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Background This study aimed to investigate the hemodynamic and anatomic factors associated with sinus thrombosis following transcatheter aortic valve replacement (TAVR), integrating in vivo patient data analysis and in vitro experiments. Methods and Results Postprocedural, 4‐dimensional, multiphase computed tomography data from 211 patients enrolled in the ADAPT‐TAVR (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement) study were analyzed. The prevalence of native sinus thrombosis was examined in relation to valve type, implant depth, and anatomic features. In vitro experiments used particle image velocimetry to observe changes in sinus flow based on the transcatheter heart valves (23‐mm SAPIEN3, Edwards Lifesciences; and 29‐mm CoreValve, Medtronic) height and coronary artery flow. Native sinus thrombosis was more common in self‐expanding valves (39.1% versus 14.9%, P=0.004). In per‐cusp analysis of in vivo patient data, adjusted transcatheter heart valve implant depth (odds ratio, 1.2 [95% CI, 1.1–1.3]; P

Background: Limited data are available on the long-term outcomes of drug-eluting stents (DES) vs bare-metal stents (BMS) in patients with left main coronary artery (LMCA) disease. Methods: In this observational cohort of the Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty vs Surgical Revascularization (MAIN-COMPARE) registry, we evaluated patients with unprotected LMCA stenosis who received DES or BMS between January 2000 and June 2006. The primary outcome was a composite of all-cause death or myocardial infarction (MI) at 10 years. Adjusted outcomes were compared using propensity scores and inverse probability of treatment weighting. Results: A total of 1102 patients underwent DES (n = 784) or BMS (n = 318) during the study period. At 10 years, the adjusted rate of the primary outcome was significantly lower in DES group than in the BMS group (27.9% vs 37.0%; hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.53-0.94; P = 0.02). The adjusted 10-year mortality rate was significantly lower in DES group than in the BMS group (20.6% vs 29.6%; HR, 0.65; 95% CI, 0.46-0.91; P = 0.01), whereas the 10-year rate of MI was similar between the 2 groups (9.9% vs 11.0%; HR, 0.93; 95% CI, 0.54-1.59; P = 0.78). DES use was associated with a significant reduction in the rate of target-lesion revascularization (10.2% vs 21.8%; HR, 0.41; 95% CI, 0.27-0.61; P < 0.001). Conclusions: In this 10-year follow-up study in patients with LMCA disease, DES use was associated with a significant reduction in the rate of the composite of death or MI, mortality, and target-lesion revascularization, when compared with BMS. Résumé: Contexte: On dispose de peu de données sur les résultats à long terme de la mise en place d'endoprothèses médicamentées par rapport aux endoprothèses non médicamentées chez les patients atteints d'une maladie de l'artère coronaire principale gauche. Méthodologie: Dans cette cohorte d'observation du registre MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty vs Surgical Revascularization), nous avons évalué les patients présentant une sténose de l'artère coronaire principale gauche non protégée et ayant reçu une endoprothèse médicamentée ou une endoprothèse non médicamentée entre janvier 2000 et juin 2006. Le paramètre d’évaluation principal était composé de la mortalité toutes causes confondues et de l'infarctus du myocarde (IM) à 10 ans. Les résultats ajustés ont été comparés en utilisant des scores de propension et la pondération inverse sur la probabilité d’être traité. Résultats: Au total, 1 102 patients ont reçu des endoprothèses médicamentées (n = 784) ou des endoprothèses non médicamentées (n = 318) pendant la période d’étude. À 10 ans, le taux ajusté de survenue du paramètre d’évaluation principal était nettement plus faible dans le groupe endoprothèses médicamentées que dans le groupe endoprothèses non médicamentées (27,9 % vs 37,0 %; rapport des risques instantanés [RRI] : 0,71; intervalle de confiance [IC] à 95 % : 0,53-0,94; p = 0,02). Le taux de mortalité ajusté à 10 ans était considérablement plus faible dans le groupe endoprothèses médicamentées que dans le groupe endoprothèses non médicamentées (20,6 % vs 29,6 %; RRI : 0,65; IC à 95 % : 0,46-0,91; p = 0,01), tandis que le taux d'IM à 10 ans était similaire dans les deux groupes (9,9 % vs 11,0 %; RRI : 0,93; IC à 95 % : 0,54-1,59; p = 0,78). L'utilisation d'endoprothèses médicamentées était associée à une diminution importante du taux de revascularisation de la lésion cible (10,2 % vs 21,8 %; RRI : 0,41; IC à 95 % : 0,27-0,61; p < 0,001). Conclusions: Dans cette étude de suivi de 10 ans menée auprès de patients atteints d'une maladie de l'artère coronaire principale gauche, l'utilisation d'endoprothèses médicamentées a été associée à une diminution importante du taux des décès ou des IM regroupés, de la mortalité et du taux de revascularisation de la lésion cible, par rapport à l'utilisation d'endoprothèses non médicamentées.

Background: Diabetes mellitus (DM) is a well-known risk factor for adverse cardiovascular events in patients receiving percutaneous coronary intervention (PCI). Limited data are available on the relative performance of different types of contemporary drug-eluting stents (DES) for diabetic patients. Objectives: The authors investigated the effectiveness and safety profiles of several contemporary DES in patients with DM in a “real-world” clinical setting. Methods: Among 24,516 patients enrolled in a multicenter, prospective registry, 7,823 patients with DM were treated with 4 contemporary DES: 2,877 with a cobalt chromium everolimus-eluting stent (EES), 789 with a biodegradable polymer biolimus-eluting stent, 2,286 with a platinum chromium-EES, and 1,871 with a Resolute zotarolimus-eluting stent. The primary outcome was target vessel failure (TVF) (a composite of cardiac death, target vessel myocardial infarction, and target vessel revascularization). Results: The median follow-up duration was 2.9 years. Observed 3-year rates of TVF were not significantly different according to different DES types. On multigroup propensity-score analysis, the adjusted HRs for TVF were similar in between-group comparisons: biodegradable polymer biolimus-eluting stent (HR: 0.94; 95% CI: 0.76-1.16; P = 0.57), platinum chromium-EES (HR: 0.94; 95% CI: 0.81-1.09; P = 0.41), and Resolute zotarolimus-eluting stent (HR: 1.01; 95% CI: 0.86-1.18; P = 0.93) compared with the cobalt chromium-EES (reference). This trend was maintained in patients with non–insulin- and insulin-treated DM. Conclusions: In this multicenter clinical-practice PCI registry, no significant between-group differences were found for a 3-year risk of TVF in patients with DM undergoing PCI with various types of contemporary DES. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133)

Background: Moderate aortic valve stenosis occurs twice as often as severe aortic stenosis (AS) and carries a similarly poor prognosis. Current European and American guidelines offer limited insight into moderate AS (MAS) patients with unexplained symptoms. Measuring valve physiology at rest while most patients experience symptoms during exertion might represent a conceptual limitation in the current grading of AS severity. The stress aortic valve index (SAVI) may delineate hemodynamically significant AS among patients with MAS. Objectives: To investigate the diagnostic value of SAVI in symptomatic MAS patients with normal left ventricular ejection fraction (LVEF ≥ 50%): aortic valve area (AVA) > 1 cm2 plus either mean valve gradient (MG) 15–39 mmHg or maximal aortic valve velocity (AOV max) 2.5–3.9 m/s. Short-term objectives include associations with symptom burden, functional capacity, and cardiac biomarkers. Long-term objectives include clinical outcomes. Methods and results: Multicenter, non-blinded, observational cohort. AS severity will be graded invasively (aortic valve pressure measurements with dobutamine stress testing for SAVI) and non-invasively (echocardiography during dobutamine and exercise stress). Computed tomography (CT) of the aortic valve will be scored for calcium, and hemodynamics simulated using computational fluid dynamics. Cardiac biomarkers and functional parameters will be serially monitored. The primary objective is to see how SAVI and conventional measures (MG, AVA and Vmax) correlate with clinical parameters (quality of life survey, 6-minute walk test [6MWT], and biomarkers). Conclusions: The SAVI-AoS study will extensively evaluate patients with unexplained, symptomatic MAS to determine any added value of SAVI versus traditional, resting valve parameters.

BackgroundAlthough there is a growing interest in prediction models based on electronic medical records (EMRs) to identify patients at risk of adverse cardiac events following invasive coronary treatment, robust models fully utilizing EMR data are limited. ObjectiveWe aimed to develop and validate machine learning (ML) models by using diverse fields of EMR to predict the risk of 30-day adverse cardiac events after percutaneous intervention or bypass surgery. MethodsEMR data of 5,184,565 records of 16,793 patients at a quaternary hospital between 2006 and 2016 were categorized into static basic (eg, demographics), dynamic time-series (eg, laboratory values), and cardiac-specific data (eg, coronary angiography). The data were randomly split into training, tuning, and testing sets in a ratio of 3:1:1. Each model was evaluated with 5-fold cross-validation and with an external EMR-based cohort at a tertiary hospital. Logistic regression (LR), random forest (RF), gradient boosting machine (GBM), and feedforward neural network (FNN) algorithms were applied. The primary outcome was 30-day mortality following invasive treatment. ResultsGBM showed the best performance with area under the receiver operating characteristic curve (AUROC) of 0.99; RF had a similar AUROC of 0.98. AUROCs of FNN and LR were 0.96 and 0.93, respectively. GBM had the highest area under the precision-recall curve (AUPRC) of 0.80, and the AUPRCs of RF, LR, and FNN were 0.73, 0.68, and 0.63, respectively. All models showed low Brier scores of 0.95, contributing majorly to the excellent results. ConclusionsExploiting the diverse fields of the EMR data set, the ML-based 30-day adverse cardiac event prediction models demonstrated outstanding results, and the applied framework could be generalized for various health care prediction models.

Background There are still limited data about the differential effect of sex on long‐term outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery disease. This extended follow‐up study of the MAIN‐COMPARE (Ten‐Year Outcomes of Stents Versus Coronary‐Artery Bypass Grafting for Left Main Coronary Artery Disease) registry evaluated clinical outcomes beyond 10 years. Methods and Results Of 2240 patients with unprotected left main coronary artery disease (PCI=1102 and CABG=1138), all‐cause mortality, the composite of death, Q‐wave myocardial infarction, or stroke, and target vessel revascularization were separately evaluated in both sexes. Of 2240 patients, 631 (28.2%) were women and 1609 (71.8%) were men. Women had lower 10‐year incidences of death and serious composite outcomes than men. The adjusted 10‐year risks of adverse outcomes were similar in men. However, the adjusted 10‐year risks were different according to a prespecified period in women. In the short‐term (0–1 year) period, PCI had a significantly lower risk for serious composite outcomes (adjusted hazard ratio [HR], 0.41; 95% CI, 0.19–0.91; P=0.03) compared with CABG. The adjusted risks for death and serious composite outcomes were significantly higher after PCI than after CABG, during the midterm (1–5 years) period (death; adjusted HR, 3.99; 95% CI, 2.01–7.92; P

Background Various ECG criteria for left ventricular hypertrophy (LVH) have been proposed, but their association with clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement is unknown. We investigated the prevalence of ECG LVH according to different criteria and its prognostic impact on clinical outcomes after transcatheter aortic valve replacement. Methods and Results In this prospective observational cohort, we evaluated 700 patients who underwent transcatheter aortic valve replacement between March 2010 and December 2019. Baseline preprocedural LVH was defined by 3 ECG criteria—Sokolow‐Lyon, Romhilt‐Estes, and Cornell voltage criteria. The primary outcome was major adverse cardiac or cerebrovascular event (MACCE; composite of death, myocardial infarction, stroke, or rehospitalization from cardiovascular cause); the key secondary outcome was all‐cause and cardiovascular mortality. Among 596 eligible patients, the prevalence of LVH was determined as 56.3% by Sokolow‐Lyon, 31.1% by Romhilt‐Estes, and 48.1% by Cornell criteria. Regardless of the criteria, patients with ECG LVH had more severe aortic stenosis hemodynamics and higher left ventricular mass index. After multivariate adjustment, the presence of LVH by the Cornell criteria was significantly associated with lower risks of MACCE (adjusted hazard ratio [HR], 0.68; 95% CI, 0.51–0.91; P=0.009), all‐cause mortality (adjusted HR, 0.55; 95% CI, 0.34–0.90 [P=0.017]), and cardiovascular mortality (adjusted HR, 0.40; 95% CI, 0.20–0.79 [P=0.008]). However, this association was absent with the Sokolow‐Lyon and Romhilt‐Estes criteria. Conclusions ECG LVH by Cornell criteria only was significantly associated with lower risks of MACCE and all‐cause or cardiovascular mortality. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03298178.

Introduction Optimal antithrombotic strategy following transcatheter aortic valve replacement (TAVR) is still unknown. We hypothesised that the direct factor Xa inhibitor edoxaban can potentially prevent subclinical leaflet thrombosis and cerebral embolisation compared with conventional dual antiplatelet therapy (DAPT) in patients undergoing TAVR.Methods and analysis The ADAPT-TAVR trial is an international, multicentre, randomised, open-label, superiority trial comparing edoxaban-based strategy and DAPT strategy in patients without an indication for oral anticoagulation who underwent successful TAVR. A total of 220 patients are randomised (1:1 ratio), 1–7 days after successful TAVR, to receive either edoxaban (60 mg daily or 30 mg daily if patients had dose-reduction criteria) or DAPT using aspirin (100 mg daily) plus clopidogrel (75 mg daily) for 6 months. The primary endpoint was an incidence of leaflet thrombosis on four-dimensional, volume-rendered cardiac CT imaging at 6 months post-TAVR. The key secondary endpoints were the number of new lesions and new lesion volume on brain diffusion-weighted MRI and the changes in neurological and neurocognitive function assessment between immediate post-TAVR and 6 months of study drug administration. Detailed clinical information on thromboembolic and bleeding events were also assessed.Ethics and dissemination Ethic approval has been obtained from the Ethics Committee/Institutional Review Board of Asan Medical Center (approval number: 2017–1317) and this trial is also approved by National Institute of Food and Drug Safety Evaluation of Republic of Korea (approval number: 31511). Results of this study will be disseminated in scientific publication in reputed journals.Trial registration number NCT03284827.

Background Although guidelines recommend the use of coronary computed tomographic angiography (CTA) in patients with stable pain syndromes, the clinical benefits of the use of coronary CTA in a broad spectrum of patients is unknown. We evaluated the contemporary practice pattern and diagnostic yield of coronary CTA and their impact on the subsequent diagnostic‐therapeutic cascade and clinical outcomes. Methods and Results We identified 39 906 patients without known coronary artery disease (CAD) who underwent coronary CTA between January 2007 and December 2013. The patients' demographic characteristics, risk factors, symptoms, results of coronary CTA, the appropriateness of downstream diagnostic and therapeutic interventions, and long‐term outcomes (death or myocardial infarction) were evaluated. The number of coronary CTAs had increased over time, especially in asymptomatic patients. Coronary CTA revealed that 6108 patients (15.3%) had obstructive CAD (23.7% of symptomatic and 9.3% of asymptomatic patients). Subsequent cardiac catheterization was performed in 19.2% of symptomatic patients (appropriate, 80.6%) and in 3.9% of asymptomatic patients (appropriate, 7.9%). The 5‐year rate of death or myocardial infarction was significantly higher in patients with obstructive CAD on CTA than those without (7.2% versus 3.0%; P

Background Data are still limited regarding whether there are differential long‐term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for left main coronary artery disease with or without diabetes mellitus (DM). Methods and Results Using the 10‐year data from the MAIN‐COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry, we sought to examine the effect of DM on comparative outcomes after percutaneous coronary intervention or CABG in patients with unprotected left main coronary artery disease. The outcomes of interest were all‐cause mortality; a composite of death, Q‐wave myocardial infarction, or stroke; and target‐vessel revascularization. The primary adjusted analyses were performed with the use of propensity scores and inverse‐probability weighting. Of 2240 patients with left main coronary artery revascularization, 722 (32%) had DM. In the overall population, the adjusted 10‐year risks of death and composite outcome were similar between percutaneous coronary intervention and CABG, irrespective of DM status (Pinteraction: 0.41, mortality; 0.40, composite outcome). However, in the cohort of bare‐metal stents and concurrent CABG, we observed differential outcomes after stenting and CABG by DM status (Pinteraction: 0.09, mortality; 0.04, composite outcome), favoring CABG in patients with DM. In the cohort of drug‐eluting stents and concurrent CABG, the better effect of CABG over stenting was narrowed in patients with DM without a significant interaction (Pinteraction: 0.63, mortality; 0.47, composite outcome). Conclusions In this cohort of patients with longest follow‐up who underwent left main coronary artery revascularization, the clinical impact of DM favoring CABG over percutaneous coronary intervention has diminished over time from the bare‐metal stent to the drug‐eluting stent era. Registration URL: http://www.clini​caltr​ials.gov. Unique identifier: NCT02791412.

ObjectiveTo investigate factors associated with enrollment and participation in cardiac rehabilitation (CR) in Korea.MethodsPatients admitted to four university hospitals with acute coronary syndrome between June 2014 and May 2016 were enrolled. The Cardiac Rehabilitation Barriers Scale (CRBS) made of 21-item questionnaire and divided in four subdomains was administered during admission. CRBS items used a 5-point Likert scale and ≥2.5 was considered as a barrier. Differences between CR non-attender and CR attender, or CR non-enroller and CR enroller in subscale and each items of CRBS were examined using the chi-square test.ResultsThe CR participation rate in four hospitals was 31% (170 of the 552). Logistical factors (odds ratio [OR]=7.61; 95% confidence interval [CI], 4.62–12.55) and comorbidities/functional status (OR=6.60; 95% CI, 3.95–11.01) were identified as a barrier to CR enrollment in the subdomain analysis. Among patients who were enrolled (agreed to participate in CR during admission), only work/time conflict was a significant barrier to CR participation (OR=2.17; 95% CI, 1.29–3.66).ConclusionDiverse barriers to CR participation were identified in patients with acute coronary syndrome. Providing the tailored model for CR according to the individual patient's barrier could improve the CR utilization. Further multicenter study with large sample size including other CR indication is required.

Background An angiography‐based supervised machine learning (ML) algorithm was developed to classify lesions as having fractional flow reserve ≤0.80 versus >0.80. Methods and Results With a 4:1 ratio, 1501 patients with 1501 intermediate lesions were randomized into training versus test sets. Between the ostium and 10 mm distal to the target lesion, a series of angiographic lumen diameter measurements along the centerline was plotted. The 24 computed angiographic features based on the diameter plot and 4 clinical features (age, sex, body surface area, and involve segment) were used for ML by XGBoost. The model was independently trained and tested by 2000 bootstrap iterations. External validation with 79 patients was conducted. Including all 28 features, the ML model with 5‐fold cross‐validation in the 1204 training samples predicted fractional flow reserve ≤0.80 with overall diagnostic accuracy of 78±4% (averaged area under the curve: 0.84±0.03). The 12 high‐ranking features selected by scatter search were involved segment; body surface area; distal lumen diameter; minimal lumen diameter; length of a lumen diameter 70%. Using those 12 features, the ML predicted fractional flow reserve ≤0.80 in the test set with sensitivity of 84%, specificity of 80%, and overall accuracy of 82% (area under the curve: 0.87). The averaged diagnostic accuracy in bootstrap replicates was 81±1% (averaged area under the curve: 0.87±0.01). External validation showed accuracy of 85% (area under the curve: 0.87). Conclusions Angiography‐based ML showed good diagnostic performance in identifying ischemia‐producing lesions and reduced the need for pressure wires.

BACKGROUND:Invasive fractional flow reserve (FFR) is a standard tool for identifying ischemia-producing coronary stenosis. However, in clinical practice, over 70% of treatment decisions still rely on visual estimation of angiographic stenosis, which has limited accuracy (about 60%-65%) for the prediction of FFR < 0.80. One of the reasons for the visual-functional mismatch is that myocardial ischemia can be affected by the supplied myocardial size, which is not always evident by coronary angiography. The aims of this study were to develop an angiography-based machine learning (ML) algorithm for predicting the supplied myocardial volume for a stenosis, as measured using coronary computed tomography angiography (CCTA), and then to build an angiography-based classifier for the lesions with an FFR < 0.80 versus ≥ 0.80. METHODS AND FINDINGS:A retrospective study was conducted using data from 1,132 stable and unstable angina patients with 1,132 intermediate lesions who underwent invasive coronary angiography, FFR, and CCTA at the Asan Medical Center, Seoul, Korea, between 1 May 2012 and 30 November 2015. The mean age was 63 ± 10 years, 76% were men, and 72% of the patients presented with stable angina. Of these, 932 patients (assessed before 31 January 2015) constituted the training set for the algorithm, and 200 patients (assessed after 1 February 2015) served as a test cohort to validate its diagnostic performance. Additionally, external validation with 79 patients from two centers (CHA University, Seongnam, Korea, and Ajou University, Suwon, Korea) was conducted. After automatic contour calibration using the caliber of guiding catheter, quantitative coronary angiography was performed using the edge-detection algorithms (CAAS-5, Pie-Medical). Clinical information was provided by the Asan BiomedicaL Research Environment (ABLE) system. The CCTA-based myocardial segmentation (CAMS)-derived myocardial volume supplied by each vessel (right coronary artery [RCA], left anterior descending [LAD], left circumflex [LCX]) and the myocardial volume subtended to a stenotic segment (CAMS-%Vsub) were measured for labeling. The ML for (1) predicting vessel territories (CAMS-%LAD, CAMS-%LCX, and CAMS-%RCA) and CAMS-%Vsub and (2) identifying the lesions with an FFR < 0.80 was constructed. Angiography-based ML, employing a light gradient boosting machine (GBM), showed mean absolute errors (MAEs) of 5.42%, 8.57%, and 4.54% for predicting CAMS-%LAD, CAMS-%LCX, and CAMS-%RCA, respectively. The percent myocardial volumes predicted by ML were used to predict the CAMS-%Vsub. With 5-fold cross validation, the MAEs between ML-predicted percent myocardial volume subtended to a stenotic segment (ML-%Vsub) and CAMS-%Vsub were minimized by the elastic net (6.26% ± 0.55% for LAD, 5.79% ± 0.68% for LCX, and 2.95% ± 0.14% for RCA lesions). Using all attributes (age, sex, involved vessel segment, and angiographic features affecting the myocardial territory and stenosis degree), the ML classifiers (L2 penalized logistic regression, support vector machine, and random forest) predicted an FFR < 0.80 with an accuracy of approximately 80% (area under the curve [AUC] = 0.84-0.87, 95% confidence intervals 0.71-0.94) in the test set, which was greater than that of diameter stenosis (DS) > 53% (66%, AUC = 0.71, 95% confidence intervals 0.65-0.78). The external validation showed 84% accuracy (AUC = 0.89, 95% confidence intervals 0.83-0.95). The retrospective design, single ethnicity, and the lack of clinical outcomes may limit this prediction model's generalized application. CONCLUSION:We found that angiography-based ML is useful to predict subtended myocardial territories and ischemia-producing lesions by mitigating the visual-functional mismatch between angiographic and FFR. Assessment of clinical utility requires further validation in a large, prospective cohort study.

BackgroundThe pathophysiology underlying very late drug‐eluting stent (DES) thrombosis is not sufficiently understood. Using optical coherence tomography, we investigated characteristics of very late stent thrombosis (VLST) according to different onset times. Methods and ResultsA total of 98 patients from 10 South Korean hospitals who underwent optical coherence tomography for evaluation of very late DES thrombosis were retrospectively included in analyses. VLST occurred at a median of 55.1 months after DES implantation. All patients were divided into 2 equal groups of earlier versus delayed presentation of VLST, according to median onset time. In total, 27 patients were treated with next‐generation DES and 71 with first‐generation DES. Based on optical coherence tomography findings at thrombotic sites, main VLST mechanisms were as follows, in descending order: neoatherosclerosis (34.7%), stent malapposition (33.7%), and uncovered struts without stent malapposition or evagination (24.5%). Compared with patients with earlier VLST, patients with delayed VLST had lower frequency of uncovered struts without stent malapposition or evagination (34.7% versus 14.3%, respectively; P=0.019). Conversely, the frequency of neoatherosclerosis was higher in patients with delayed versus earlier VLST (44.9% versus 24.5%, respectively; P=0.034). The frequency of stent malapposition was not different between patients with earlier and delayed VLST (34.7% versus 32.7%, respectively; P=0.831). The frequency of stent malapposition, evagination, and uncovered struts was still half of delayed VLST. ConclusionsThe pathological mechanisms of very late DES thrombosis changed over time. Delayed neointimal healing remained a substantial substrate for VLST, even long after DES implantation.

BACKGROUND: The optimal functional evaluation of coronary artery stenosis in patients with severe aortic stenosis (AS) has not been established. The objective of the study was to evaluate the instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) in patients with and without severe AS. METHODS: We retrospectively investigated 395 lesions in 293 patients with severe AS and 2257 lesions in 1882 patients without severe AS between 2010 and 2022 from a subgroup of the Interventional Cardiology Research In-Cooperation Society FFR Registry. All patients had FFR values, and iFR was analyzed post hoc using dedicated software only in lesions with adequate resting pressure curves (311 lesions in patients with severe AS and 2257 lesions in patients with nonsevere AS). RESULTS: The incidence of iFR ≤0.89 was 66.6% and 31.8% (P<0.001), while the incidence of FFR ≤0.80 was 45.3% and 43.9% (P=0.60) in the severe AS group and the nonsevere AS group, respectively. In the severe AS group, most lesions (95.2%) with iFR >0.89 had FFR >0.80, while 36.2% of lesions with iFR ≤0.89 had FFR >0.80. During a median follow-up of 2 years, FFR ≤0.80 was significantly associated with deferred lesion failure (adjusted hazard ratio, 2.71 [95% CI, 1.08-6.80]; P=0.034), while iFR ≤0.89 showed no prognostic value (adjusted hazard ratio, 1.31 [95% CI, 0.47-3.60]; P=0.60) in the severe AS group. Lesions with iFR ≤0.89 and FFR >0.80, in particular, were not associated with a higher rate of deferred lesion failure at 3 years compared with lesions with iFR >0.89 (15.4% versus 17.0%; P=0.58). CONCLUSIONS: This study suggested that FFR appears to be less affected by the presence of severe AS and is more associated with prognosis. iFR may overestimate the functional severity of coronary artery disease without prognostic significance, yet it can be useful for excluding significant stenosis in patients with severe AS. [ABSTRACT FROM AUTHOR]

BACKGROUND: We previously reported the use of minimal stent area to predict angiographic in-stent restenosis after drugeluting stent implantation for unprotected left main (LM) disease. We aimed to evaluate the optimal minimal stent area criteria for up-front LM 2-stenting based on long-term clinical outcomes. METHODS: We identified 292 consecutive patients with LM bifurcation stenosis who were treated using the crush technique. The final minimal stent area was measured in the ostial left anterior descending artery (LAD), ostial left circumflex artery (LCX), and distal LM. The primary outcome was 5-year major adverse cardiac events, including all-cause death, myocardial infarction, and target lesion revascularization. RESULTS: The minimal stent area cutoff values that best predicted the 5-year major adverse cardiac events were 11.8 mm² for distal LM (area under the curve, 0.57; P=0.15), 8.3 mm² for LAD ostium (area under the curve, 0.62; P=0.02), and 5.7 mm² for LCX ostium (area under the curve, 0.64; P=0.01). Using these criteria, the risk of 5-year major adverse cardiac events was significantly associated with stent underexpansion in the LAD ostium (hazard ratio, 3.14; [95% CI, 1.23–8.06]; P=0.02) and LCX ostium (hazard ratio, 2.60 [95% CI, 1.11–6.07]; P=0.03) but not in the distal LM (hazard ratio, 0.81 [95% CI, 0.34–1.91]; P=0.63). Patients with stent underexpansion in both ostial LAD and LCX had a significantly higher rate of 5-year major adverse cardiac events than those with no or 1 underexpanded stent of either ostium (P<0.01). CONCLUSIONS: Stent underexpansion in the LAD and LCX ostium was significantly associated with long-term outcomes in patients who underwent up-front 2-stenting for LM bifurcation stenosis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Intravascular imaging--guided percutaneous coronary intervention (PCI) with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) showed superior clinical outcomes compared with angiography-guided PCI. However, the comparative effectiveness of OCT-guided and IVUS-guided PCI regarding clinical outcomes is unknown. METHODS: In this prospective, multicenter, open-label, pragmatic trial, we randomly assigned 2008 patients with significant coronary artery lesions undergoing PCI in a 1:1 ratio to undergo either an OCT-guided or IVUS-guided PCI. The primary end point was a composite of death from cardiac causes, target vessel--related myocardial infarction, or ischemia-driven targetvessel revascularization at 1 year, which was powered for noninferiority of the OCT group compared with the IVUS group. Safety outcomes were also assessed. RESULTS: At 1 year, primary end point events occurred in 25 of 1005 patients (Kaplan-Meier estimate, 2.5%) in the OCT group and in 31 of 1003 patients (Kaplan-Meier estimate, 3.1%) in the IVUS group (absolute difference, -0.6 percentage points; upper boundary of one-sided 97.5% CI, 0.97 percentage points; P<0.001 for noninferiority). The incidence of contrastinduced nephropathy was similar (14 patients [1.4%] in the OCT group versus 15 patients [1.5%] in the IVUS group; P=0.85). The incidence of major procedural complications was lower in the OCT group than in the IVUS group (22 [2.2%] versus 37 [3.7%]; P=0.047), although imaging procedure-related complications were not observed. CONCLUSIONS: In patients with significant coronary artery lesions, OCT-guided PCI was noninferior to IVUS-guided PCI with respect to the incidence of a composite of death from cardiac causes, target vessel--related myocardial infarction, or ischemia-driven target-vessel revascularization at 1 year. The selected study population and lower-than-expected event rates should be considered in interpreting the trial. [ABSTRACT FROM AUTHOR]

Objective: Little information exists about inter-racial differences in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). We investigated whether differences in baseline characteristics between Asian and non-Asian population may contribute to disparities in clinical outcomes after TAVI.Methods: We performed a registry-based, multinational cohort study of patients with severe AS who underwent TAVI at two centres in the USA and one centre in South Korea. The primary outcome was a composite of death, stroke or rehospitalisation at 1 year.Results: Of 1412 patients, 581 patients were Asian and 831 were non-Asian (87.5% white, 1.7% black, 6.1% Hispanic or 4.7% others). There were substantial differences in baseline characteristics between two racial groups. The primary composite outcome was significantly lower in the Asian group than in the non-Asian group (26.0% vs 35.0%; HR 0.73; 95% CI 0.59 to 0.89; p=0.003). However, after adjustment of baseline covariates, the risk of primary composite outcome was not significantly different (HR 0.79; 95% CI 0.60 to 1.03; p=0.08). The all-cause mortality at 1 year was significantly lower in the Asian group than the non-Asian group (7.4% vs 12.5%; HR 0.60; 95% CI 0.41 to 0.88; p=0.009). After multivariable adjustment, the risk of all-cause mortality was also similar (HR 1.17; 95% CI 0.73 to 1.88; p=0.52).Conclusions: There were significant differences in baseline and procedural factors among Asian and non-Asian patients who underwent TAVI. Observed inter-racial differences in clinical outcomes were largely explained by baseline differences in clinical, anatomical and procedural factors.Trial Registration Number: NCT03826264 (https://wwwclinicaltrialsgov). [ABSTRACT FROM AUTHOR]

BACKGROUND: Compared with angiographic guidance, intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) is associated with better clinical outcomes. However, its very long-term clinical effect is still unclear in patients undergoing PCI for unprotected left main coronary artery disease. METHODS: To compare 10-year outcomes of IVUS-guided versus angiography-guided PCI for left main coronary artery disease, we evaluated 975 patients who underwent unprotected left main coronary artery PCI between January 2000 and June 2006 from the MAIN-COMPARE (The Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. The 10-year rates of clinical outcomes (death; the composite of death, Q-wave myocardial infarction [MI], or stroke; and target-vessel revascularization) were compared between IVUS guidance and angiography guidance. Adjusted analyses were performed with the use of inverse-probability-treatment-weighting and propensity score matching. RESULTS: Among the 975 patients, 756 (77.5%) had IVUS guidance. The observed 10-year incidence rate of death (16.4% versus 31.0%, P<0.001) and composite of death, Q-wave MI, or stroke (19.2% versus 32.9%, P<0.001) was significantly lower in the IVUS-guided than in the angiography-guided group. The 10-year incidence rate of target-vessel revascularization was similar between the 2 groups (21.8% versus 18.3%, P=0.41). After adjusting for potential confounders with inverseprobability- treatment-weighting, IVUS was associated with lower incidence of mortality (hazard ratio, 0.75 [95% CI, 0.55- 1.03]; P=0.07) and composite of death, Q-wave MI, or stroke (hazard ratio, 0.79 [95% CI, 0.59-1.06]; P=0.11). In 208 propensity score-matched pairs, IVUS was also associated with lower incidence of death (hazard ratio, 0.73 [95% CI, 0.53- 1.02]; P=0.07) and composite outcome of death, Q-wave MI, or stroke (hazard ratio, 0.71 [95% CI, 0.52-0.97]; P=0.03). The benefit of IVUS-guided PCI was consistent in the various subsets of clinical and anatomic characteristics. CONCLUSIONS: In patients undergoing PCI for unprotected left main coronary artery disease, IVUS-guided PCI compared with angiography-guided PCI was associated with lower long-term (10-year) risks of morality and composite of death, Q-wave MI, or stroke. [ABSTRACT FROM AUTHOR]

Aims Using balloon sizing to determine device size may cause complications and increase procedure time in performing transcatheter closure of atrial septal defect (ASD). We aimed to validate the clinical utility of a formula using measurements from 3D transoesophageal echocardiography (TOE) images in performing the procedure without balloon sizing. Methods and results We enrolled 248 consecutive patients with ASD in a prospective registry. In the first tier (n = 53), we determined the device size before the procedure using our formula and performed balloon sizing during the procedure to verify our decision. In the second tier (n = 195), the procedure was performed without balloon sizing. In the first tier, the estimated device size correlated well with the device size finally implanted (R = 0.961, P < 0.001; bias, 0.38 ± 1.5 mm, P < 0.001) and with the stretched balloon diameter (R = 0.929, P < 0.001; bias, 0.13 ± 2.0 mm, P < 0.001). In the second tier, the device size derived from the formula was used in all patients, with the exception of one patient who showed a deficient rim on the aorta and superior sides and ASD that was not on a single plane. Two patients with unfavourable morphologies for device implantation experienced embolization of the device. Of the 193 patients with procedural success (99.0%), 2 suffered from haemopericardium caused by atrial wall erosion by the device. There were no procedure-related deaths. Conclusion The transcatheter closure of ASD using the 3D TOE-derived formula without balloon sizing is clinically feasible and safe. However, caution should be taken to exclude unfavourable features of ASD (ClinicalTrials.gov number NCT 02097758). [ABSTRACT FROM AUTHOR]

Background--The applicability of Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery scores to left main coronary artery disease (CAD) has been questioned. A simplified alternative is needed for guiding decision making. Methods and Results--We evaluated the prognostic value of a simplified angiographic classification in comparison with a Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score-based approach for patients with left main CAD undergoing drug-eluting stent implantation. The proposed approach classified left main CAD as either extensive (n=819), defined as left main bifurcation lesions with an involvement of ostial left circumflex artery or as any left main lesion plus multivessel CAD, or limited (n=453), defined as ostial/midshaft lesions or left main bifurcation lesions without an involvement of ostium of left circumflex artery, alone or plus 1-vessel disease. The databases from 4 prospective Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease studies were pooled, and the primary outcome was a major adverse cardiac event, defined as death, myocardial infarction, or repeat revascularization. During follow-up (median 38 months; interquartile range, 36-61 months), the risk for major adverse cardiac event was significantly higher with extensive than with limited left main CAD (adjusted hazard ratio, 2.13; 95% confidence interval, 1.54-2.94; P<0.001). The risk for a composite outcome of death or myocardial infarction was also higher with extensive left main CAD (adjusted hazard ratio, 1.75; 95% confidence interval, 1.08-2.85; P=0.02). However, Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score tertiles did not effectively stratify these 2 outcome measures. Conclusions--Compared with Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery scores, the simpler angiographic approach provided better discrimination for future cardiovascular events in patients with left main CAD undergoing drug-eluting stent implantation. [ABSTRACT FROM AUTHOR]

Purpose: Few studies have reported on predicting prognosis using myocardial perfusion single-photon emission computed tomography (SPECT) during coronary artery disease (CAD) treatment. Therefore, we aimed to assess the clinical implications of myocardial perfusion SPECT during follow-up for CAD treatment. Materials and Methods: We enrolled 1153 patients who had abnormal results at index SPECT and underwent follow-up SPECT at intervals ≥6 months. Major adverse cardiac events (MACE) were compared in overall and 346 patient pairs after propensity-score (PS) matching. Results: Abnormal SPECT was associated with a significantly higher risk of MACE in comparison with normal SPECT over the median of 6.3 years (32.3% vs. 19.8%; unadjusted p<0.001). After PS matching, abnormal SPECT posed a higher risk of MACE [32.1% vs. 19.1%; adjusted hazard ratio (HR)=1.73; 95% confidence interval (CI)=1.27-2.34; p<0.001] than normal SPECT. After PS matching, the risk of MACE was still higher in patients with abnormal follow-up SPECT in the revascularization group (30.2% vs. 17.9%; adjusted HR=1.73; 95% CI=1.15-2.59; p=0.008). Low ejection fraction [odds ratio (OR)=5.33; 95% CI=3.39-8.37; p<0.001] and medical treatment (OR=2.68; 95% CI=1.93-3.72; p<0.001) were independent clinical predictors of having an abnormal result on follow-up SPECT. Conclusion: Abnormal follow-up SPECT appears to be associated with a high risk of MACE during CAD treatment. Follow-up SPECT may play a potential role in identifying patients at high cardiovascular risk. [ABSTRACT FROM AUTHOR]

This study discerns optimal rules for coordinated operation of existing dams and eight newly constructed weirs in the Nakdong River through use of a system network while considering the water supply and operating facilities. To determine the operation rules, capacity was simulated by reservoir operations modeling and evaluated separately under the following three cases: (1) when dams were operated individually; (2) when they were operated in conjunction with other dams; and (3) when dams and weirs were operated in conjunction with each other. The water supply capacity of the Nakdong was highest in Case 3. When considering operational losses (9.1 and 14.8% in Cases 2 and 3, respectively), water supply decreased. Findings show that when water levels drop below the target, hydrological facilities should flexibly adjust water storage and flow rates at each dam in the system. Further studies are needed to investigate the influence of agricultural reservoirs and river channel discharged flows and to identify regions vulnerable to water shortages driven by future fluctuations in water resources due to climate change. [ABSTRACT FROM AUTHOR]

Background—The mechanism of statin for atheroma stabilization remains unclear. We aimed to assess the relationship between on-treatment changes in serum inflammatory biomarker levels and plaque composition in differed nonculprit coronary lesions. Methods and Results—The changes in serum biochemical values, and intravascular ultrasound data were evaluated in 218 patients with virtual histology (VH)-intravascular ultrasound—defined fibroatheroma-containing segments after 12-month rosuvastatin treatment. When stratifying patients into quartiles according to the change in high-sensitivity C-reactive protein (hsCRP), there was a significant positive linear relationship for the changes in %necrotic core (coefficient, 1.31; standard error, 0.54) and %dense calcium volumes (coefficient, 0.80; standard error, 0.27), but a negative linear relationship for the changes in %fibrous (coefficient, −0.94; standard error, 0.45) and %fibrofatty volumes (coefficient, −1.17; standard error, 0.56; all P<0.05). The decrease in hsCRP (−1.2±3.9 versus 0.5±3.4 mg/L; P=0.02) was greater in those without VH-defined thin-cap fibroatheroma (TCFA, defined as >30° of necrotic core abutting the lumen in 3 consecutive slices) than those with VH-TCFA at follow-up. Diabetes mellitus, a larger normalized total atheroma volume, and the presence of VH-TCFA at baseline predicted the presence of VH-TCFA at follow-up (odds ratio, 4.01, 1.18, and 9.21, respectively; all P<0.05), whereas the change in hsCRP showed a trend (odds ratio, 1.19; P=0.07). The change in low-density lipoprotein-cholesterol had no relationship with the changes in hsCRP or plaque compositions. Conclusions—With 12-month rosuvastatin therapy, a greater hsCRP reduction (not low-density lipoprotein-cholesterol) was associated with a greater decrease in %necrotic core volume and the absence of VH-TCFA, indicating a link between the anti-inflammatory action of statin and plaque stabilization by reducing NC and reinforcing fibrous cap. [ABSTRACT FROM AUTHOR]

Background--Identifying predictive factors for major cardiovascular events and death in patients with unprotected left main coronary artery disease is of great clinical value for risk stratification and possible guidance for tailored preventive strategies. Methods and Results--The Interventional Research Incorporation Society-Left MAIN Revascularization registry included 5795 patients with unprotected left main coronary artery disease (percutaneous coronary intervention, n=2850; coronary- artery bypass grafting, n=2337; medication alone, n=608). We analyzed the incidence and independent predictors of major adverse cardiac and cerebrovascular events (MACCE; a composite of death, MI, stroke, or repeat revascularization) and all-cause mortality in each treatment stratum. During follow-up (median, 4.3 years), the rates of MACCE and death were substantially higher in the medical group than in the percutaneous coronary intervention and coronary-artery bypass grafting groups (P<0.001). In the percutaneous coronary intervention group, the 3 strongest predictors for MACCE were chronic renal failure, old age (≥65 years), and previous heart failure; those for all-cause mortality were chronic renal failure, old age, and low ejection fraction. In the coronary-artery bypass grafting group, old age, chronic renal failure, and low ejection fraction were the 3 strongest predictors of MACCE and death. In the medication group, old age, low ejection fraction, and diabetes mellitus were the 3 strongest predictors of MACCE and death. Conclusions--Among patients with unprotected left main coronary artery disease, the key clinical predictors for MACCE and death were generally similar regardless of index treatment. This study provides effect estimates for clinically relevant predictors of long-term clinical outcomes in real-world left main coronary artery patients, providing possible guidance for tailored preventive strategies. Clinical Trial Registration--URL: https://clinicaltrials.gov. Unique identifier: NCT01341327. [ABSTRACT FROM AUTHOR]

Aims: Fractional flow reserve (FFR) has proven to its prognostic and therapeutic value. However, the additive prognostic value of coronary flow reserve (CFR) remains unclear. This study sought to investigate the clinical utility of combined FFR and CFR measurements to predict outcomes. Methods and results: Using the prospective, multicentre Interventional Cardiology Research Incooperation Society-FFR registry, a total of 2088 lesions from 1837 patients were included in this substudy. Based on baseline and hyperaemic pressure gradients, we computed physiologic limits of CFR [the so called pressure-bounded (pb) CFR] and classified lesions as low (<2) or high (≥2). The primary endpoint was major adverse cardiac events (MACE, a composite of cardiac death, myocardial infarction, and revascularization) analysed on a per-patient basis. During a median follow-up of 1.9 years (interquartile range: 1.0-3.0 years), MACE occurred in 5.7% of patients with FFR ≤0.80 vs. 2.8% of patients with FFR >0.80 [adjusted hazard ratio (aHR): 2.15, 95% confidence interval (CI): 1.19-3.89; P = 0.011. In contrast, the incidence of MACE did not differ between patients with pb-CFR< 2 vs. pb-CFR ≥ 2 (4.2% vs. 4.2%; aHR: 0.98, CI: 0.60 to 1.58; P= 0.92). Incorporation of FFR significantly improved model prediction of MACE (global χ² 38.8-48.1, P = 0.002). However, pb-CFR demonstrated no incremental utility to classify outcomes (global χ² 48.1-48.2, P> 0.99). Conclusions: In this large, prospective registry of over 2000 coronary lesions, FFR was strongly associated with clinical outcomes. In contrast, a significant association between pb-CFR and clinical events could not be determined and adding knowledge of pb-CFR did not improve prognostication over FFR alone. [ABSTRACT FROM AUTHOR]

Aims: To assess the impact of the SYNTAX scores I and II in outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for patients with diabetes and multivessel disease (MVD). Methods and results: We performed a patient-level pooled analysis of three large randomized trials of patients with MVD. The impact of coronary anatomic complexity as measured by the SYNTAX score in the differences in outcomes following PCI and CABG was assessed at a median follow-up of 5 years. We also assessed the performance of the SYNTAX II score model in patients with and without diabetes. From the 3280 patients enrolled in the three trials, a total of 1068 (32.6%) had diabetes. The rate of the composite of death, myocardial infarction (MI), or stroke was similar in the PCI and CABG arms in patients with low-intermediate (≤32) SYNTAX scores (15.1% vs. 14.9%, respectively; P = 0.93) while it was significantly higher in the PCI arm in patients with high (≥33) SYNTAX scores (24.5% vs. 13.2%, respectively; P = 0.018). The SYNTAX score II showed good calibration and moderate discrimination ability in patients with diabetes (c-index = 0.68) as well as in those without (c-index = 0.67). Conclusions: Differences in 5 years outcomes following PCI and CABG for patients with MVD and diabetes were influenced by anatomic complexity as measured by the SYNTAX score. The SYNTAX score II mortality prediction model showed similar performance regardless of the diabetes status. [ABSTRACT FROM AUTHOR]

Background: We evaluated the prognosis of deferred and revascularized coronary stenoses after fractional flow reserve (FFR) measurement to assess its revascularization threshold in clinical practice.Methods: The IRIS-FFR registry (Interventional Cardiology Research In-cooperation Society Fractional Flow Reserve) prospectively enrolled 5846 patients with ≥1coronary lesion with FFR measurement. Revascularization was deferred in 6468 lesions and performed in 2165 lesions after FFR assessment. The primary end point was major adverse cardiac events (cardiac death, myocardial infarction, and repeat revascularization) at a median follow-up of 1.9 years and analyzed on a per-lesion basis. A marginal Cox model accounted for correlated data in patients with multiple lesions, and a model to predict per-lesion outcomes was adjusted for confounding factors.Results: For deferred lesions, the risk of major adverse cardiac events demonstrated a significant, inverse relationship with FFR (adjusted hazard ratio, 1.06; 95% confidence interval, 1.05-1.08; P<0.001). However, this relationship was not observed in revascularized lesions (adjusted hazard ratio, 1.00; 95% confidence interval, 0.98-1.02; P=0.70). For lesions with FFR ≥0.76, the risk of major adverse cardiac events was not significantly different between deferred and revascularized lesions. Conversely, in lesions with FFR ≤0.75, the risk of major adverse cardiac events was significantly lower in revascularized lesions than in deferred lesions (for FFR 0.71-0.75, adjusted hazard ratio, 0.47; 95% confidence interval, 0.24-0.89; P=0.021; for FFR ≤0.70, adjusted hazard ratio 0.47; 95% confidence interval, 0.26-0.84; P=0.012).Conclusions: This large, prospective registry showed that the FFR value was linearly associated with the risk of cardiac events in deferred lesions. In addition, revascularization for coronary artery stenosis with a low FFR (≤0.75) was associated with better outcomes than the deferral, whereas for a stenosis with a high FFR (≥0.76), medical treatment would be a reasonable and safe treatment strategy.Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01366404. [ABSTRACT FROM AUTHOR]

Multifunctional weirs can be used to maintain water supply during dry seasons and to improve downstream water quality during drought conditions through discharge based on retained flux. Sixteen multifunctional weirs were recently constructed in four river systems as part of the Four Rivers Restoration Project. In this study, three multifunctional weirs in the Geum River Basin were investigated to analyze the environmental effects of multifunctional weir operation on downstream flow. To determine seasonal vulnerability to drought, the basin was evaluated using the Palmer Drought Severity Index (PDSI). Furthermore, the downstream flow regime and the effect on water quality improvement of a coordinated dam-multifunctional weir operation controlled by: (a) a rainfall-runoff model; (b) a reservoir optimization model; and (c) a water quality model, were examined. A runoff estimate at each major location in the Geum River Basin was performed using the water quality model, and examined variation in downstream water quality depending on the operational scenario of each irrigation facility such as dams and weirs. Although the water quality was improved by the coordinated operation of the dams and weirs, when the discharged water quality is poor, the downstream water quality is not improved. Therefore, it is necessary to first improve the discharged water quality on the lower Geum River. Improvement of the water quality of main stream in the Geum River is important, but water quality from tributaries should also be improved. By applying the estimated runoff data to the reservoir optimization model, these scenarios will be utilized as basic parameters for assessing the optimal operation of the river. [ABSTRACT FROM AUTHOR]

Background--The impact of sex on clinical outcomes of percutaneous coronary intervention and coronary artery bypass graft for patients with multivessel coronary disease and unprotected left main disease could be dissimilar between Western and Asian populations. Methods and Results--To assess clinical outcomes after percutaneous coronary intervention or coronary artery bypass graft in women and men with multivessel coronary disease and unprotected left main disease, a pooled analysis (n=3280) was performed using the patient-level data from 3 large randomized trials: SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and BEST (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) trials. The primary end point was all-cause death. Of 3280 patients, 794 patients (24.2%) were women. The median follow-up period was 1806 days (1611-1837 days). In women, a high heterogeneity of the treatment effect among the 3 trials was found for all-cause death (I2>50%), whereas in men, it was consistent across the 3 trials. In the Western trial (SYNTAX), female sex favored coronary artery bypass graft compared with percutaneous coronary intervention (hazard ratio(percutaneous coronary intervention) 2.213; 95% confidence interval, 1.242-3.943; P=0.007), whereas in the Asian women (PRECOMBAT and BEST), the treatment effect was neutral between both strategies. Sex interaction with treatment strategy was evident in the Western trial (Pinteraction=0.019) but not in the Asian trials (PRECOMBAT Pinteraction=0.469 and BEST Pinteraction=0.472; I2=58%). Conclusions--The present meta-analysis suggested the presence of the heterogeneous sex--treatment interaction across Asian and Western trials. Considering the ongoing globalization of our medical practice, the heterogeneity of the sex--treatment interaction needs to be well recognized and taken into account during the decision making of the treatment strategy. Clinical Trial Registrations--URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00114972, NCT00997828, NCT00422968. [ABSTRACT FROM AUTHOR]

OBJECTIVES: There are limited data comparing long-term outcomes of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in patients with high surgical risk. We evaluated 5-year outcomes following CABG versus PCI with DES in 598 patients with left main or multivessel coronary artery disease (CAD) and a high surgical risk [EuroSCORE (European system for cardiac operative risk evaluation) > 6]. METHODS: Databases were merged from the BEST, PRECOMBAT and SYNTAX trials. The primary outcome was a major adverse cardiocerebral event (MACCE), defined as the composite of all-cause death, myocardial infarction, stroke or repeat revascularization. RESULTS: During 5-year follow-up, the rates of MACCE were 29.4% in the CABG group and 43.8% in the PCI group [hazard ratio (HR), 0.64; 95% confidence interval (CI), 0.49 - 0.84; P = 0.001]. The MACCE was significantly better with CABG than with PCI in patients with high and intermediate SYNTAX scores (34.9% vs 46.3%, P = 0.039, and 29.7% vs 47.6%, P = 0.010, respectively), but comparable between the two groups in those with low SYNTAX scores. The rates of all-cause death and stroke were similar between the two groups. However, CABG was associated with fewer myocardial infarctions (HR, 0.50; 95% CI, 0.27 - 0.93; P = 0.027) and repeat revascularizations (HR, 0.32; 95% CI, 0.20 - 0.52; P < 0.001). CONCLUSIONS: Among high surgical risk patients with left main or multivessel CAD, CABG compared to PCI with DES was associated with a lower rate of MACCE. [ABSTRACT FROM AUTHOR]

Aims To compare the diagnostic accuracy of on-site computed tomography (CT)-derived fractional flow reserve (FFR) and stress CT myocardial perfusion (CTP) in patients with coronary artery disease. Methods and results Using a prospective CTP registry, 72 patients with invasive FFR were enrolled. CT-derived FFR was computed on-site using rest-phase CTP data. The diagnostic accuracies of coronary CT angiography (CCTA), CT-derived FFR, and stress CTP were evaluated using an area under the receiver-operating characteristic curve (AUC) with invasive FFR as a reference standard. Logistic regression and the net reclassification index (NRI) were used to evaluate incremental differences in CT-derived FFR or CTP compared with CCTA alone. The per-vessel prevalence of haemodynamically significant stenosis (FFR ≤ 0.80) was 39% (54/138). Per-vessel sensitivity and specificity were 94 and 66% for CCTA, 87 and 77% for CT-derived FFR, and 79 and 91% for CTP, respectively. There was no significant difference in the AUC values of CT-derived FFR and CTP (P = 0.845). The diagnostic performance of CCTA (AUC = 0.856) was improved by combining it with CT-derived FFR (AUC = 0.919, P = 0.004, NRI = 1.01) or CTP (AUC = 0.913, P = 0.004, NRI = 0.66). CT-derived FFR values had a moderate correlation with invasive FFR (r = 0.671, P < 0.001). Conclusion On-site CT-derived FFR combined with CCTA provides an incremental diagnostic improvement over CCTA alone in identifying haemodynamically significant stenosis defined by invasive FFR, with a diagnostic accuracy comparable with CTP. [ABSTRACT FROM AUTHOR]

Objective: In patients with multivessel disease and proximal left anterior descending artery (LAD) involvement, the best revascularisation strategy is still unclear. We assess outcomes after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents in a pooled analysis of individual patient-level data of the SYNTAX and BEST randomised trials.Design: Proximal LAD involvement was defined by any lesion ≥ 50% diameter stenosis in the arterial segment starting from the left-main bifurcation up to (and including) the origin of the first major septal branch. The primary endpoint was the composite of all-cause death, myocardial infarction (MI) or stroke at 5 years of follow-up.Results: The present study population comprises 1166 patients of which 577 were randomised to PCI and 589 to CABG. Baseline characteristics were well balanced across study arms. The primary endpoint occurred in 94 (16.3%) patients in the PCI arm and in 68 (11.5%) patients in the CABG arm (HR 1.43; 95%CI 1.05 to 1.95; p=0.026). CABG was also associated with a significantly lower rate of cardiac death (p=0.007), MI (p<0.001), all-cause revascularisation (p<0.001) and major adverse cardiovascular and cerebrovascular events (all-cause death, MI, stroke, revascularisation) (p<0.001). The rates of all-cause mortality (p=0.06) and stroke (p=0.09) were not statistically different between the two groups. The overall study results for the primary outcome were consistent across several subgroups.Conclusions: In patients with multivessel disease with proximal LAD involvement, CABG is associated with lower rates of the safety composite endpoint of death, MI or stroke as compared with PCI with drug-eluting stents at 5 years of follow-up (number needed to treat=21).Trial Registration Number: PRECOMBAT clinicaltrials.gov NCT00997828; SYNTAX: clinicaltrials.gov identifier: NCT00114972 NCT00114972. [ABSTRACT FROM AUTHOR]

Background---Recent evidence suggests that the diagnostic accuracy of myocardial perfusion imaging is improved by quantifying stress myocardial blood flow (MBF) in absolute terms. We evaluated a comprehensive quantitative 13N-ammonia positron emission tomography (13NH3-PET) diagnostic panel, including stress MBF, coronary flow reserve (CFR), and relative flow reserve (RFR) in conjunction with relative perfusion defect (PD) assessments to better detect functionally significant coronary artery stenosis. Methods and Results---A total of 130 patients (307 vessels) with coronary artery disease underwent both 13NH3-PET and invasive coronary angiography with fractional flow reserve (FFR) measurement. Diagnostic accuracy, optimal cut points, and discrimination indices of respective 13NH3-PET quantitative measures were compared, with FFR as standard reference. The capacity to discern disease with stepwise addition of stress MBF, CFR, and RFR to qualitatively assessed relative PD was also gauged, using the category-free net reclassification index. All quantitative measures showed significant correlation with FFR (PET-derived CFR, r=0.388; stress MBF, r=0.496; and RFR, r=0.780; all P<0.001). Optimal respective cut points for FFR ≤0.8 and ≤0.75 were 1.99 and 1.84 mL/min per g for stress MBF and 2.12 and 2.00 for PET-derived CFR. Discrimination indices of quantitative measures that correlated with FFR ≤0.8 were all significantly higher than that of relative PD (area under the curve: 0.626, 0.730, 0.806, and 0.897 for relative PD, CFR, stress MBF, and RFR, respectively; overall comparison P<0.001). The capacity for functionally significant coronary stenosis was incrementally improved by the successive addition of CFR (net reclassification index=0.629), stress MBF (net reclassification index=0.950), and RFR (net reclassification index=1.253; all P<0.001) to relative PD. Conclusions---Integrating quantitative 13NH3-PET measures with qualitative myocardial perfusion assessment provides superior diagnostic accuracy and improves the capacity to detect functionally significant coronary artery stenosis. [ABSTRACT FROM AUTHOR]

Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method. [ABSTRACT FROM AUTHOR]

he article discusses research which compared percutaneous coronary intervention (PCI) with everolimus-eluting stents and coronary-artery bypass grafting (CABG) in patients with multivessel coronary artery disease. Topics covered include the occurrence of the primary end point which was a composite of death, myocardial infarction or target-vessel revascularization and the higher rate of adverse cardiovascular events in patients who had undergone PCI.