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ImportanceIn patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion–only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown.ObjectiveTo determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD.Design, Setting, and ParticipantsThis secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021.InterventionsFollowing PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization.Main Outcomes and MeasuresSeattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end.ResultsOf 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion–only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P P P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion–only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02).Conclusions and RelevanceIn patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion–only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.

Background: Morphine is commonly used to relieve pain, anxiety and dyspnea in STEMI but it lowers blood pressure and delays the activity of oral antiplatelet agents. The impact of morphine on clinical outcomes remains unknown. This analysis was performed to determine if morphine use was associated with increased risk of adverse clinical events among STEMI patients treated with fibrinolytic therapy and clopidogrel or ticagrelor. Methods: In the Ticagrelor in Patients with ST Elevation Myocardial Infarction Treated with Pharmacological Thrombolysis (TREAT) study, 3799 STEMI patients treated with fibrinolysis were randomized to receive clopidogrel or ticagrelor. Morphine use was left to the discretion of the treating physicians. In this pre-specified analysis, we evaluated clinical outcomes based on the use and timing of morphine administration. Outcomes were stratified by randomized treatment group. Multivariable analysis was performed using Inverse Probability Treatment Weighting (IPTW) weighting. Results: Morphine was used in 53% of patients. After adjustment using IPTW weighting, morphine use was associated with higher hazard of reinfarction at 7 days (HR 4.9, P = .0006) and 30 days (HR 1.7, P = .04), and lower hazard of major bleeding (HR 0.37, P = .006). There was no significant difference in mortality at any time point. Conclusions: Among patients with STEMI treated with fibrinolytic therapy, morphine use was associated with a higher risk of early reinfarction and a lower risk of major bleeding but no difference in mortality.

Background: It is unclear whether more effective forms of thrombus removal than current aspiration catheters would lead to improved outcomes. We sought to evaluate the prognostic role of residual thrombus burden (rTB), after manual thrombectomy, in patients undergoing primary percutaneous coronary intervention with routine manual thrombectomy in the TOTAL trial (Thrombectomy Versus PCI Alone). Methods: This is a single-arm analysis of patients from the TOTAL trial who underwent routine manual aspiration thrombectomy. The rTB was quantified by an angiographic core laboratory using the Thrombolysis in Myocardial Infarction criteria and validated using existing optical coherent tomography data. Large rTB was defined as grade ≥3. The primary outcome was death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or new or worsening heart failure within 180 days. Results: Of 5033 patients randomized to routine thrombectomy, 2869 patients had quantifiable rTB (1014 [35%] had large rTB). Patients with large rTB were more likely to have hypertension, previous percutaneous coronary intervention, myocardial infarction, or Killip class III on presentation but less likely to have Killip class I. The primary outcome occurred more frequently in patients with large rTB, even after adjustment for known risk predictors (8.6% versus 4.6%; adjusted hazard ratio, 1.83 [95% CI, 1.34–2.48]). These patients also had a higher risk of cardiovascular death (adjusted hazard ratio, 1.83 [95% CI, 1.13–2.95]), cardiogenic shock (adjusted hazard ratio, 2.02 [95% CI, 1.08–3.76]), and heart failure (adjusted hazard ratio, 1.74 [95% CI, 1.02–2.96]) but not myocardial infarction or stroke. Conclusions: Large rTB is a common finding in primary percutaneous coronary intervention and is associated with increased risk of adverse cardiovascular outcomes, including cardiovascular death. Future technologies offering better thrombus removal than current devices may decrease or even eliminate the risk associated with rTB. This, potentially, can turn into a strategic option to be studied in clinical trials. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01149044.

Patients on uniterrupted chronic oral anticoagulation (OAC) therapy are at high-risk of bleeding during cardiac catheterization. We aimed to investigate the safety and efficacy of the StatSeal® disc for adjunct hemostasis in patients undergoing transradial coronary angiography under uninterrupted OAC therapy.Patients who underwent transradial cardiac catheterization without interrupted OAC therapy were included in this study.Among 180 patients, 85 (47.2%) patients were on warfarin and 95 (52.8%) patients on novel oral anticoagulants (NOACs). Patients on NOACs were older (72.9 ± 9.6 versus 69.7 ± 10.8 years, P 0.001) and had more atrial fibrillation/flutter (94.7% versus 62.4%, P 0.001), whereas patients on Warfarin were more often women (43.5% versus 26.3%, P = 0.02) and had mechanical heart valves (27.1% versus 0%, P 0.001). Intravenous unfractioned heparin (UFH) was administered in 96.5% of patients on warfarin (3799 ± 1342 units) and 93.7% patients on NOACs (4028 ± 1362 units), P = 0.27. There were no differences in terms of type and sheath size and the need for ad hoc coronary intervention. Time-to-first release of the hemostatic wristband was 56.2 ± 12.6 min and complete hemostasis was achieved in 71.1 ± 13.0 min, with shorter times among patients on NOACs (54.1 ± 11.7 and 58.5 ± 13.2 min, 68.9 ± 11.7 versus 73.6 ± 14.0 min, P = 0.02, for both). There were no significant differences in terms of bleeding. There was no radial artery occlusion among 112 participants who underwent color Doppler ultrasound.The present study shows that in patients undergoing transradial coronary angiogram under contemporary uninterrupted OAC therapy and periprocedural administration of UFH, the use of StatSeal® disc for adjunctive hemostasis was associated with short times to complete hemostasis.

Background: The COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI) demonstrated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular events in patients with ST-segment–elevation myocardial infarction and multivessel coronary artery disease. It is unclear whether consistent benefit is observed in patients undergoing a pharmacoinvasive strategy compared with primary PCI. Methods: Following culprit lesion PCI, 4041 patients with ST-segment–elevation myocardial infarction and multivessel coronary artery disease were randomized to either routine nonculprit lesion PCI or culprit lesion only PCI. In a prespecified analysis, we determined the treatment effect in 303 patients undergoing a pharmacoinvasive strategy versus 3738 patients undergoing primary PCI on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Results: The first coprimary was reduced with complete revascularization both in the patients undergoing a pharmacoinvasive strategy (2.1%/y versus 4.7%/y, hazard ratio, 0.45 [95% CI, 0.21–0.97]) and in patients undergoing primary PCI (2.7%/y versus 3.6%/y, hazard ratio, 0.77 [95% CI, 0.62–0.95]; interaction P =0.18). The second coprimary outcome was reduced with complete revascularization in patients undergoing a pharmacoinvasive strategy (2.3%/y versus 8.5%/y, hazard ratio, 0.28 [95% CI, 0.14–0.56]), and in patients undergoing primary PCI (3.2%/y versus 6.0%/y, hazard ratio, 0.53 [95% CI, 0.44–0.64], interaction P =0.07). Conclusions: Among patients with ST-segment–elevation myocardial infarction and multivessel disease, complete revascularization with multivessel PCI consistently reduces major cardiovascular events in patients undergoing an initial pharmacoinvasive strategy as well as in those undergoing primary PCI. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01740479.

Chronic kidney disease (CKD) increases the risk of adverse outcomes in acute coronary syndrome (ACS). The optimal regimen of dual antiplatelet therapy (DAPT) post-percutaneous coronary intervention (PCI) in CKD poses a challenge due to the increased bleeding and clotting tendencies, particularly since patients with CKD were underrepresented in randomized controlled trials. We examined the practice patterns of DAPT prescription stratified by the presence of CKD. The multicentre prospective Canadian Observational Antiplatelet Study (COAPT) enrolled patients with ACS between December 2011 and May 2013. The present study is a subgroup analysis comparing type and duration of DAPT and associated outcomes among patients with and without CKD (eGFR 60 ml/min/1.73 m

Reperfusion therapy has resulted in significant improvement in post-myocardial infarction morbidity and mortality in over the last 4 decades. Nonetheless, it is well recognized that simply restoring patency of the epicardial artery may not stop or reverse damage at microvascular level, and myocardial salvage is often suboptimal. Numerous efforts have been undertaken to elucidate the mechanisms underlying extensive myonecrosis to facilitate the discovery of therapies to provide additional and incremental benefits over current therapeutic pathways. To date, conclusively effective strategies to promote myocardial recovery have not yet been established. Novel approaches are investigating the foundational cellular and molecular bases of myocardial ischemia and irreversible injury. Herein, we review the emerging concepts and proposed therapies that may improve myocardial protection and reduce infarct size. We examine the preclinical and clinical evidence for reduced infarct size with these strategies, including anti-inflammatory agents, intracellular ion channel modulators, agents affecting the reperfusion injury salvage kinase (RISK) and nitric oxide signaling pathways, modulators of mitochondrial function, anti-apoptotic agents, and stem cell and gene therapy. We review the potential reasons of failures to date and the potential for new strategies to further promote myocardial recovery and improve prognosis.

Background: Complete revascularization with routine percutaneous coronary intervention of nonculprit lesions after primary percutaneous coronary intervention improves outcomes in ST-segment–elevation myocardial infarction. Whether this benefit is associated with nonculprit lesion vulnerability is unknown. Methods: In a prospective substudy of the COMPLETEs trial (Complete vs Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI), we performed optical coherence tomography of at least 2 coronary arteries before nonculprit lesion percutaneous coronary intervention in 93 patients with ST-segment–elevation myocardial infarction and multivessel disease; and the ST-segment–elevation myocardial infarction culprit vessel if there was unstented segment amenable to imaging. Nonculprit lesions were categorized as obstructive (≥70% stenosis by visual angiographic assessment) or nonobstructive, and as thin-cap fibroatheroma (TCFA) or non-TCFA by optical coherence tomography criteria. TCFA was defined as a lesion with mean fibrous cap thickness 90°. Results: On a patient level, at least one obstructive TCFA was observed in 44/93 (47%) of patients. On a lesion level, there were 58 TCFAs among 150 obstructive nonculprit lesions compared with 74 TCFAs among 275 nonculprit lesions (adjusted TCFA prevalence: 35.4% versus 23.2%, P =0.022). Compared with obstructive non-TCFAs, obstructive TCFAs had similar lesion length (23.1 versus 20.8 mm, P =0.16) but higher lipid quadrants (55.2 versus 19.2, P P P P P =0.11), but more lipid quadrants (36.4 versus 13.5, P P Conclusions: Among patients who underwent optical coherence tomography imaging in the COMPLETE trial, nearly 50% had at least one obstructive nonculprit lesion containing complex vulnerable plaque. Obstructive lesions more commonly harbored vulnerable plaque morphology than nonobstructive lesions. This may help explain the benefit of routine percutaneous coronary intervention of obstructive nonculprit lesions in patients with ST-segment–elevation myocardial infarction and multivessel disease. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01740479s.

BACKGROUND Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, yet its pathophysiology is only partially understood. We sought to assess the association between endothelial dysfunction (ED) and SCAD. METHODS We prospectively assessed patients presenting with acute coronary syndrome who were diagnosed with SCAD. The control arm had established coronary artery atherosclerotic disease (AD) according to previous coronary angiography. ED was assessed using the EndoPAT 2000 while patients returned to their steady state condition. A total of 16 patients with SCAD and 66 patients with AD were included. RESULTS Microvascular reactivity as assessed with the EndoPAT was significantly worse in the AD group compared to the SCAD group. The median RHI in the AD group was 1.76 (IQR 1.52, 2.2) vs. a median RHI of 2.08 (IQR 1.73, 2.79) in the SCAD group (p

Background Radial artery occlusion (RAO) is the most common complication following transradial approach (TRA) for cardiac catheterization. Our aim was to assess if decreasing radial hemostatic device (RHD) time reduces the risk of RAO among individuals receiving small sheath sizes with no adjunctive heparin. Methods We randomized 450 individuals undergoing diagnostic cardiac catheterization via the TRA to 3 durations of RHD time: 10, 20 or 30 minutes. After this time period, the RHD was gradually released over 20 minutes. The primary efficacy endpoint was forearm hematoma grade ≥2 (5-10 cm) and the primary safety endpoint was RAO (as determined by Doppler ultrasound) one-hour post RHD removal (pre-discharge). Results The mean age was 66 years and 64% were male. 5 French sheaths were used in all patients. Hematoma grade ≥2 occurred only in 1 patient in the 20 minutes groups (P=0.39). RAO occurred in 6.7% of patients in the 10 minute group, 10.7% in the 20 minute group and 6% in the 30 minute group (P=0.26). Conclusion Among patients receiving small caliber sheaths without adjunctive heparin, the incidence of forearm hematoma and RAO are low. Shorter durations of RHD time did not further reduce the risk of these complications. Brief summary We assessed if reducing radial hemostatic device (RHD) time decreases the risk of radial artery occlusion (RAO) in patients undergoing cardiac catheterization via the trasradial approach while small size sheaths and no heparin are used. We randomized 450 individuals into 3 durations of RHD time: 10, 20 or 30 minutes. The incidence of forearm hematoma and RAO were low and not different between groups.

BACKGROUND AND AIMS Lecithin:cholesterol acyltransferase (LCAT), a key enzyme in high-density lipoprotein (HDL) metabolism and reverse cholesterol transport (RCT), has been associated with atheroprotection. However, its relation to plaque characteristics has not been confirmed to date. We aimed to determine the relationship between plasma LCAT mass concentration and plaque burden in a multi-center imaging study. METHODS Two hundred sixty-seven patients with angiographically proven coronary artery disease (CAD) underwent intravascular ultrasonography (IVUS) imaging. Ninety-six patients without CAD served as controls for biochemistry assessments. RESULTS Plasma LCAT mass concentration was higher in CAD patients as compared to controls (8.94 ± 2.51 μg/mL vs. 7.89 ± 2.99 μg/mL, p = 0.003), while cholesterol esterification rate (CER) was downregulated (253.6 ± 83.9 μM/2 h vs. 315.3 ± 115.0 μM/2 h, p

Percutaneous coronary intervention (PCI) of coronary bifurcation lesions (CBL) remains a challenge in contemporary practice due to the procedural and technical difficulties involved. We sought to review the current evidence on the safety and clinical outcomes of dedicated bifurcation stent (DBS) implantation in comparison with established treatment strategies for CBL-PCI.We conducted a comprehensive search to identify randomized control trials (RCTs) reporting 1-year clinical and angiographic outcomes of patients undergoing CBL-PCI with DBS vs conventional CBL-PCI strategies. Random-effects meta-analyses were performed to estimate the effect of DBS compared with conventional CBL-PCI using aggregate data.A total of 5 RCTs comprising 1249 participants met the inclusion criteria. The use of DBS was comparable to conventional stenting techniques in terms of major adverse cardiovascular event (MACE) rate (odds ratio [OR], 1.28; 95% confidence interval [CI], 0.90- 1.82; I²=0%), all-cause mortality (OR, 0.80; 95% CI, 0.31-2.07; I²=0%), cardiac mortality (OR, 0.16; 95% CI, 0.02-1.39; I²=0%), myocardial infarction (OR, 1.26; 95% CI, 0.84-1.89; I²=0%), definite stent thrombosis (OR, 1.75; 95% CI, 0.36-8.52; I²=0%), cumulative target-lesion revascularization (OR, 1.39; 95% CI, 0.85-2.27; I²=0%), clinically driven target-lesion revascularization (OR, 1.23; 95% CI, 0.68-2.22; I²=0%), or target-vessel revascularization (OR, 1.43; 95% CI, 0.92-2.22; I²=0%).The present analysis suggests that CBL-PCI with DBS may be associated with similar 1-year clinical and angiographic outcomes compared with conventional CBL-PCI strategies. However, the low quality of evidence and limited follow-up warrant further studies to ascertain any significant differences in patient-important outcomes before the adoption of DBS into routine CBL-PCI practice.

Background Hybrid coronary revascularization ( HCR ) involves the integration of coronary artery bypass grafting ( CABG ) and percutaneous coronary intervention to treat multivessel coronary artery disease. Our objective was to perform a comparative analysis with long‐term follow‐up between HCR and conventional off‐pump CABG . Methods and Results We compared all double off‐pump CABG (n=216) and HCR (n=147; robotic‐assisted minimally invasive direct CABG of the left internal thoracic artery to the left anterior descending artery and percutaneous coronary intervention to one of the non–left anterior descending vessels) performed at a single institution between March 2004 and November 2015. To adjust for the selection bias of receiving either off‐pump CABG or HCR , we performed a propensity score analysis using inverse‐probability weighting. Both groups had similar results in terms of re‐exploration for bleeding, perioperative myocardial infarction, stroke, blood transfusion, in‐hospital mortality, and intensive care unit length of stay. HCR was associated with a higher in‐hospital reintervention rate ( CABG 0% versus HCR 3.4%; P =0.03), lower prolonged mechanical ventilation (>24 hours) rate (4% versus 0.7%; P =0.02), and shorter hospital length of stay (8.1±5.8 versus 4.5±2.1 days; P CABG and 96 (53–115) months for HCR , the HCR group of patients had a trend toward improved survival (85% versus 96%; P =0.054). Freedom from any form of revascularization was similar between the 2 groups (92% versus 91%; P =0.80). Freedom from angina was better in the HCR group (73% versus 90%; P Conclusions HCR seems to provide, in selected patients, a shorter postoperative recovery, with similar excellent short‐ and long‐term outcomes when compared with standard off‐pump CABG .

Spontaneous coronary artery dissection (SCAD) is a cause of about 4% of acute coronary syndrome. The pathophysiology of SCAD is not yet fully understood. Loeys-Dietz syndrome is a connective tissue disorder characterized by aortic aneurysms, arterial tortuosity, and aortic dissections. It is caused by mutations in the genes affecting the transforming growth factor β pathway. We describe a family with a SMAD3 gene mutation and Loeys-Dietz syndrome presenting with recurrent SCAD episodes.

We present two cases where fractional flow reserve (FFR) was utilised to guide management of coronary artery fistula (CAF), an approach advocated in recent case studies. CAF is a coronary anomaly that may present with a variety of syndromes though is frequently asymptomatic. When to exclude the fistula (surgically or percutaneously) is not always clear. A way to quantify if the fistula is physiologically meaningful would be advantageous. Our findings suggest FFR may only be assessing the concomitant epicardial coronary artery disease (CAD) rather than the degree of coronary steal and its routine use in this setting is not supported.

Summary Spontaneous coronary artery dissection (SCAD) is an under-recognised presentation of acute coronary syndrome. A high index of suspicion is essential. If diagnostic doubt is high, intracoronary imaging, performed carefully, can be useful, although it can result in worsening of the clinical condition. The current report exemplifies the complexity of diagnosis and management of SCAD in a patient with out-of-hospital cardiac arrest and non-diagnostic angiography.

The long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in patients undergoing early percutaneous coronary intervention (PCI) after fibrinolytic therapy is unknown. From May 2014 to August 2016, 212 patients undergoing PCI within 24 h of Tenecteplase (TNK), Aspirin, and Clopidogrel for ST-elevated myocardial infarction (STEMI) were randomized at four Canadian sites to receive additional Clopidogrel or Ticagrelor initiated prior to PCI. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline), at 4 and 24 h post PCI, and follow-up appointment. A mixed-model analysis with time as the repeated measure and drug as the between-subjects factor was calculated using 2 separate 1 × 4 ANOVAs, with students t-tests used to compare drugs within each time point. Complete clinical follow-up data (median 115.0 days; IQR 80.3–168.8) was available in 50 patients (23.6%) randomized to either Clopidogrel (n = 23) or Ticagrelor (n = 27). Analyses revealed significant decreases in PRU from baseline to 4 h (261.4 vs. 71.7; Mdiff = − 189.7; p

Patients undergoing PCI early after fibrinolytic therapy are at high risk for both thrombotic and bleeding complications. We sought to assess the pharmacodynamic effects of ticagrelor versus clopidogrel in the fibrinolytic-treated STEMI patients undergoing early PCI.Patients undergoing PCI within 24 hours of tenecteplase (TNK), aspirin, and clopidogrel for STEMI were randomized to receive additional clopidogrel 300 mg followed by 75 mg daily or ticagrelor 180 mg followed by 90 mg twice daily. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline) at 4 and 24 hours post-PCI. The primary end point was PRU ≤208 at 4 hours. A total of 140 patients (74 in ticagrelor and 66 in clopidogrel group) were enrolled. The mean PRU values at baseline were similar for the 2 groups (257.8±52.9 vs 259.5±56.7, P=.85, respectively). Post-PCI, patients on ticagrelor, compared to those on clopidogrel, had significantly lower PRU at 4 hours (78.7±88 vs 193.6±86.5, respectively, P.001) and at 24 hours (34.5±35.0 and 153.5±75.5, respectively, P.001). The primary end point was observed in 87.8% (n=65) in the ticagrelor-treated patients compared to 57.6% (n=38) of clopidogrel-treated patients, P.001.Fibrinolysis-treated STEMI patients who received clopidogrel and aspirin at the time of fibrinolysis and were undergoing early PCI frequently had PRU208. In this high-risk population, ticagrelor provides more prompt and potent platelet inhibition compared with clopidogrel (Funded by Astra Zeneca; NCT01930591, https://clinicaltrials.gov/ct2/show/NCT01930591).

Advances in medical and interventional therapy over the last few decades have revolutionized the treatment of acute myocardial infarction. Despite the ability to restore epicardial coronary artery patency promptly through percutaneous coronary intervention, tissue level damage may continue. The reported 30-day mortality after all acute coronary syndromes is 2 to 3%, and around 5% following myocardial infarction. Post-infarct complications such as heart failure continue to be a major contributor to cardiovascular morbidity and mortality. Inadequate microvascular reperfusion leads to worse clinical outcomes and potentially strategies to reduce infarct size during periods of ischemia-reperfusion can improve outcomes. Many strategies have been tested, but no single strategy alone has shown a consistent result or benefit in large scale randomised clinical trials. Herein, we review the historical efforts, current strategies, and potential novel concepts that may improve myocardial protection and reduce infarct size.

Objective Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. Methods From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ±41.4 months. Results Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. Conclusions Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

The clinical value of ischemic conditioning during percutaneous coronary intervention (PCI) and mode of administration is controversial. Our aim was to assess the long-term effect of remote ischemic postconditioning among patients undergoing PCI. We randomized 360 patients undergoing PCI who presented with a negative troponin T at baseline into 3 groups: 2 groups received remote ischemic postconditioning (with ischemia applied to the arm in 1 group and to the thigh in the other group), and the third group acted as a control group. Remote ischemic postconditioning was applied during PCI immediately following stent deployment, by 3, 5-minute cycles of blood pressure cuff inflation to >200 mm Hg on the arm or thigh (20 mm Hg to the arm in the control), with 5-minute breaks between each cycle. There were no differences in baseline characteristics among the 3 groups. Periprocedural myocardial injury occurred in 33% (P = 0.64). After 1 year, there was no difference between groups in death (P = 0.91), myocardial infarction (P = 0.78), or repeat revascularization (P = 0.86). During 3 years of follow-up, there was no difference in death, myocardial infarction, and revascularization among the groups (P = 0.45). Remote ischemic postconditioning during PCI did not affect long-term cardiovascular outcome. A similar effect was obtained when remote ischemia was induced to the upper or lower limb. ClinicalTrials.gov Identifier: NCT00970827.

Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors, and clinical impact of CIED dysfunction (CIED-D) after radiotherapy for cancer treatment. Clinical characteristics, cancer, different types of CIEDs, and radiation dose were evaluated. The investigation identified 230 patients, mean age 78 ± 8 years and 70% were men. A total of 199 patients had pacemakers (59% dual chamber), 21 (9%) cardioverter-defibrillators, and 10 (4%) resynchronizators or defibrillators. The left pectoral (n = 192, 83%) was the most common CIED location. Sixteen patients (7%) experienced 18 events of CIED-D after radiotherapy. Reset to backup pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrioventricular dyssynchrony. Those who had CIED-D tended to have a shorter device age at the time of radiotherapy compared to those who did not (2.5 ± 1.5 vs 3.8 ± 3.4 years, p = 0.09). The total dose prescribed to the tumor was significantly greater among those who had CIED-D (66 ± 30 vs 42 ± 23 Gy, p0.0001). Multivariate logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio 1.19 for each increase in 5 Gy, 95% confidence interval 1.08 to 1.31, p = 0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to backup pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias, or conduction disorders.

Rotational atherectomy (RA) has been traditionally performed via the transfemoral approach, mostly utilizing large guide catheters (≥7 Fr), which can accommodate the passage of large burrs (≥1.75 mm). However, contemporary data show that using smaller sheath and catheter sizes reduces the risk of procedural access-site related complications. Therefore, the aim of this study was to assess the feasibility of performing RA using smaller burrs and subsequently smaller-sized sheath catheters.A total of 220 patients underwent RA procedures between January 2011 and July 2017. We compared 162 patients who underwent RA using a maximal burr size of 1.5 mm (small-burr group) with 58 patients who underwent RA using burrs1.5 mm in diameter (large-burr group). Clinical, procedural, safety, and feasibility data were evaluated and compared between the two groups.Baseline characteristics of the two groups were quite similar other than a higher prevalence of smoking (21.0% vs 5.2%; P.01) and a lower body weight (80.9 ± 17.5 kg vs 86.8 ± 17.2 kg; P=.03) in the small-burr group vs the large-burr group. The indications for the procedure for the small-burr group vs large-burr group were stable angina in 53% vs 62%, unstable angina in 16% vs 17%, non-ST elevation myocardial infarction (MI) in 26% vs 17%, and ST-elevation MI in 3.7% vs 3.4%, respectively (P=NS for all). The target-vessel (TV) diameter was significantly larger in the large-burr group vs the small-burr group (3.5 ± 0.3 mm vs 3.2 ± 0.5 mm, respectively; P.01). Importantly, a sheath size6 Fr was used in 56.0% of the small-burr group vs 89.5% of the large-burr group (P.01). Moreover, in 53% of the small-burr group, a guide catheter6 Fr was used. Radial access was used in 33% of the small-burr group and 17% of the large-burr group (P=.03). Procedural success was achieved in 93% of the small-burr group and 100% of the large-burr group (P=.07).In the majority of cases, RA can be successfully performed using smaller-sized burrs while achieving a high procedural success rate. Notably, our study also highlights the overuse of large sheaths and catheters to deliver small burrs. These results further support the contemporary strategy of using 6 Fr guide catheters, thereby increasing the possibility of using the radial approach for more complex interventional procedures.

AIMS Despite the widespread use of the radial approach in coronary interventions, left ventricular endomyocardial biopsy (LV-EMB) is most frequently performed via the femoral artery. We sought to assess the feasibility and safety of radial compared to femoral access in a large cohort of patients undergoing LV-EMB. METHODS AND RESULTS Data from 264 patients who underwent LV-EMB in Germany, Portugal, Japan and Canada were collected. Clinical, procedural, safety and feasibility data were evaluated and compared between the two groups. LV-EMB was successfully performed by the radial approach in 129 (99%) of 130 and in 134 (100%) patients by the femoral access. Patients in the radial group were older (mean age 55.7 versus 44.3 years) and were more likely to have moderate-severe mitral regurgitation (27.7% versus TF 0%). Sheathless guides were used in 108 (83.1%) of the radial and 2 (1.5%) of the femoral patients, so the mean guiding catheter size (radial 7.0±1.0 Fr versus femoral 8.0±0.0 Fr) was significantly smaller in the radial group (p

Objectives To assess the relationship between preprocedural anticoagulation use and clinical and angiographic outcomes. Background For patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), the optimal timing of anticoagulant administration remains uncertain. Methods Patients enrolled in the TOTAL trial were stratified based on whether or not they had received any parenteral anticoagulant prior to randomization and PCI. Baseline and procedural characteristics were compared. For one-year clinical outcomes, Cox proportional modeling adjusted on a propensity score was used to analyze differences between groups. Angiographic endpoints were analyzed by logistic regression models adjusted for propensity scores. Results In the trial, 10,064 patients were enrolled and underwent PCI. Preprocedural anticoagulation was used in 6,381 patients (63%).The most common anticoagulant was intravenous unfractionated heparin (5,188, 81%). Patients who received preprocedural anticoagulation had higher rates of TIMI-2-3 or TIMI-3 flow and lower grades of thrombus prior to PCI. Pretreatment with anticoagulation was associated with lower use of bailout thrombectomy, GP IIb/IIIa inhibitors, and intra-aortic balloon pump. After adjustment, preprocedural anticoagulation was associated with lower rates of CABG and minor bleeding at 1 year but there were no significant differences in death, stroke, recurrent MI, cardiogenic shock, or congestive heart failure. Conclusions Preprocedural anticoagulation is associated with improved flow and reduced thrombus in the IRA prior to PCI, less bailout thrombectomy during PCI but no difference in death, recurrent infarction, or heart failure at 1 year.

Robust comparisons between oral P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) in ST-elevation myocardial infarction (STEMI) patients who undergo primary percutaneous coronary intervention are lacking. We sought to evaluate outcomes on the basis of P2Y12 inhibitor therapy in patients from the Thrombectomy With PCI Versus PCI Alone in Patients With STEMI Undergoing Primary PCI (TOTAL) trial.We grouped 9932 patients according to P2Y12 inhibitor at hospital discharge: clopidogrel (n = 6500; 65.5%), prasugrel (n = 1244; 12.5%), or ticagrelor (n = 2188; 22.0%). The primary composite end point of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or New York Heart Association class IV heart failure was examined at 1 year. Secondary efficacy and safety end points were also assessed. Cox proportional hazard ratios were determined and adjusted for confounders via propensity scoring.Baseline characteristics differing between the 3 groups were mainly age 75 years or older, diabetes, and previous stroke. After adjustment, ticagrelor use was associated with a lower rate of the primary composite outcome compared with clopidogrel (adjusted hazard ratio [aHR], 0.72; 95% confidence interval [CI], 0.57-0.91; P0.02) and prasugrel (aHR, 0.65; 95% CI, 0.48-0.89; P = 0.02). Prasugrel use was not associated with a lower rate of the primary outcome compared with clopidogrel (aHR, 1.09; 95% CI, 0.86-1.39; P 0.99). Neither prasugrel nor ticagrelor were associated with increased risk of stroke compared with clopidogrel. Compared with clopidogrel, ticagrelor was associated with significantly lower rates of major bleeding.In this observational analysis of STEMI patients who underwent primary percutaneous coronary intervention, ticagrelor was associated with improved outcomes compared with clopidogrel and prasugrel. An appropriately powered randomized trial is needed to confirm these findings.

Objective Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients. Methods Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart. Results The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0–20) and the median hospital length of stay was 5 days (range = 3–43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death. Conclusions The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.

Key Points Question Is thrombus aspiration beneficial for patients who present early with ST-segment elevation myocardial infarction (STEMI)? Findings In this post hoc analysis of a randomized clinical trial, thrombus aspiration was associated with a greater reduction in distal embolization in patients who presented early with STEMI; however, it was not associated with improved clinical outcomes irrespective of time. Total ischemic time and door-to-device time were also important factors associated with mortality among patients with STEMI. Meaning This analysis suggests that thrombus aspiration does not appear to be associated with a benefit irrespective of ischemic time among patients with STEMI., Importance Patients with shorter ischemic times have a greater viable myocardium and may derive greater benefit from thrombus aspiration. Objective To study the association of thrombus aspiration with outcomes among patients presenting with ST-segment elevation myocardial infarction (STEMI) based on time. Design, Setting, and Participants The TOTAL (Thrombectomy With PCI vs PCI Alone in Patients with STEMI) trial was an international randomized clinical trial of 10 732 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) within 12 hours of symptom onset. Patients were recruited between August 5, 2010, and July 25, 2014, and were followed up for 1 year. Data analysis was performed from February 22, 2019, to January 5, 2021. Interventions Thrombus aspiration vs PCI alone. Main Outcomes and Measures Post hoc subgroup analyses were performed for total ischemic time and first medical contact (FMC)–to–device time for the primary outcomes (cardiovascular [CV] mortality, myocardial Infarction [MI], cardiogenic shock, and New York Heart Association class IV heart failure) and angiographically determined distal embolization. In addition, a multivariable analysis was performed to assess the association of total ischemic time and FMC-to-device time with CV mortality at 1 year. Results The study randomized 10 732 patients, and 9986 underwent primary PCI and had time data available (7737 men [77.5%]; mean [SD] age, 61.0 [12.0] years). For the randomized comparison of thrombus aspiration, there was a reduction in angiographic distal embolization with thrombus aspiration that was more pronounced in patients with short ischemic times (6 hours: OR, 0.70 [95% CI, 0.33-1.50]; P = .12 for interaction). However, for the primary composite outcome, there was no benefit based on (1) total ischemic time (6 hours: HR, 0.87 [95% CI, 0.60-1.27]; P = .46 for interaction) or (2) FMC-to-device time (90-120 minutes: HR, 1.19 [95% CI, 0.85-1.67]; >120 minutes: HR, 0.89 [95% CI, 0.70-1.14]; P = .54 for interaction). In a multivariable analysis, both total ischemic time (>2 hours: HR, 1.26 [95% CI, 1.00-1.58) and FMC-to-device time (>120 minutes: HR, 1.45 [95% CI, 1.18-1.79]) were independently associated with CV mortality. Conclusions and Relevance This analysis suggests that thrombus aspiration does not appear to be associated with an improvement in clinical outcomes regardless of ischemic time. In the current STEMI era, both total ischemic time and FMC-to-device times continue to be important factors associated with mortality. Trial Registration ClinicalTrials.gov Identifier: NCT01149044, This post hoc analysis of a randomized clinical trial studies the association of thrombus aspiration with outcomes among patients presenting with ST-segment elevation myocardial infarction based on time.

Background Contemporary use of dual antiplatelet therapy and consistency with guideline recommendations in acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI) have not been well characterized. Methods The COAPT was a prospective, observational, multicenter, longitudinal study of patients with myocardial infarction (MI) undergoing PCI. Baseline characteristics, treatment patterns, processes of care, factors associated with switching to and from novel adenosine diphosphate receptor inhibitors (ADPris), and in-hospital outcomes are described. Results Among 2,179 MI patients undergoing PCI during their index hospitalization, 1,328 (60.9%) had ST elevation. Initial ADPri use included clopidogrel in 1,812 (83.2%), prasugrel in 125 (5.7%), and ticagrelor in 242 (11.1%). At discharge, 1,597 patients (73.4%) were prescribed clopidogrel, 220 (10.1%) prasugrel, and 358 (16.5%) ticagrelor. Switching between ADPri therapies during the index hospitalization occurred in 15.3%, 22.4%, and 25.2% of patients initially started on clopidogrel, prasugrel, and ticagrelor, respectively. Most switches over the 15-month study period occurred during the index admission (16.8% of patients vs 4.4% switches postdischarge). Major adverse cardiovascular events occurred in 7.5% of patients during the index hospitalization. In-hospital bleeding events occurred in 6.0% of patients and most were mild. Conclusions Despite randomized trial evidence and guideline recommendations, only a minority of Canadian MI patients undergoing PCI initially received or were discharged on one of the newer ADPri agents. These findings suggest an opportunity to improve upon the appropriate selection of the ADPris at index hospitalization and discharge in Canadian MI patients undergoing PCI.

The duration of red blood cell (RBC) storage may have a negative impact on endothelial nitric oxide bioavailability. We tested the hypothesis that transfused fresh blood will have a more favorable effect on microvascular endothelial function as compared to older standard issue blood.Participants requiring chronic RBC transfusions were enrolled in a crossover design study to receive fresh (7 days of storage) or standard (up to 42 days of storage) blood on 2 separate visits. Endothelial function was assessed by reactive hyperemia peripheral arterial tonometry that was measured before and after transfusions. For each participant, the difference between endothelial function pretransfusion and posttransfusion was assessed in relation to blood storage time.Twenty-one patients (71 ± 16 years, 52% females) were enrolled. Mean age of fresh blood was 5.5 days (±1.0), and that of standard blood was 24.5 days (±7.9 days). The pretransfusion hemoglobin was 83.1 ± 2.5 g/L; and posttransfusion, 98.9 ± 2.6 g/L. An average of 2 U of packed RBCs was transfused. Microvascular endothelial function decreased more frequently after transfusion of standard blood compared to fresh blood. Standard issue blood transfusion was associated with decrease in reactive hyperemia peripheral arterial tonometry index (-0.25 ± 0.63) compared to fresh blood (+0.03 ± 0.49); P = .026.Transfusions of standard issue blood are associated with less favorable effect on microvascular endothelial function as compared to fresh blood.

Out-of-hospital cardiac arrest (OHCA) carries an enormous global burden of mortality and morbidity. The post-cardiac arrest syndrome consists of complex pathophysiological changes that result in hypoxic brain injury, myocardial and peripheral organ dysfunction, and the systemic ischemia-reperfusion response. We review common cardiac arrest cases to highlight key management issues and recommendations in post-resuscitation care, including therapeutic hypothermia, coronary angiography and revascularization, and circulatory support. Guidelines still suggest mild therapeutic hypothermia be administered for OHCA over targeted temperature management preventing pyrexia. Similarly, early invasive coronary angiography is particularly beneficial when there is ST-elevation on the post-resuscitation electrocardiogram, but might be considered in the absence of ST-elevation if there is no noncardiac cause to explain the OHCA. However, there remain a large number of unanswered questions that require ongoing research.

Ticagrelor has shown superiority compared with clopidogrel in reducing cardiovascular events [(1)][1]. Although some of the clinical benefits of ticagrelor may simply reflect its potency in inhibiting platelet aggregation, the action of this drug on blood vessels may also play a role. Ticagrelor

Aims Spontaneous coronary artery dissection (SCAD) was underdiagnosed and poorly understood for decades. It is increasingly recognized as an important cause of myocardial infarction (MI) in women. We aimed to assess the natural history of SCAD, which has not been adequately explored. Methods and results We performed a multicentre, prospective, observational study of patients with non-atherosclerotic SCAD presenting acutely from 22 centres in North America. Institutional ethics approval and patient consents were obtained. We recorded baseline demographics, in-hospital characteristics, precipitating/predisposing conditions, angiographic features (assessed by core laboratory), in-hospital major adverse events (MAE), and 30-day major adverse cardiovascular events (MACE). We prospectively enrolled 750 SCAD patients from June 2014 to June 2018. Mean age was 51.8 ± 10.2 years, 88.5% were women (55.0% postmenopausal), 87.7% were Caucasian, and 33.9% had no cardiac risk factors. Emotional stress was reported in 50.3%, and physical stress in 28.9% (9.8% lifting >50 pounds). Predisposing conditions included fibromuscular dysplasia 31.1% (45.2% had no/incomplete screening), systemic inflammatory diseases 4.7%, peripartum 4.5%, and connective tissue disorders 3.6%. Most were treated conservatively (84.3%), but 14.1% underwent percutaneous coronary intervention and 0.7% coronary artery bypass surgery. In-hospital composite MAE was 8.8%; peripartum SCAD patients had higher in-hospital MAE (20.6% vs. 8.2%, P = 0.023). Overall 30-day MACE was 8.8%. Peripartum SCAD and connective tissue disease were independent predictors of 30-day MACE. Conclusion Spontaneous coronary artery dissection predominantly affects women and presents with MI. Despite majority of patients being treated conservatively, survival was good. However, significant cardiovascular complications occurred within 30 days. Long-term follow-up and further investigations on management are warranted.

Aims\ud Coronary angiography and intervention to saphenous venous grafts (SVGs) remains challenging. This study aimed to investigate the feasibility and safety of the radial approach compared to femoral access in a large cohort of patients undergoing SVG angiography and intervention.\ud \ud Methods and Results\ud Data from 1481 patients from Canada, United States and Spain who underwent procedures between 2010 and 2016 were collected. Patients must have undergone SVG coronary angiography and/or intervention. Demographics, procedural data and in-hospital complications were recorded. Procedures were undertaken by either the radial (n=863, 211 intervention) or femoral (n=618, 260 intervention) approach. The mean number of SVGs per-patient was similar between groups (radial 2.3±0.7 versus femoral 2.6±1.1, P=0.61) but the radial group required a fewer number of catheters (2.6±1.7 versus 4.1±1.1, P

A 57-year-old female presented with Canadian Cardiovascular Society class 2 angina and a positive stress test. Angiography was performed via right radial approach, resulting in spiral dissection and TIMI 0 flow.

© Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved., Left ventricular endomyocardial biopsy (LV-EMB) may offer a superior diagnostic yield compared with right ventricular endomyocardial biopsy (RV-EMB) in conditions predominantly affecting the LV but is underused compared with RV-EMB. Despite the steep uptake of radial approach in coronary interventions, LV-EMB is usually performed via the femoral artery in contemporary practice. Therefore, the aim of this study was to assess the safety and feasibility of LV-EMB via a transradial approach in a multicentre registry., Contexte La biopsie endomyocardique du ventricule gauche (BEM-VG) peut offrir un rendement diagnostique supérieure à celui de la BEM du ventricule droit (BEM-VD) dans des troubles qui touchent principalement le ventricule gauche (VG), mais est sous-utilisée par rapport à la BEM-VD. Malgré l’augmentation rapide de l’utilisation de la voie radiale dans les interventions coronariennes, la BEM-VG s’effectue en général par l’artère fémorale dans la pratique contemporaine. Par conséquent, l’objectif de cette étude était d’évaluer, à partir d’un registre multicentrique, la sûreté et la faisabilité de la BEM-VG par la voie transradiale. Méthodologie Cent deux patients qui avaient subi une BEM-VG par l’approche transradiale ont été inclus. Les caractéristiques cliniques et les données relatives à l’intervention, à l’innocuité et à la faisabilité ont été analysées. Résultats La BEM-VG a été effectuée avec succès par la voie transradiale chez 101 (99 %) patients. Spasme radiale légère ou modérée s’est produit chez 12 (12 %) patients, mais la conversion en voie fémorale n’a été nécessaire que chez 1 (0,98 %) patient en raison d’un spasme sévère. Au total, 80 (78 %) patients ont subi une BEM-VG au moyen d’un cathéter guide sans gaine d’introducteur (sheathless). Pour ces interventions, le diamètre externe du guide sans gaine d’introducteur inséré était de 7,5 French chez 77 (96,3 %) patients et de 8,5 French chez 3 (3,8 %) patients. Un introducteur radiale a été utilisé chez les 22 autres patients, d’un diamètre externe de 5 French chez 21 de ces derniers. Une dose médiane de 5000 (3000–5000) unités internationales (UI) d’héparine a été administrée à 93,1 % des patients. Pour les autres patients, une stratégie provisoire a été appliquée en fonction de l’obtention d’une hémostase manifeste. Aucune complication liée à la voie d’accès n’a été rapportée. Il n’y a eu aucune complication majeure (tamponnade péricardique, arythmie potentiellement mortelle, accident vasculaire cérébral ou décès). Conclusion Dans une population de patients ayant subi une BEM-VG par la voie transradiale, le taux de succès de l’intervention a été élevé et présentait un excellent profil d’innocuité. Des études ultérieures portant sur la comparaison des voies transradiale et transfémorale pourraient être utiles pour contribuer à populariser le recours à la voie transradiale dans les BEM-VG.

Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) are occasionally found to have no culprit lesion on coronary angiography and are classified as presenting with false-positive STEMI. The clinical presentation and outcomes of these patients need to be further explored. In this case-controlled study, 259 consecutive patients with true code STEMI were compared to 104 consecutive STEMI patients without culprit lesions on emergent coronary angiography. We compared the clinical presentation, electrocardiographic features, etiology, and outcomes of the two groups. STEMI patients without culprit lesions were less likely to have typical chest pain (46% vs. 79%, P < 0.01). The ST-elevation in the group without culprit lesion was more likely to be concave (56% vs. 31%, P < 0.01), with less reciprocal ST-depression (19% vs. 71%, P < 0.01). The group without culprit lesions had a higher rate of ventilator support requirement (12.4% vs. 5.4%, P = 0.02), and higher rate of 30-day mortality (11.0% vs. 5.9%, P = 0.02). However, after excluding the patients with out-of-hospital cardiac arrests from both groups, the difference was no longer significant (P = 0.40 and 0.34 respectively). The relative poor outcomes of patients with false-positive code STEMI reflect the severity of their underlying medical condition. Careful history and review of ECG may help differentiate this group from true STEMI.

The primary outcome occurred in 347 of 5033 patients (6.9%) in the thrombectomy group versus 351 of 5030 patients (7.0%) in the PCI-alone group (hazard ratio in the thrombectomy group, 0.99; 95% confidence interval [CI], 0.85 to 1.15; P = 0.86). The rates of cardiovascular death (3.1% with thrombectomy vs. 3.5% with PCI alone; hazard ratio, 0.90; 95% CI, 0.73 to 1.12; P = 0.34) and the primary outcome plus stent thrombosis or target-vessel revascularization (9.9% vs. 9.8%; hazard ratio, 1.00; 95% CI, 0.89 to 1.14; P = 0.95) were also similar. Stroke within 30 days occurred in 33 patients (0.7%) in the thrombectomy group versus 16 patients (0.3%) in the PCI-alone group (hazard ratio, 2.06; 95% CI, 1.13 to 3.75; P = 0.02). Conclusions In patients with STEMI who were undergoing primary PCI, routine manual thrombectomy, as compared with PCI alone, did not reduce the risk of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days but was associated with an increased rate of stroke within 30 days. (Funded by Medtronic and the Canadian Institutes of Health Research; TOTAL ClinicalTrials.gov number, NCT01149044.)

Rotational atherectomy (RA) performed during percutaneous coronary intervention is commonly associated with distal embolization of calcific particles resulting in conduction abnormalities. As a result, temporary pacing is often used during these procedures. It is unknown whether temporary pacing should be routinely used.We performed an analysis of 134 consecutive patients who underwent RA at our institution between January 2011 and September 2013 for the presence of intraprocedural heart block or pacemaker activation.A temporary pacemaker was inserted in 50% of cases. Forty-two (31%) patients experienced either heart block (n = 16) or pacemaker activation (n = 26). There was no difference in baseline characteristics between those who experienced heart block or required temporary pacing, and those who did not. Interventional characteristics including burr size, maximum rotations per minute used, and maximum run duration were also similar among the groups. Only target RA vessel was associated with the presence of heart block or temporary pacing in multivariate analysis (P0.0001). Heart block or temporary pacing occurred in 28 (53%) of RA to the right coronary artery, 2 (5%) of the left anterior descending artery, 8 (62%) of the left-dominant circumflex artery, and 2 (18%) with RA to the circumflex artery with right-dominant circulation. Asystole occurred only in patients who underwent RA to the right coronary artery.Heart block or temporary pacing was more commonly associated with right coronary artery and left-dominant circumflex lesions. Prophylactic pacemaker insertion might be avoided with RA to other vessels.

BACKGROUND The use of radial approach for coronary angiography, followed by same-day inter-facility transfer for percutaneous coronary intervention (PCI) has not yet been evaluated. OBJECTIVES We sought to assess the safety and feasibility of using the transradial as compared to the transfemoral approach in patients undergoing diagnostic angiogram with same-day transfer to a PCI facility. METHODS Patients that underwent diagnostic coronary angiography between January 2011 and June 2017 in a referring facility, and were transferred for same-day PCI were included. Patients' demographics, as well as procedural data and in-hospital outcome, were collected. RESULTS Three hundred fifty-two participants were included. Of these, 36 (10.2%) patients received transradial access. Patients in the transradial group were older (68 ± 10 vs 62 ± 12 years, P = 0.007), and received a significantly higher total dose of heparin including both, diagnostic and PCI procedures (5935 ± 1865 vs 10029 ± 2771 units, P

Axillary access for an intra-aortic balloon pump allows patients with advanced heart failure (HF) to sit upright and ambulate while waiting for destination therapy or bridging to heart transplantation. We describe the combination of radial access for positioning a 4F pigtail catheter to allow axillary angiography and provide a target for a micropuncture needle entry point in a fully anticoagulated patient with advanced HF.

To assess the predictive value of Pd/Pa after nitroglycerin administration (Pd/Pa[N]) as compared with standard fractional flow reserve (FFR).Consecutive patients with intermediate coronary lesions assessed by FFR between January 2014 and October 2015 were included. We measured Pd/Pa at baseline, Pd/Pa(N), and Pd/Pa after incremental doses of intracoronary adenosine.A total of 134 patients (27% females; mean age, 65 years) were included. The diagnostic performance of Pd/Pa(N) and identification of cut-off value for Pd/Pa(N) compared with FFR threshold of 0.8 using receiver-operating characteristic (ROC) area under the curve analysis was between 0.98 (95% confidence interval, 0.95-1.00; P.05) for 48 μg and 0.86 (95% confidence interval, 0.79-0.94; P.05) for 240 μg adenosine. Pd/Pa(N) ≤0.8 had 100% positive predictive value. Pd/Pa(N) ≥0.94 provided 100% negative predictive value with a high sensitivity (92%). Optimal diagnostic accuracy of Pd/Pa(N) was achieved for values ≤0.84. The Pearson's correlation between Pd/Pa(N) and FFR varied between 0.89 for 24 μg adenosine and 0.77 for 240 μg (P.01).Pd/Pa(N) values can be used for diagnosis of hemodynamically significant lesions. Pd/Pa(N) correlates well with standard FFR. Pd/Pa(N) cut-off of ≤0.8 can be considered significant without need for adenosine injection. The value of using adenosine whenever Pd/Pa(N) is ≥0.94 is limited.

This clinical trial assesses ticagrelor administration and endothelial function and arterial stiffness in patients with coronary artery disease.

The safety and efficacy of drug eluting stents (DES) in the setting of ST elevation myocardial infarction (STEMI) is not well established.In the TOTAL trial, patients presenting with STEMI were randomized to routine thrombectomy versus PCI alone. In this post-hoc analysis, propensity matching was used to assess relative safety and efficacy according to type of stent used.Each propensity-matched cohort included 2313 patients. The composite primary outcome of cardiovascular death, recurrent MI, cardiogenic shock or class IV heart failure within one year was lower in the DES group (HR 0.67; 95% CI 0.54 to 0.84, p=0.0004). Cardiovascular death (HR 0.61; 95% CI 0.43 to 0.86, p=0.005), recurrent MI (HR 0.51; 95% CI 0.35 to 0.75, p=0.0005), target vessel revascularization (HR 0.47; 95% CI 0.36 to 0.62, p0.0001) and stent thrombosis (HR 0.60; 95% CI 0.40 to 0.89, p=0.01) were lower in the DES group. There was no difference in major bleeding between groups.In this observational analysis, the use of DES was associated with improvement in cardiovascular outcomes compared to the use of BMS. These results support the use of DES during primary PCI for STEMI.

Objectives We aimed to describe global practice patterns of unfractionated heparin (UFH) use for diagnostic transradial cardiac catheterization. Background The use of the radial artery approach for cardiac catheterization is increasing globally. Limited contemporary data exist to support the use or optimal dosing of UFH to prevent radial artery occlusion (RAO) and other thromboembolic complications. Methods We performed a web-based international survey of 450 interventional cardiologists from 34 countries. We collected information regarding the experience and use of UFH for diagnostic transradial cardiac catheterization. Results The survey was conducted between June and July 2016 and was completed by 227 (50.4%) interventional cardiologists. Overall, 83.3% performed >75% of their coronary angiograms via a radial approach, with the plurality (41.9%) having 10-20 years of clinical experience. Of all respondents, 7.5% did not use UFH for routine diagnostic transradial heart catheterization. Of the 92.5% who did use UFH, it was preferentially administered intra-arterially by 60% and intravenously by 40%. The majority (62.6%) of interventionalists used a fixed UFH dose with 5,000 IU being the most common dose (used in 48%). For those using a weight-based UFH (50 IU/kg) dosing regimen for diagnostic procedures (36.1%), the administered UFH dose ranged from 2,000 up to 10,000 IU. Conclusions Despite the lack of firm evidence, the majority of interventional cardiologists who participated in the survey use UFH to prevent RAO for diagnostic transradial coronary angiography. However, there exist large practice disparities with regards to dose and route of administration. Given this knowledge gap, a dedicated randomized trial is warranted.

Background Radial artery occlusion is a known complication following transradial cardiac catheterization. A shorter duration of postprocedural radial clamp time may reduce radial artery occlusion ( RAO ) but might be associated with incomplete hemostasis. Methods and Results In total, 568 patients undergoing transradial diagnostic cardiac catheterization were randomly assigned to either 20 minutes (ultrashort) or 60 minutes (short) hemostatic compression time using patent hemostasis. Subsequently, clamp pressure was reduced gradually over 20 minutes. Access site hemostasis and RAO were assessed after clamp removal. Repeated assessment of RAO was determined at 1 week in 210 (37%) patients. Mean age was 64±11 years, and 30% were female. Percutaneous coronary intervention was performed in 161 patients. RAO immediately after clamp removal was documented in 14 (4.9%) and 8 (2.8%) patients in the 20‐ and 60‐minute clamp application groups, respectively ( P =0.19). The incidence of grade 1 hematoma was higher in the 20‐minute group (6.7% versus 2.5%, P =0.015). RAO at 1 week after the procedure was 2.9% and 0.9% in the 20‐ and 60‐minute groups, respectively ( P =0.36). Requirement for clamp retightening (36% versus 16%, P =0.01) was higher among patients who had RAO . Need for clamp retightening was the only independent predictor of RAO ( P =0.04). Conclusions Ultrashort radial clamp application of 20 minutes is not preferable to a short duration of 60 minutes. The 60‐minute clamp duration is safe and provides good access site hemostasis with low RAO rates. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02269722.

Aims Survivors of out-of-hospital cardiac arrest (OHCA) have a high rate of morbidity and mortality. Invasive cardiac assessment with coronary angiography offers the potential for improving outcomes by facilitating early revascularization. The aim of the present study was to review the published data on early coronary angiography for survivors of OHCA, and its impact on survival and neurological outcomes. Methods Medline, Embase and PubMed were searched with a structured search query. The primary outcome was in-hospital (or if not available, 30 day or 6 month) survival. Rates of survival with good neurological outcome were a secondary endpoint. The time period of the search was from 1 January 1980 to 1 January 2014. Data was pooled with means and 95% CI interval calculated. Meta-analysis of the main outcomes was performed using a weighted random effects model. Results Following review of all identified records, 105 relevant full text articles were retrieved. Fifty had adequate outcome information stratified by the use of coronary angiography for analysis. In studies where a control group was available for comparison, the overall survival in the acute angiography group was 58.8% versus 30.9% in the control group (Odds ratio 2.77, 95% CI 2.06–3.72). Survival with good neurological outcome (as per the Utstein framework) in the early angiography group was 58% versus 35.8% in the control group (Odds ratio 2.20, 95% CI 1.46–3.32). Conclusions Early coronary angiography in patients following OHCA is associated with improved outcome and better survival.

The mechanism by which depression affects postoperative outcome may involve arrhythmias. The purpose of this study was to evaluate whether untreated depression is associated with an increased incidence of postoperative arrhythmias in patients undergoing coronary artery bypass graft surgery (CABG).One hundred seven patients were assessed for signs of depression with the Prime-MD Patient Health Questionnaire (brief PHQ) one week before surgery and subsequently underwent Holter monitoring for 48-72 hr postoperatively. The incidences of atrial fibrillation (AF); supraventricular tachycardia (SVT); ventricular tachycardia (VT), defined as three or more consecutive beats at a cycle length less than 600 msec; ventricular fibrillation (VF); and average heart rate (HR) were recorded in patients with and without signs of depression.The incidence of preoperative untreated depression was 27% (29/107). Twenty patients had mild depression (brief PHQ score of 5-9), seven patients had moderate depression (a score of 10-14), and two patients had severe depression (a score of 20). The incidences of postoperative AF, SVT, and non-sustained VT in depressed and non-depressed patients were 37.9% vs 35.9%, respectively (P = 0.50), 34.4% vs 52.5%, respectively (P = 0.07), and 17.2% vs 37.1%, respectively (P = 0.04). The average (SD) postoperative HR was similar in both groups [95 (12) beats·min(-1) in depressed patients and 92 (10) beats·min(-1) in non-depressed patients, (P = 0.25)]. Multivariate regression analysis showed that older age, but not depression, was a risk factor for postoperative arrhythmia.Preoperative untreated depression is not related to postoperative arrhythmia in the early postoperative period in patients undergoing elective CABG. This trial was registered at clinicaltrials.gov (number: NCT00622024).