (95% CI: 0.784-0.855, P < 0.01), the best cut-off point was 6.02 and the sensitivity and specificity of MPVLR for predicting poorly formed CCC were 72.3 and 82.4%, respectively. In patients with coronary CTO, MPVLR was negatively correlated with CCC and a high MPVLR level was an independent predictor of poorly formed CCC.

Role of collateral flow in infarct border zone extent and contractile function in patients with chronic coronary total occlusion

PurposeThere is a paucity of data regarding the border zone parameters in patients with chronic coronary total occlusion (CTO). We investigated the border zone extent and contractile function and their associations with collateral flow. MethodsCTO patients (n = 47) and sex- and age-matched volunteers (n = 15) were prospectively enrolled and underwent cardiac MRI examinations to acquire cine and late-gadolinium enhancement (LGE) images. Myocardial peak strain (PS) and the time to PS were determined at the segmental level and global level. Infarct, border zone, adjacent, and remote regions were defined according to the transmural extent of infarction (TEI) by LGE at each segment. Angiographic collateral flow was evaluated using the Rentrop grading system. ResultsCTO patients with well-developed collateral flow had a higher TEI in border zone regions compared to patients with poorly developed collateral flow (p = 0.02). Conversely, CTO patients with poorly developed collaterals showed a higher TEI in infarct regions (p < 0.01). Enhanced border function, characterized by greater PS and earlier time to PS, was noted in well-developed collaterals (all p < 0.05). In the multivariate linear analyses, the level of collateral flow was an independent predictor of the border zone extent (β = 0.40, p = 0.02) and contractile function (radial: β = -0.42, p = 0.02; circumferential: β = 0.39, p = 0.02; and longitudinal: β = 0.47, p < 0.01). ConclusionsIn CTO patients, the presence of well-developed collateral flow was closely linked to a greater extent of LGE and contractile function in border zone regions. Our findings shed light on the cardiac MRI-based pathophysiological underpinning in border zone regions, which could offer complementary and prognostic information in clinical practice.

Incidence and impact of totally occluded culprit coronary artery in patients with non-ST segment elevation myocardial infarction acute coronary syndrome

Abstract Background Significance of totally occluded culprit coronary artery in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI) is underestimated. Purpose The aim of this study was to evaluate the incidence and impact of totally occluded culprit artery on in-hospital and 6 months follow-up outcomes of NSTEMI acute coronary syndrome (ACS) patients. Methods We collected retrospectively data of 500 NSTEMI patients who presented to our hospital from June 2016 to June 2017. All patients underwent PCI within 72 h of presentation. We excluded patients with cardiogenic shock, prior CABG, and STEMI. Patients were divided into two groups according to pre-procedural culprit vessel thrombolysis in myocardial infarction (TIMI) flow. Group 1, TIMI flow 0 total coronary occlusion, included 112 patients (22.4%). Group 2, TIMI flow 1–3 non-total occlusion, included 388 patients (77.6%). Results Group 1 patients had significantly higher incidence of smoking (p=0.01), significantly higher level of cardiac enzymes (p&amp;lt;0.001), significantly more collaterals (p&amp;lt;0.001), and significantly more LCX and RCA as the culprit vessel (p&amp;lt;0.01), while group 2 patients had significantly higher incidence of diabetes (p=0.02) and significantly more LAD as the culprit vessel. There were no significant differences between the two groups regarding the major adverse cardiac and cerebrovascular events (MACCE) in-hospital (5.3% in totally occluded group vs. 1% in non-totally occluded group, p=0.07), but group 1 patients had significantly higher incidence of in-hospital arrhythmia (8.9% in group 1 vs. 1% in group 2, p=0.007). After 6 months follow-up, there were no significant differences regarding MACCE between the 2 groups after 6 months follow-up (5.4% in group 1 vs. 4.6% of group 2, P=0.24). Conclusion 22.4% of NSTEMI patients have a totally occluded culprit artery. The presence of an occluded culprit artery did not significantly affect the clinical outcomes of NSTEMI patients either in-hospital or after 6 months follow-up but was associated with significantly higher incidence of in-hospital arrhythmia. Funding Acknowledgement Type of funding sources: None.

Heparin pre-treatment in patients with ST elevation myocardial infarction: a cohort study investigating the effects on coronary artery occlusion, mortality, and bleeding

Abstract Background Unfractionated heparin (UFH) is often administered before arrival at the cath lab in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, large studies regarding the clinical impacts of UFH pre-treatment are scarce. Purpose To investigate if pre-treatment with heparin affects total coronary artery occlusion at angiography, mortality at 30 days, and major bleeding during hospitalization in patients with STEMI undergoing primary PCI. Methods The study population was extracted from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) and consisted of unique patients with a first STEMI event undergoing PCI during the study period 2008 to 2016. Patients receiving UFH pre-treatment were compared with patients not receiving UFH pre-treatment. To obtain relative risks of the outcomes adjusted Poisson regression models with robust standard errors were used. In the adjusted models, we included age, sex, smoking status, year, comorbidities (as specified under tables 1 and 2), and anti-thrombotic treatment (as specified under tables 1 and 2). To obtain absolute risk differences, analyses of propensity score (PS) matched groups were performed. PS was based on the same variables as in the adjusted Poisson regression, and a caliper of 0.02 was used. Results A total of 41,631 patients were included in the study population (median age: 67 years; 71% male), with 16,026 receiving pre-treatment with UFH and 25,605 not receiving UFH pre-treatment. The adjusted Poisson model revealed that UFH pre-treatment was associated with an 11% relative risk reduction of coronary artery occlusion (95% confidence interval (CI): 9%; 12%), and an 13% (95% CI: 2%; 23%) reduced relative risk of mortality. For bleeding, no statistically significant difference was found. In the PS-matched analysis (median age: 67 years, 71% male), the absolute risk differences were for coronary artery occlusion 8.3% (95% CI: 7.1%; 9.5%) in favour of UFH pre-treatment, and for mortality 0.5% (−0.1%; 1.2%), with a modest trend in favour of UFH pre-treatment. For bleeding, no statistically significant difference was found. Conclusion UFH pre-treatment was associated with a reduction in coronary artery occlusion at presentation at the cath lab in patients with STEMI, the number needed to treat being 13, without increasing the risk of bleeding. Regarding mortality, a reduced relative risk was found in the adjusted regression analysis, but the absolute risk difference was small and not statistically significant in the PS-matched analysis. Due to the retrospective study design, residual confounding cannot be excluded. Funding Acknowledgement Type of funding sources: None.

Predicting success of the retrograde approach in percutaneous coronary intervention of chronic total coronary occlusions as guided by collateral grading systems

Abstract Background Retrograde chronic total coronary occlusion (CTO) percutaneous coronary intervention (PCI) requires selection of appropriate interventional collaterals. At present, utilization of the Rentrop and Werner grading systems are encouraged to assess the collateral channels (CCs) prior to attempted guidewire (GW) crossing [1]. The J-Channel score was recently introduced to predict CC GW crossing difficulty, yet data on its applicability is lacking [2]. Purpose To investigate the predictive ability of the J-Channel score for CC GW crossing success and technical CTO-PCI success compared to the Rentrop and Werner grading systems. Methods A total of 262 patients who underwent single-vessel retrograde CTO-PCI were prospectively recruited in a single-center registry. The J-Channel score, Rentrop and Werner grade were assessed by invasive coronary angiography. Crossing of CCs was considered successful if the GW reached the distal cap of the CTO body. Technical CTO-PCI success was defined as Thrombolysis in Myocardial Infarction flow grade 3 and residual stenosis &amp;lt;30%. Results Mean J-Channel score was found at 1.9±1.2. Median Rentrop and Werner grade were 3 [IQR 2–3] and 1 [IQR 1–2]. Technical CTO-PCI success was 90%. In 211 (81%) cases, CC GW crossing was successful. Receiver operating characteristics analysis showed comparable discriminatory capacity for Rentrop and Werner grade (AUC 0.67 and 0.65, p=0.611), whereas the predictive ability of the J-Channel score (AUC 0.74) was superior to the Werner grade (p&amp;lt;0.001). A high J-Channel score was inversely associated with CC GW crossing success (p&amp;lt;0.001). For technical CTO-PCI success, overall performance of all grading systems weakened, wherein Rentrop grade was numerically highest, followed by the J-Channel score and Werner grade (AUC 0.69, 0.67, and 0.58, respectively). Notably, a high Rentrop grade was associated with increased CC GW crossing and technical CTO-PCI success (p&amp;lt;0.001). Conclusions In retrograde CTO-PCI, there is limited incremental value of the J-Channel score, Rentrop classification and Werner grade in predicting technical CTO-PCI success. However, their application might aid in strategic collateral channel selection prior to attempted guidewire crossing. Funding Acknowledgement Type of funding sources: None.

Long-term clinical outcome in patients with isolated chronic total occlusion treated percutaneously or pharmacologically

Abstract Purpose Chronic Total Coronary Occlusion (CTO) is defined as the total obstruction of coronary blood flow for at least 3 months duration. The aim of this study was to compare the long-term clinical outcome in patients with stable angina (CCS I-III) and isolated CTO treated with successful percutaneous coronary intervention (PCI) or conservative management (a priori pharmacologically or after failed PCI) and to detect potential risk factors of unsuccessful PCI. Methods The inclusion criteria were: isolated CTO of one CA, previously confirmed viability of myocardium in the area of occluded CA, stable coronary disease, absence of significant valve disease resulting in predicted survival below 1 year. Choice of management was based on individualized risk/benefit analysis encompassing ischemia assessment and angiographic considerations. Clinical follow-up of 24 months duration was conducted with regard to occurrence of major adverse cardiac events (MACE) including death, acute myocardial infarction (MI), need for repeat revascularization (surgical or PCI), major bleeding and hospitalization for angina. Results The study group consisted of 119 pts with isolated CTO (88 males, mean age 60.7±9.6 years)– 75 (63%) in the right CA, 28 (23,5%) in the left anterior descending CA, 16 (13,5%) in the circumflex CA. The history of MI was revealed in 37 pts in medically treated group, 10 pts in PCI group and 7 pts after failed PCI. Successful PCI was performed in 39 (33%) pts while 80 (67%) pts were treated pharmacologically (16 after failed PCI). Over a mean 24-months follow-up there were 58 MACE in all groups, including: 2 cardiac deaths (1 in medically treated group and 1 in PCI group), hospitalization due to angina in 17 pts (10 in medically treated group, 6 in PCI group, 1 after failed PCI), 4 repeated revascularizations (1 in PCI group, 3 after failed PCI), 33 pts developed unstable angina (25 medically treated, 6 in PCI group, 2 after failed PCI), major bleeding occurred in 2 pts in medically treated group. The risk of MACE was lower in pts after successful PCI comparing both with patients treated medically as well as those with failed PCI (p=0.05 for both). Univariate analysis showed that left ventricular endsystolic (p=0.001) and enddiastolic diameter (p=0.01), left ventricular ejection fraction (p=0.03), higher NYHA class (p=0.002) and duration of angina (p=0.05) were significant predictors of MACE. Multivariate analysis identified two independent predictors of MACE: absence of effective PCI (as an intention-to-treat and per protocol) (OR 3.6, 95% CI 1.6–8.3) and larger left ventricular systolic diameter (OR=1.16, 95% CI 1.04–1.29). The independent negative predictors of procedural success were severity of calcification (p=0.001) and length of occlusion (p=0.02). Conclusions Successful PCI of CTO leads to a significant reduction in MACE in 24 months follow-up. Failed PCI is predicted by the occlusion length and extent of calcification. Funding Acknowledgement Type of funding sources: None.

Diagnostic accuracy of angiography-based vessel fractional flow reserve after chronic coronary total occlusion recanalization

Abstract Background Angiography-Based Vessel FFR (vFFR) demonstrated a strong correlation with invasive fractional flow reserve (FFR) in both a pre- and post-percutaneous coronary intervention (PCI) setting. However, the role of vFFR and its correlation with post-PCI FFR in chronic coronary occlusion (CTO) has not been evaluated yet. We sought to investigate the diagnostic performance of post-PCI vFFR with post-PCI FFR as a reference in patients undergoing successful CTO PCI. Methods Between March 2016 and September 2019, a total of 80 patients from the FFR-SEARCH and FFR REACT studies underwent successful CTO recanalization [1,2]). A total of 50 patients (median age 66 (IQR: 56–74) years, 76% were male) were eligible for the analysis. Median FFR was 0.89 (IQR: 0.84–0.94) while median vFFR was 0.91 (IQR: 0.85–0.94). Suboptimal physiological results, defined as FFR and vFFR &amp;lt;0.90, were identified in 26 (52%) and in 21 (42%) patients, respectively. A strong correlation (r=0.79) was found between vFFR and FFR with a mean bias of 0.013±0.051. Receiver-operating characteristics curve analysis revealed an excellent accuracy of vFFR in predicting FFR &amp;lt;0.90 (AUC: 0.97; 95% CI: 0.93–1.00). Conclusion vFFR shows a good agreement with FFR and a high diagnostic accuracy for FFR ≤0.90 in patients undergoing successful PCI of a CTO lesion. Funding Acknowledgement Type of funding sources: None.

LncRNA PVT1 is a novel mediator promoting the angiogenesis response associated with collateral artery formation.

Angiogenesis plays a key role in coronary collateral circulation (CCC), the compensatory formation of new blood vessels during chronic total coronary occlusion. This study aimed to determine whether plasmacytoma variant translocation 1 (PVT1), a long non-coding (lnc) RNA involved in tumor angiogenesis, plays a role in regulating angiogenesis during chronic coronary ischemia. Patients with coronary artery disease, and ≥90% stenosis, were examined and divided into "Good" and "Poor" CCC groups based on Rentrop Cohen classification. RNA samples were obtained from all patients, as well as from oxygen and glucose-deprived (OGD) HUVECs. PVT1, miR-15b-5p and AKT3 levels were measured with RT-qPCR or Western blot, while HUVEC migration and angiogenesis were detected by, respectively, wound-healing and tube formation assays. Luciferase reporter assay confirmed direct PVT1-miR-15b-5p binding. Increased PVT1 was found in "Good CCC" patient plasma, along with being highly expressed among OGD HUVECs; PVT1 knockdown reduced HUVEC migration, tube formation, and pro-angiogenic factor expression. Conversely, OGD HUVECs had downregulated miR-15b-5p, and miR-15b-5p overexpression significantly depressed their angiogenic capabilities. These PVT1 knockdown- or miR-15b-5p overexpression-associated reductions in angiogenic effects were reversed by AKT3 overexpression. In vivo, neovascularization and functioning in both ischemic mice hind-limbs and infarcted myocardium injected with ADV-sh-PVT1 were reduced, which were ameliorated by concurrent antagomiR-15b-5p injections. Circulating PVT1 may serve as a useful biomarker to distinguish between good versus poor CCC, as it is involved in orchestrating angiogenesis via the miR-15b-5p-AKT3 axis; it thus has potential as a target for treating ischemic disease.

Ventricular Septal Rupture (VSR) in Post-Acute Anterior Myocardial Infarction Patients : A Case Series

Case Summary: We present 2 cases of post-STEMI VSR. They had anterior AMI without reperfusion therapy because of patient delay and limited resources. Thereafter apical VSR occurs on 5th day. VSR was suspected because of sudden hemodynamic deterioration and new holosystolic murmur (Grade III/VI) at left parasternal line of fourth-fifth ICS. Then it was confirmed by echocardiography. Both patients underwent hemodynamic stabilization while waiting for surgical therapy. Unfortunately, they deceased because of cardiogenic shock accompanied by other comorbidities. Discussion: VSR causes shunt from left to the right ventricle, which overloads the RV, leading to cardiogenic shock. The peak incidence of VSR in the first 24 hours or 3-5 days post-AMI. This fits both of our cases. VSR occurs in total coronary occlusion, which then causes coagulation necrosis in the ischemic area, characterized by neutrophils that trigger apoptosis and lytic enzymes, so that septum becomes thin, brittle then ruptures. VSR is most common in anterior AMI and the defect is at apical septum, as in our patients. Definitive therapy for VSR is surgical closure, but the best timing is still under debate. This article is expected to make us more aware of post-AMI VSR, so we can quickly diagnose and promptly treat the patients with multidisciplinary approach. This is very important to optimize patient’s outcomes even in limited resources area.

TCT-115 The Presence of a Chronic Total Coronary Occlusion Is Associated With Appropriate ICD Shocks and Mortality in the Nationwide Prospective Dutch Outcome in ICD Therapy (DO-IT) Registry

TCT-115 The Presence of a Chronic Total Coronary Occlusion Is Associated With Appropriate ICD Shocks and Mortality in the Nationwide Prospective Dutch Outcome in ICD Therapy (DO-IT) Registry

TCT-40 Impact of Total Coronary Occlusion on Long-Term Outcomes in Patients With ST-Segment Elevation Myocardial Infarction and Single-Vessel Disease

TCT-40 Impact of Total Coronary Occlusion on Long-Term Outcomes in Patients With ST-Segment Elevation Myocardial Infarction and Single-Vessel Disease

TCT-263 Viability and Ischemia Assessment in Chronic Coronary Total Occlusions According to Collaterals Distribution: A Stress CMR Study

TCT-263 Viability and Ischemia Assessment in Chronic Coronary Total Occlusions According to Collaterals Distribution: A Stress CMR Study

Feasibility of Percutaneous Transluminal Coronary Angioplasty (PTCA) in Total Coronary Artery Occlusion (TCO)

Percutaneous transluminal coronary angioplasty,(PTCA), was attempted in twenty consecutive patients with 100% coronary occlusion, without antegrade visualization of contrast material in the occluded vessel. The time interval between coronary angiography and angioplasty was 7.8 days. Of the twenty patients that underwent angioplasty, six had unstable angina, eleven had stable angina, one had acute myocardial infarction, and two had post-infarction angina. The occluded vessel was the left anterior descending, (LAD), coronary artery in thirteen patients, the right coronary artery, (RCA), in six patients, and the left circumflex, (LCX), coronary artery in one patient.

Angiographic outcome in patients treated with deferred stenting after ST-segment elevation myocardial infarction—results from DANAMI-3-DEFER

Stent implantation during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) occasionally results in flow disturbances and distal embolization, which may cause adverse clinical outcomes. Deferred stent implantation seems to reduce the impairment on myocardial function, although the mechanisms have not been clarified. We sought to evaluate whether deferred stenting could reduce flow disturbance in patients treated with primary PCI. Patients with STEMI included in the DANAMI-3-DEFER trial were randomized to deferred versus immediate stent implantation. The primary and secondary outcomes of this substudy were the incidences of slow/no reflow and distal embolization. A total of 1205 patients were included. Deferred stenting (n = 594) resulted in lower incidences of distal embolization [odds ratio (OR) 0.67, 95% confidence interval (CI) 0.46-0.98, P = 0.040] and slow/no reflow (OR 0.60, 95%CI 0.37-0.97, P = 0.039). In high-risk subgroups, the protective effect was greatest in patients >65 years of age (slow/no reflow: OR 0.36, 95% CI 0.17-0.72, P = 0.004 and distal embolization: OR 0.34, 95% CI 0.18-0.63, P = 0.001), in patients presenting with occluded culprit artery at admission (slow/no reflow: OR 0.33, 95% CI 0.16-0.65, P = 0.001 and distal embolization: OR 0.54, 95% CI 0.31-0.96, P = 0.036) and in patients with thrombus grade >3 (slow/no reflow: OR 0.37, 95% CI 0.20-0.67, P = 0.001 and distal embolization: OR 0.39, 95% CI 0.24-0.64, P < 0.001) with a significant P for interaction for all. Deferred stent implantation reduces the incidences of slow/no reflow and distal embolization, especially in older patients and in those with total coronary occlusion or high level of thrombus burden.

Blood flow modeling reveals improved collateral artery performance during the regenerative period in mammalian hearts.

Collateral arteries bridge opposing artery branches, forming a natural bypass that can deliver blood flow downstream of an occlusion. Inducing coronary collateral arteries could treat cardiac ischemia, but more knowledge on their developmental mechanisms and functional capabilities is required. Here we used whole-organ imaging and three-dimensional computational fluid dynamics modeling to define spatial architecture and predict blood flow through collaterals in neonate and adult mouse hearts. Neonate collaterals were more numerous, larger in diameter and more effective at restoring blood flow. Decreased blood flow restoration in adults arose because during postnatal growth coronary arteries expanded by adding branches rather than increasing diameters, altering pressure distributions. In humans, adult hearts with total coronary occlusions averaged 2 large collaterals, with predicted moderate function, while normal fetal hearts showed over 40 collaterals, likely too small to be functionally relevant. Thus, we quantify the functional impact of collateral arteries during heart regeneration and repair-a critical step toward realizing their therapeutic potential.

Combining electrocardiographic criteria for predicting acute total left main coronary artery occlusion.

BackgroundPrediction of left main artery (LM) occlusion may contribute to the administration of early reperfusion. We sought to identify electrocardiographic (ECG) features associated with acute total LM occlusion and explore the relationship between ECG features and collateral circulation.MethodsWe retrospectively studied ECGs in 84 consecutive patients with LM occlusion between January 2001 and April 2022. The ECG findings in these patients were compared with those in 468 consecutive patients with LM subtotal occlusion and non-LM occlusion.ResultsThree main ECG patterns were described according to the characteristics of ST elevation (STE) in LM occlusion: ST-segment elevation myocardial infarction (STEMI), STE in aVR with diffuse ST depression, and STE in both aVR and aVL. These ECG patterns were associated with different collateral filling territories. One-third STEMI in LM occlusion showed STE in the precordial leads including V1, while 2/3 STEMI showed STE in the precordial leads from V2 to V5 without STE in V1. The following ECG characteristics predicted LM occlusion: STE in both aVR and aVL; STE in I, aVL, and V2–V5 without V1; left anterior fascicular block (LAFB); right bundle branch block (RBBB) + LAFB; and prolongation of the QRS interval. The incidences of STE in aVR and STE in aVR and V1 were higher in LM subtotal occlusion than in LM occlusion. The combination of two different STE criteria (STE in aVR and aVL and STE in I, aVL, V2-V5 without V1) predicted LM occlusion with 62% sensitivity and 95% specificity. The combination of the STE criteria and fascicular block criteria (LAFB and LAFB + RBBB) further improved the specificity to 99% but reduced the sensitivity to 39%.ConclusionThe combination of STE criteria predicted LM occlusion with high specificity and moderate sensitivity, and the addition of fascicular block criteria further improved the specificity with some loss of sensitivity.

Relationship between contrast-induced nephropathy and long-term mortality after percutaneous coronary intervention in patients with chronic coronary total occlusion.

SUMMARYOBJECTIVE:Intervention in chronic total occlusion lesions involves long procedure time, a serious contrast load, and complex procedures. In this study, we aimed to investigate mortality rate of patients who had procedural coronary angiography done for chronic total occlusion lesions in coronary angiography series and who developed contrast-induced nephropathy.METHODS:A total of 218 patients with chronic total occlusion lesion in at least one coronary artery, from three different medical centers, who underwent procedural coronary angiography were recruited for the study. Patient population was divided into two groups: those who developed contrast-induced nephropathy and those who did not. Mortality due to all causes was investigated between both groups throughout a 100-month follow-up.RESULTS:Mean age of patients with incidence of contrast-induced nephropathy was 66.7±11.8, and 23.8% of them were comprised by female. We found a significantly higher mortality in long-term follow-up in the patient group with contrast-induced nephropathy (42.9 vs. 57.1%, p=<0.001). According to Kaplan-Meier analysis performed additionally, survival during follow-up was significantly shorter in this group and, in logistic regression analysis, it was an independent predictor of mortality (OR 11.78; 95%CI 3.38–40.9).CONCLUSION:We identified that the development of contrast-induced nephropathy is associated with long-term mortality. It might be possible to reduce adverse events with prophylactic approaches before the procedure and close follow-up of such patients after the procedure.