Search

Background: Ticagrelor improves clinical outcomes in patients with acute coronary syndromes compared with clopidogrel. Ticagrelor also inhibits cell uptake of adenosine and has been associated with cardioprotective effects in animal models. We sought to investigate the potential cardioprotective effects of ticagrelor, as compared with clopidogrel, in stable patients undergoing percutaneous coronary intervention (PCI)., Methods and Results: This was a Prospective Randomized Open Blinded End-points (PROBE) trial enrolling stable patients with coronary artery disease (CAD) requiring fractional flow reserve-guided PCI of intermediate epicardial coronary lesions. ST-segment elevation at intracoronary electrocardiogram (IC-ECG) during a two-step sequential coronary balloon inflations in the reference vessel during PCI was used as an indirect marker of cardioprotection induced by ischemic preconditioning (IPC). The primary endpoint of the study was the comparison of the delta (Δ) (difference) ST-segment elevation measured by IC-ECG during two-step sequential coronary balloon inflations., Results: Fifty-three patients were randomized to either clopidogrel or ticagrelor. The study was stopped earlier because the primary endpoint was met at a pre-specified interim analysis. ΔST-segment elevation was significantly higher in ticagrelor as compared to clopidogrel arms (P < 0.0001). Ticagrelor was associated with lower angina score during coronary balloon inflations. There was no difference in coronary microvascular resistance between groups. Adenosine serum concentrations were increased in patients treated with ticagrelor as compared to those treated with clopidogrel., Conclusions: Ticagrelor enhances the cardioprotective effects of IPC compared with clopidogrel in stable patients with CAD undergoing PCI. Further studies are warranted to fully elucidate the mechanisms through which ticagrelor may exert cardioprotective effects in humans., Clinical Trial Registration: http://www.clinicaltrials.gov. Unique Identifier: NCT02701140., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The FORZA trial (FFR or OCT Guidance to Revascularize Intermediate Coronary Stenosis Using Angioplasty) prospectively compared the use of fractional flow reserve (FFR) or optical coherence tomography (OCT) for treatment decisions and percutaneous coronary intervention (PCI) optimization in patients with angiographically intermediate coronary lesions. Murray law-based quantitative-flow-ratio (μQFR) is a novel noninvasive method for the computation of FFR. In the present study, we evaluated the clinical impact of μQFR, FFR, or OCT guidance in FORZA trial lesions at 3-year follow-up., Methods: μQFR was assessed at baseline and, in the case of a decision to intervene, after (FFR- or OCT-guided) PCI. The baseline μQFR was considered the final μQFR for deferred lesions, and post-PCI μQFR value was taken as final for stented lesions. The primary end point was target vessel failure ([TVF]; cardiac death, target-vessel-related myocardial infarction, and target-vessel-revascularization) at a 3-year follow-up., Results: A total of 419 vessels (199 OCT-guided and 220 FFR-guided) were included in the FORZA trial. μQFR was evaluated in 256 deferred lesions and 159 treated lesions (98 OCT-guided PCI and 61 FFR-guided PCI). In treated lesions, post-PCI μQFR was higher in OCT-group compared with FFR-group (median, 0.93 versus 0.91; P =0.023), and the post-PCI μQFR improvement was greater in FFR-group (0.14 versus 0.08; P <0.0001). At 3-year follow-up, OCT- and FFR-guided treatment decisions resulted in comparable TVF rate (6.7% versus 7.9%; P =0.617). Final μQFR was the only predictor of TVF. μQFR ≤0.89 was associated with 3× increase in TVF (11.6% versus 3.7%; P =0.004). PCI was a predictor of higher final μQFR (odds ratio, 0.22 [95% CI, 0.14-0.34]; P <0.001)., Conclusions: In vessels with angiographically intermediate coronary lesions, OCT-guided PCI resulted in comparable clinical outcomes as FFR-guided PCI. μQFR estimated at the end of diagnostic or interventional procedure predicted 3-year TVF., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01824030., Competing Interests: Disclosures Dr Wijns reports institutional research grants and past honoraria from MicroPort; senior advisor of Rede Optimus Research, Corrib Core Laboratory and co-founder of Argonauts, an innovation facilitator. Dr Tu is a co-founder of Pulse Medical and reports research grant and consultancy from Pulse Medical. Drs Burzotta, Trani, and Aurigemma received speaker’s fees from Abbott, Medtronic, Abiomed and Terumo. Dr Leone received speaking honoraria from St. Jude Medical/Abbott, Medtronic, Abiomed and from Bracco Imaging. The other authors report nop conflicts.

Background: Coronary flow reserve (CFR) has an emerging role to predict outcome in patients with and without flow-limiting stenoses. However, the role of its surrogate pressure bounded-CFR (Pb-CFR) is controversial. We investigated the usefulness of combined use of fractional flow reserve (FFR) and Pb-CFR to predict outcomes., Methods: This is a sub-study of the PROPHET-FFR Trial, including patients with chronic coronary syndrome and functionally tested coronary lesions. Patients were divided into four groups based on positive or negative FFR (cut-off 0.80) and preserved (lower boundary ≥2) or reduced (upper boundary <2) Pb-CFR: Group1 FFR≤0.80/ Pb-CFR <2; Group 2 FFR≤0.80/Pb-CFR≥2; Group 3 FFR >0.80/Pb-CFR<2; Group 4 FFR>0.80/Pb-CFR≥2. Lesions with positive FFR were treated with PCI. Primary endpoint was the rate of major adverse cardiac events (MACEs), defined as a composite of death from any cause, myocardial infarction, target vessel revascularization, unplanned cardiac hospitalization at 36-months., Results: A total of 609 patients and 816 lesions were available for the analysis. At Kaplan-Meier analysis MACEs rate was significantly different between groups (36.7% Group 1, 27.4% Group 2, 19.2% Group 3, 22.6% Group 4, P=0.019) and more prevalent in groups with FFR≤0.80 irrespective of Pb-CFR. In case of discrepancy, no difference in MACEs were observed between groups stratified by Pb-CFR. FFR≤0.80 was associated with an increased MACEs rate (30.2% vs. 21.5%, P<0.01) while Pb-CFR<2 was not (24.5% vs. 24.2% Pb-CFR≥2 P=0.67)., Conclusions: FFR confirms its ability to predict outcomes in patients with intermediate coronary stenoses. Pb-CFR does not add any relevant prognostic information.

Background: Routine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI)., Methods: PubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA., Results: A total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to -0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to -3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = -2.13, p = 0.03; z = -3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04)., Conclusion: TA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling., (Copyright © 2023 Elsevier B.V. All rights reserved.)

The introduction of transradial access for percutaneous coronary diagnostic and interventional procedures has led to a decrease in access site complications. The aim of this paper is to propose a combined stepwise technical approach where real time ultrasound ("echo-first" approach) can be used to select the best vascular access and, together with angiography, to manage the potential obstacles that may occur during transradial procedures. In each section, we summarize some tips and tricks based on both our experience and current literature that can be easily implemented in daily practice to increase the success of transradial procedures., (© 2024 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Introduction: The association of coronary stent malapposition (SM) and adverse clinical outcomes after percutaneous coronary intervention (PCI) remains unclear. We aimed to perform a systematic review and meta-analysis of randomized and observational studies to assess the association between acute and persistent SM detected using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and adverse cardiovascular outcomes., Evidence Acquisition: Available studies were identified through a systematic search of PubMed, reference lists of relevant articles, and Medline. Main efficacy outcomes of interest were: device-oriented composite endpoint (DoCE, including cardiac death, myocardial infarction [MI], target lesion revascularization [TLR], and stent thrombosis [ST]), major safety events (MSE, including cardiac death, MI and ST), TLR, and ST. A sensitivity analysis regarding the impact of major malapposition was also performed., Evidence Synthesis: A total of 9 studies enrolling 6497 patients were included in the meta-analysis. After a mean follow-up of 24±14 months, overall acute and/or persistent malapposition was not significantly associated with the occurrence of all the outcomes of interest, including DoCE (risk ratio [RR] 1.00, 95% confidence interval [CI, 0.79-1.26], P=0.99), MSE (RR 1.42, 95%CI [0.81-2.50], P=0.22), TLR (RR 0.84, 95%CI [0.59-1.19], P=0.33), and ST (RR 1.16, 95%CI [0.48-2.85], P=0.74). In the sensitivity analysis, we found a significant increase of MSE in patients with major malapposition (RR 2.97, 95%CI [1.51-5.87], P=0.001)., Conclusions: Acute and persistent SM were not overall associated with adverse cardiovascular clinical outcomes at follow-up. However, major malapposition was associated with an increased risk of major safety events, including cardiac death, MI and ST. These findings should be taken into account during stent implantation and PCI optimization.

Background: The use of Impella support is increasingly adopted to "protect" patients with severe coronary artery disease (CAD) and left ventricle (LV) dysfunction undergoing percutaneous coronary intervention (PCI)., Aims: To evaluate the impact of Impella-protected (Abiomed, Danvers, Massachusetts, USA) PCIs on myocardial function recovery., Methods: Patients with significant LV dysfunction undergoing multi-vessel PCIs with pre-intervention Impella implantation were evaluated by echocardiography before PCI and at median follow up of 6 months: global and segmental LV contractile function were assessed by LV ejection fraction (LVEF) and wall motion score index (WMSI), respectively. Extent of revascularization was graded using the British Cardiovascular Intervention Society Jeopardy score (BCIS-JS). Study endpoints were LVEF and WMSI improvement, and its correlation with revascularization., Results: A total of 48 high surgical risk (mean EuroSCORE II 8) patients with median LVEF value of 30%, extensive wall motion abnormalities (median WMSI 2.16), and severe multi-vessel CAD (mean SYNTAX score 35) were included. PCIs brought a significant reduction of ischemic myocardium burden with BCIS-JS decrease from mean value of 12 to 4 (p < 0.001). At follow-up, WMSI reduced from 2.2 to 2.0 (p = 0.004) and LVEF increased from 30% to 35% (p = 0.016). WMSI improvement was proportional to the baseline impairment (R - 0.50, p < 0.001), and confined to revascularized segments (from 2.1 to 1.9, p < 0.001)., Conclusions: In patients with extensive CAD and severe LV dysfunction, multi-vessel Impella-protected PCI was associated to an appreciable contractile recovery, mainly determined by regional wall motion improvement in revascularized segments., Competing Interests: Declaration of Competing Interest Dr. Romagnoli, Dr. Burzotta, Dr. Aurigemma, and Dr. Trani has received speaker's fees by Medtronic, Abiomed, and St. Jude. The other authors disclose no conflicts of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Dr Bianchini has received a research grant from Abbott Vascular. Dr Romagnoli has received speaker fees from Abbott Vascular and Terumo. Dr Aurigemma has received speaker fees from Abbott Vascular, Abiomed, Medtronic, Terumo, and Daiichi Sankyo. Profs Burzotta and Trani have received speaker fees from Abbott Vascular, Abiomed, Medtronic, and Terumo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: In patients with complex coronary bifurcation lesions undergoing percutaneous coronary intervention (PCI), various 2-stent techniques might be utilised. The Visible Heart Laboratories (VHL) offer an experimental environment where PCI results can be assessed by multimodality imaging., Aims: We aimed to assess the post-PCI stent configuration achieved by 2-stent techniques in the VHL and to evaluate the procedural factors associated with suboptimal results., Methods: Bifurcation PCI with 2-stent techniques, performed by expert operators in the VHL on explanted beating swine hearts, was studied. The adopted bifurcation PCI strategy and the specific procedural steps applied in each procedure were classified according to Main, Across, Distal, Side (MADS)-2 and to their adherence to the European Bifurcation Club (EBC) recommendations. Microcomputed tomography (micro-CT) was used to assess the post-PCI stent configuration. The primary endpoint was "suboptimal stent implantation", defined as a composite of stent underexpansion (<90%), side branch ostial area stenosis >50% and the gap between stents., Results: A total of 82 PCI with bifurcation stenting were assessed, comprised of 29 crush, 25 culotte, 28 T/T and small protrusion (TAP) techniques. Suboptimal stent implantation was observed in as many as 53.7% of the cases, regardless of baseline anatomy or the stenting strategy. However, less frequent use of the proximal optimisation technique (POT; p=0.015) and kissing balloon inflations (KBI; p=0.027) and no adherence to EBC recommendations (p=0.004, p multivariate=0.006) were significantly associated with the primary endpoint., Conclusions: Commonly practised bifurcation 2-stent techniques may result in imperfect stent configurations. More frequent use of POT/KBI and adherence to expert recommendations might reduce the occurrence of post-PCI suboptimal stent configurations.

Background: Microvascular obstruction (MVO) is a frequent occurrence after primary percutaneous coronary intervention (pPCI), and is associated with adverse left ventricular remodeling and worse clinical outcome. Distal embolization of thrombotic material is one of the most important underlying mechanisms. The aim of this study was to investigate the relation between the thrombotic volume evaluated by dual quantitative coronary angiography (QCA) prior to stenting and the occurrence of MVO as assessed by cardiac magnetic resonance (CMR)., Methods: Forty-eight patients with ST-segment elevation myocardial infarction (STEMI) undergoing pPCI and receiving CMR within 7 days from admission were included. Pre-stenting residual thrombus volume at the site of the culprit lesion was measured by applying automated edge detection and video-assisted densitometry techniques (i.e., dual-QCA), and patients were categorized into tertiles of thrombus volume. The presence of delayed-enhancement MVO, as well as its extent (MVO mass), were assessed by CMR., Results: Pre-stenting dual-QCA thrombus volume was significantly greater in patients with MVO than in those without (5.85 mm 3 [2.05-16.71] vs. 1.88 mm 3 [1.03-6.92], P=0.009). Patients in the highest tertile showed greater MVO mass compared to those in the mid and lowest tertiles (113.3 gr [0.0-203.8] vs. 58.5 g [0.00-144.4] vs. 0.0 g [0.0-60.225], respectively; P=0.031). The best cut-off value of dual-QCA thrombus volume for prediction of MVO was 2.07 mm 3 (AUC: 0.720). The addition of dual-QCA thrombus volume to the traditional angiographic indices of no-reflow enhanced the prediction of MVO by CMR (R=0.752)., Conclusions: Pre-stenting dual-QCA thrombus volume is associated with the presence and extent of MVO detected by CMR in patients with STEMI. This methodology may aid the identification of patients at higher risk of MVO and guide adoption of preventive strategies.

Background: The combination of coronary imaging assessment and blood flow perturbation estimation has the potential to improve percutaneous coronary intervention (PCI) guidance., Objectives: We aimed to evaluate a novel method for fast computation of Murray law-based quantitative flow ratio (μQFR) from coregistered optical coherence tomography (OCT) and angiography (OCT-modulated μQFR, OCT-μQFR) in predicting physiological efficacy of PCI., Methods: Patients treated by OCT-guided PCI in the OCT-arm of the Fractional Flow Reserve versus Optical Coherence Tomography to Guide RevasculariZAtion of Intermediate Coronary Stenoses trial (FORZA, NCT01824030) were included. Based on angiography and OCT before PCI, simulated residual OCT-μQFR was computed by assuming full stent expansion to the intended-to-treat segment. Plaque composition was automatically characterized using a validated artificial intelligence algorithm. Actual post-PCI OCT-μQFR pullback was computed based on coregistration of angiography and OCT acquired immediately after PCI. Suboptimal functional stenting result was defined as OCT-μQFR ≤ 0.90., Results: Paired simulated residual OCT-μQFR and actual post-PCI OCT-μQFR were obtained in 76 vessels from 74 patients. Simulated residual OCT-μQFR showed good correlation (r = 0.80, p < 0.001), agreement (mean difference = -0.02 ± 0.02, p < 0.001), and diagnostic concordance (79%, 95% confidence interval: 70%-88%) with actual post-PCI OCT-μQFR. Actual post-PCI in-stent OCT-μQFR had a median value of 0.02 and was associated with left anterior descending artery lesion location (β = 0.38, p < 0.001), higher baseline total plaque burden (β = 0.25, p = 0.031), and fibrous plaque volume (β = 0.24, p = 0.026)., Conclusions: This study based on patients enrolled in a prospective OCT-guidance PCI trial shows that simulated residual OCT-μQFR had good correlation, agreement, and diagnostic concordance with actual post-PCI OCT-μQFR. In OCT-guided procedures, OCT-μQFR in-stent pressure drop was low and was significantly predicted by pre-PCI vessel/plaque characteristics., (© 2023 Wiley Periodicals LLC.)

Background: Stepwise provisional stenting is the gold standard for percutaneous coronary intervention (PCI) on bifurcation lesions, but the optimal ballooning technique for eventual side branch treatment is not established. The objective of the present study was to compare the stent configuration obtained by 2 different side branch optimization techniques performed after main vessel (MV) stent implantation: proximal optimization technique+kissing balloon inflation+final proximal optimization technique (POT/KBI/POT [PKP]) versus proximal optimization technique+isolated side branch dilation+final proximal optimization technique (POT-side-POT [PSP])., Methods: We realized a 1:1 prospective randomized trial comparing bifurcation PCI conducted (under angiographic and angioscopic visualization) with either PKP or PSP in reanimated swine hearts using commercially available drug-eluting stents. After PCI, the obtained stent configuration (expansion, eccentricity, apposition) was assessed by optical coherence tomography and micro-computed tomography dividing the stent in 4 segments. Primary study end point was minimum stent expansion at the distal MV segment., Results: A total of 30 PCIs were successfully performed according to randomization obtaining overall good results (average minimum stent expansion >90% at optical coherence tomography and micro-computed tomography) with PSP or PKP. Minimum stent expansion at the distal MV segment was significantly higher with PKP as compared with PSP at optical coherence tomography (97.9±4.2% versus 91.0±7.7%; P =0.002) and micro-computed tomography (98.1±4.1% versus 91.3±7.9%; P =0.006). Other significant findings included higher stent eccentricity index at proximal MV with PSP, higher side branch scaffolding length and lower malapposition (at bifurcation core and distal MV) with PKP., Conclusions: This first prospective randomized trial in a unique non-atherosclerotic preclinical environment showed that bifurcation PCI conducted with PSP and PKP achieves different stent configurations. These findings might be useful in bifurcation PCI practice and call for further evaluations in clinical ground.

Introduction and Objectives: Coronary artery disease (CAD) is found in 30%-50% of patients with severe aortic stenosis (AS) undergoing treatment. The best management of CAD in AS patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear. We investigated the clinical impact of the extent of jeopardized myocardium in patients with concomitant CAD and severe AS treated by TAVI., Methods: Consecutive patients who underwent TAVI procedures at our hospital were identified. In the presence of CAD, the myocardium jeopardized before TAVI was graded using the British Cardiovascular Intervention Society (BCIS) jeopardy score (JS). The study population was divided in 3 groups: patients without concomitant CAD (no-CAD), patients with CAD and BCIS-JS ≤ 4 (CAD BCIS-JS ≤ 4) and patients with concomitant CAD and BCIS-JS> 4 (CAD BCIS-JS> 4). The primary study endpoint was major adverse cardiovascular and cerebrovascular events (MACCE)., Results: A total of 403 patients entered the study: 223 no-CAD, 94 CAD BCIS-JS ≤ 4 and 86 CAD BCIS-JS> 4. At> 3 months of follow-up [range 104-3296 days], patients without CAD and CAD patients with BCIS-JS ≤ 4 had better survival free from MACCE compared with those with less extensive revascularization (BCIS-JS> 4) (P=.049). This result was driven by a significant reduction in death (P=.031). On multivariate analysis, residual BCIS-JS ≤ 4 and NYHA class III-IV independently predicted MACCE., Conclusions: In patients with concomitant CAD and severe AS, the extent of jeopardized myocardium before TAVI impacts on clinical outcomes., (Copyright © 2022 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Cardiac assistance represents an emerging issue in cardiovascular medicine. The evolution of invasive cardiology techniques is making the catheterization laboratory one of the main hospital sites where implantation of percutaneous ventricular assistance devices (PVADs) is discussed and performed. Among available PVADs, intra-aortic balloon pump (IABP), Impella, and extracorporeal membrane oxygenation (ECMO) are the most popular and offer completely different levels and ways to assist critical patients. The main settings calling for PVAD consideration in the catheterization laboratory are clinically indicated high-risk patients (CHIP) undergoing percutaneous coronary intervention (PCI) and patients with cardiogenic shock or refractory cardiac arrest. In CHIP, PVAD serves the purpose of preventing hemodynamic collapse during PCI. This may also allow more extensive revascularizations and higher quality revascularization plans (imaging use, debulking, stent result optimization). IABP or Impella are more commonly selected whereas ECMO is seldom considered as a third option for highly selected patients. The "elective" nature of CHIP-PCI should allow careful procedure planning (peripheral artery disease assessment, access site selection and management) in order to minimize vascular/bleeding complications. Cardiogenic shock is still associated with high mortality rates, and PVAD theoretically offers further recovery chances. The lack of benefit observed with systematic IABP use is currently prompting consideration of the roles of Impella and ECMO. Prolonged assistance is often needed. Thus, team decisions and shared protocols for PVAD selection have to be promoted, taking into consideration available resources and operators' skills. In this paper, we critically review the available data in the field and highlight the possible decisionmaking hubs that catheterization-laboratory teams may consider in order to rationalize PVAD selection.

In humans, the most common anatomic variation of the left main (LM) stem is represented by its distal division in 3 branches (LM trifurcation) instead of 2. LM trifurcation disease accounts for ≈10% to 15% of all LM diseases and is often managed by cardiac surgery. Over the last decades, due to the improvement of interventional material and techniques, percutaneous coronary intervention started gaining acceptance to treat patients with LM disease including those with trifurcated anatomy. Yet, LM trifurcation stenosis with its intrinsic anatomic complexity (3 branches, at least 4 angles, wide variability in branch size and disease) is recognized as a challenging lesion subset for percutaneous coronary intervention. In this review, we summarize available data about LM trifurcation anatomy, its influence on percutaneous coronary intervention feasibility, and the evidence collected regarding the different technical options (including trissing balloon inflation).

Background: PCI in CBL is common and technically demanding. Whether such patients have adverse outcome during the follow-up after successful PCI is unclear. We aim to compare the clinical outcome after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation of coronary bifurcation lesions (CBL) and non-CBL., Methods: We performed a systematic literature search to identify studies reporting the clinical outcome of patients undergoing PCI in CBL or not. Patients with left main disease constituted a predefined subgroup. Primary study end-point was major adverse cardiac events (MACE)., Results: Fifteen publications on 23 891 patients with coronary artery disease treated by DES in CBL or not were identified. Median follow-up length was 24 months (range: 12-60). MACE at the longest available follow-up were significantly higher in CBL as compared with non-CBL (19.0 vs. 12.1%, P < 0.001). Similar results were obtained in the subanalysis restricted to second-generation DES studies. The MACE rate was higher early, then decreased during the follow-up being, however, appreciable at all timings up to 36 months. In the left main (LM) subanalysis (four studies, 3210 patients), patients underwent DES implantation in distal LM, as compared with nondistal LM, had increased the MACE rate during the follow-up (27.4 vs. 17.4%, P < 0.001), which was driven by higher target vessel revascularization., Conclusions: In the contemporary DES era, CBL represent a subset of lesions associated with increased rate of MACE after PCI. This data prompt for studies aimed at improving the clinical outcomes of patients with CAD.

Objectives: The aim of this study was to compare optical coherence tomographic (OCT) guidance and fractional flow reserve (FFR) guidance in patients with angiographically intermediate coronary lesions (AICLs) in a single-center, prospective, 1:1 randomized trial., Background: FFR and OCT imaging may help both in the assessment of AICLs and in percutaneous coronary intervention optimization., Methods: Patients with AICLs were randomized to FFR or OCT imaging. In the FFR arm, PCI was performed if FFR was ≤0.80. In the OCT imaging arm, PCI was performed if area stenosis was ≥75% or 50% to 75% with minimal luminal area <2.5 mm 2 or plaque rupture. Angina (evaluated using the Seattle Angina Questionnaire), major adverse cardiac events, and cost were assessed at the end of follow-up. The pre-defined primary endpoint was the composite of major adverse cardiac events or significant angina (defined as Seattle Angina Questionnaire frequency scale score <90) at 13 months., Results: A total of 350 patients (with 446 AICLs) were enrolled (176 randomized to FFR and 174 to OCT imaging). The primary endpoint of major adverse cardiac events or significant angina at 13 months occurred in 14.8% of patients in the FFR arm and in 8.0% in the OCT imaging arm (p = 0.048). This result was driven by a statistically nonsignificant lower occurrence of all primary endpoint components. Up to 13 months, the rate of medically managed patients was significantly higher (p < 0.001) and total cost significantly lower (p < 0.001) with FFR in comparison with OCT imaging., Conclusions: In patients with AICLs, OCT guidance is associated with lower occurrence of the composite of major adverse cardiac events or significant angina. FFR guidance is associated with a higher rate of medical management and lower costs. FFR or OCT Guidance to Revascularize Intermediate Coronary Stenosis Using Angioplasty [FORZA]; NCT01824030)., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background Fractional flow reserve (FFR) and optical coherence tomography (OCT) may help both in assessment and in percutaneous coronary intervention optimization of angiographically intermediate coronary lesions. We designed a prospective trial comparing the clinical and economic outcomes associated with FFR or OCT in angiographically intermediate coronary lesions. Methods and Results Three hundred fifty patients with angiographically intermediate coronary lesions (n=446) were randomized to FFR or OCT guidance. In the FFR arm, percutaneous coronary intervention was performed if FFR was ≤0.80 aiming for a postprocedure FFR >0.90. In the OCT arm, percutaneous coronary intervention was performed if percentage of area stenosis was ≥75% or 50% to 75% with minimal lumen area <2.5 mm 2 or plaque ulceration. Costs, angina frequency, and major adverse cardiac events were assessed at 1 month and at 13 months. We present early data at 1 month consistent with a prespecified analysis of secondary end points. Patients randomized to FFR, as compared with OCT, were significantly more commonly managed with medical therapy alone (67.7% versus 41.1%; P<0.001), required less contrast media (245±137 versus 280±129 mL; P=0.004), and exhibited a lower occurrence of contrast-induced acute kidney injury (1.7% versus 8.6%; P=0.034). At 1 month, in comparison to FFR, OCT was associated with increased total costs (2831±1288 versus 4292±3844 euros/patient; P<0.001) whereas occurrence of major adverse cardiac events or significant angina was similar. Conclusions In patients with angiographically intermediate coronary lesions, a functional guidance by FFR, as compared with OCT, increased the rate of patients treated with medical therapy alone. This translated into a significant reduction in administered contrast, contrast-induced acute kidney injury, and total costs at 1 month with FFR. Clinical Trial Registration URL: http://www.clinicaltrialsgov. Unique identifier: NCT01824030.

Objective: To investigate the effect of extent of revascularization in complex high-risk indicated patients (CHIP) undergoing Impella-protected percutaneous coronary intervention (PCI)., Background: Complete revascularization has been shown to be associated with improved outcomes. However, the impact of more complete revascularization during Impella-protected PCI in CHIP has not been reported., Methods: A total of 86 CHIP undergoing elective PCI with Impella 2.5 or Impella CP between April 2007 and December 2016 from 2 high volume Italian centers were included. Baseline, procedural, and clinical outcomes data were collected retrospectively. Completeness of coronary revascularization was assessed using the British Cardiovascular Intervention Society myocardial jeopardy score (BCIS-JS) derived revascularization index (RI). The primary end-point was all-cause mortality. A multivariate regression model was used to identify independent predictors of mortality., Results: All patients had multivessel disease and were considered unsuitable for surgery. At baseline, 44% had left main disease, 78% had LVEF ≤ 35%, and mean BCIS-JS score was 10±2. The mean BCIS-JS derived RI was 0.7±0.2 and procedural complications were uncommon. At 14-month follow-up, all-cause mortality was 10.5%. At follow-up, 67.4% of CHIP had LVEF ≥ 35% compared to 22.1% before Impella protected-PCI. Higher BCIS-JS RI was significantly associated with LVEF improvement (p=0.002). BCIS-JS RI of ≤ 0.8 (HR 0.11, 95% CI 0.01- 0.92, and p = 0.042) was an independent predictor of mortality., Conclusions: These results support the practice of percutaneous Impella use for protected PCI in CHIP. A more complete revascularization was associated with significant LVEF improvement and survival., Competing Interests: Dr. Burzotta discloses to have been involved in advisory board meetings or having received speaker's fees from Medtronic, St Jude Medical, Abiomed, Biotronic. Dr. Trani discloses to have been involved in advisory board meetings or having received speaker's fees from St Jude Medical, Abiomed, Biotronic. Dr. Aurigemma has been involved in advisory board activities by Biotronic. The remaining authors have nothing to disclose., (Copyright © 2019 Francesco Burzotta et al.)

Background: Long drug-eluting stents may limit the need of stent overlaps in patients with diffusely diseased coronary arteries. We evaluated the clinical results of percutaneous-coronary-intervention (PCI) using a novel ultra-long (48 mm) everolimus-eluting stent (EES) in a real-word population., Methods: Patients who underwent PCI with 48 mm EES between June 2015 and April 2017 in our Center were enrolled. The only exclusion criteria was cardiogenic shock established before PCI. Target vessels were divided in "very long lesion" (>38 mm) and "multiple focal disease" (multiple stenoses separated by healthy coronary segments >10 mm). Clinical follow-up was obtained to evaluate the occurrence of device-oriented composite endpoint (DOCE) (primary end-point)., Results: A total of 216 patients were identified (70.6±11 years, 48.1% acute coronary syndrome) who were treated on 230 vessels. The target vessel appearance was "very long lesion" in 44.8% of cases and "multiple focal disease" in 55.2%. A single 48-mm EES was implanted in 129 (56.1%), while additional overlapping stents were needed in 101 cases (43.9%). Total stent length was 64.9±24.0 mm. The median follow-up time was of 474 (411-614) days, DOCE occurred in 7% of patients. No stent thrombosis was noticed. At multivariate analysis, diabetes was associated with DOCE increase (P=0.02), while "multiple focal disease" predicted lower DOCE (P=0.02)., Conclusions: The present real-world experience shows promising clinical results with the use of ultra-long stents in order to limit the need of stents overlaps in patients with diffuse coronary disease undergoing PCI.

Background: Optical-coherence-tomography (OCT) is an emerging invasive coronary imaging with still undefined clinical value. Recent data have underlined daily impact of such technique in several clinical settings such as acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI) guidance. We aimed at assessing the trends and outcomes of OCT use in a high-volume percutaneous coronary interventions (PCI)-center., Methods: Over 6 years, 1025 coronary artery segments in 877 patients underwent OCT evaluation. Clinical and procedural characteristics were prospectively collected. Clinical setting for OCT was: "Diagnostic OCT" (OCT for lesion evaluation after coronary angiography without further PCI); "PCI-guidance OCT" (OCT as a guidance for complex PCI, both by intention or after diagnostic OCT). Primary study end-point was the occurrence of target-vessel-failure (TVF) during the follow-up., Results: Overall, OCT was successful in 99.1% of attempted lesions. Only one complication (coronary dissection requiring urgent PCI) occurred during OCT. After a follow-up of 695 ± 562 days, TVF occurred in 8.2% of cases. Despite similar baseline characteristics, TVF-free survival curves were different in the two populations (5.4% after diagnostic OCT and 9.9% after PCI-guidance OCT). Minimal-lumen-area (MLA) of target lesion was independently associated with TVF (HR 0.7, 95% CI 0.6-0.8). This was mainly driven by a significant impact of MLA in patients not revascularized (HR 0.6, 95% CI 0.4-0.9). TVF did not change according to the study period despite the selection of patients with increasing complexity., Conclusions: OCT has a good safety profile across a broad spectrum of patients encountered in daily practice. The easy-to-assess MLA parameter may help stratify prognosis of patients undergoing OCT. These data call for further evaluations of OCT clinical impact., Summary: OCT is a light-based imaging tool which had subvert the quite ordinary world of coronary imaging and the present study evaluates OCT use in a high-volume center. Our results suggest that application of OCT in "real world" patients presenting higher risk has a good safety profile. Several factors could predict a worse long-term outcome in patients undergoing OCT evaluation, mostly related to more complex clinical conditions. These findings could encourage even low-to intermediate volume centers to improve their OCT use in daily practice., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims: Stent implantation in ST-segment elevation myocardial infarction (STEMI) patients can be challenging and sometimes associated with immediate and long-term suboptimal results. Stent malapposition and strut uncoverage, predictors of stent thrombosis, are frequently detected in STEMI patients at medium/long-term follow-up. Nevertheless, data at a short follow-up are missing. We aimed to assess the extent of stent malapposition and struts coverage in the subacute phase of STEMI after stent implantation in primary or rescue percutaneous coronary intervention (PCI)., Methods: STEMI patients undergone primary or rescue PCI and scheduled for a second coronary angiography after 2-7 days were enrolled. During the second procedure, frequency domain optical coherence tomography (FD-OCT) was performed to assess percentage of malapposed struts (MS%), percentage area of malapposition (MA%), percentage of uncovered struts (US%), percentage area of atherothrombotic prolapse (PA%) and optical coherence tomography thrombus score (OCT-TS)., Results: Twenty patients were included and 21 stents (19 865 struts) were evaluated. Strut uncoverage was relatively limited [US% = 11.1 (8.1-13.6) %]. Stent malapposition was observed frequently, even if at low degree [MS% = 6.4 (3.3-13.3) %, MA% = 1.80 (0.46-2.76) %] as well as atherothrombotic prolapse [PA% = 0.09 (0.00-1.06) %]. Both MA% and PA% were significantly related to residual OCT-TS (R = -0.52, P = 0.02 and R = 0.71, P < 0.001, respectively), use of thrombolysis (P = 0.001 and P = 0.004, respectively) and time elapsed from PCI to FD-OCT analysis (P = 0.001)., Conclusion: In the subacute phase after stenting in STEMI patients, strut uncoverage is relatively limited, while stent malapposition and atherothrombotic prolapse are common albeit limited features. Residual thrombus burden influences the degree of both stent malapposition and atherothrombotic prolapse.

Background: Percutaneous ventricular-assistance by Impella (IMP) represents an emerging strategy to manage patients with reduced left-ventricular (LV) ejection-fraction (EF) undergoing percutaneous-coronary-intervention (PCI). The hemodynamic behave during IMP-protected PCI has been scarcely investigated., Methods: We reviewed the IMP console's function and hemodynamic data (which are continuously recorded during assistance) in a consecutive series of 37 patients who underwent elective IMP-protected PCI in two high-volume centers. All patients had multivessel disease and impaired LVEF. Coronary artery disease burden was graded using the British-Cardiovascular-Intervention-Society jeopardy-score (BCIS-JS) score. IMP motor speed and pressure signals (systolic blood pressure, SBP, and mean blood pressure, MBP) were analyzed. Primary hemodynamic end-points were "critical systolic blood pressure (SBP) drop" (SBP decrease ≥ 20 mm Hg reaching ≤90 mm Hg values) and "critical mean blood pressure (MBP) drop" (MBP decrease reaching ≤60 mm Hg)., Results: Over mean assistance duration of 254 ± 549 min, no IMP motor drop occurred. During PCI, SBP and MBP significantly decreased but all patients had SBP values >78 mm Hg. Critical SBP and MBP drops occurred in 10.8% of patients. Among all baseline and procedural characteristics, BCIS-JS was the only significant predictor of SBP drop (p = 0.001) while BCIS-JS and LV end-diastolic volume significantly predicted MBP drop (p = 0.001 for both)., Conclusions: In patients with reduced EF undergoing IMP-protected PCI, a significant pressure decrease occurs during PCI but pressure is systematically maintained at levels warranting vital organ perfusion. Critical pressure drops during PCI occur in some patients with higher jeopardized myocardium and left ventricular diastolic volumes., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The completeness of revascularization in patients with multivessel coronary artery disease (CAD) remains an unanswered question. Despite 20 years of investigation there are still major doubts in this topic, reaching as far as to the lack of a standardized definition. The employment of different definition and the multiplicity of confounding variables that in general favor patients who receive a complete revascularization (CR) are the reason of difficult comparisons between studies. The complexity of coronary anatomy diseases and the clinical features play important role in the revascularization strategy. However, the clinical impact of CR is different in particular clinical subsets, such as diabetes, ST-segment elevation myocardial infarction, cardiogenic shock, ischemic heart failure. The CR is a desirable objective, but it is not mandatory and sometimes a reasonable incomplete revascularization (IR) offers comparable results. Clinical variables, including patient's age, life expectancy, the severity of symptoms at presentation, comorbidities (particularly diabetes mellitus), left ventricular function and myocardial viability, as well as coronary anatomy should be considered in the decision making whether to attempt CR or to follow a reasonable IR strategy, for both percutaneous coronary intervention and coronary artery bypass graft surgery, in patients with multivessel CAD.

Background The role of endothelial dysfunction in predicting angina recurrence after percutaneous coronary intervention is unknown. Design We assessed the role of peripheral endothelial dysfunction measured by reactive-hyperaemia peripheral-artery tonometry (RH-PAT) in predicting recurrence of angina after percutaneous coronary intervention. Methods We enrolled consecutive patients undergoing percutaneous coronary intervention with second-generation drug-eluting stents. RH-PAT was measured at discharge. The endpoint was repeated coronary angiography for angina recurrence and/or evidence of myocardial ischaemia at follow-up. Patients with in-stent restenosis and/or significant de novo stenosis were defined as having angina with obstructed coronary arteries (AOCA); all other patients as having angina with non-obstructed coronary arteries (ANOCA). Results Among 100 patients (mean age 66.7 ± 10.4 years, 80 (80.0%) male, median follow-up 16 (3-20) months), AOCA occurred in 14 patients (14%), ANOCA in nine patients (9%). Repeated coronary angiography occurred more frequently among patients in the lower RH-PAT index tertile compared with middle and upper tertiles (14 (41.2%) vs. 6 (18.2%) vs. 3 (9.1%), p = 0.006, respectively). ANOCA was more frequent in the lower RH-PAT index tertile compared with middle and upper tertiles. In the multivariate regression analysis, the RH-PAT index only predicted angina recurrence. The receiver operating characteristic curve of the RH-PAT index to predict the angina recurrence demonstrated an area under the curve of 0.79 (95% confidence interval: 0.69-0.89; p < 0.001), with a cut-off value of 1.705, having sensitivity 74% and specificity 70%. Conclusions Non-invasive assessment of peripheral endothelial dysfunction using RH-PAT might help in the prediction of recurrent angina after percutaneous coronary intervention, thus identifying patients who may need more intense pharmacological treatment and risk factor control.

Background: Patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES) on unprotected left main (ULM) represent a complex subset. The role of routine coronary angiography at follow up in this subset remains debated., Methods: At the documented center, all patients undergoing successful PCI on ULM lesions performing angiographic follow-up is suggested, but adherence to such a recommendation is inhomogeneous. Consecutive patients undergoing DES PCI on ULM were enrolled and experienced no adverse events during the first 6 months. Patients were then allocated to two groups: those undergoing routine control angiography (CA) and those undergoing clinical follow-up (CF). Primary endpoint was major adverse cardiac events (MACE) defined as cardiac death, myocardial infarction and urgent repeat target vessel revascularization., Results: A total of 190 patients underwent successful DES implantation on ULM and the study population was without early events. CA was performed at 6 months after the index procedure in 91 (48%) patients. After 35 ± 21 months, MACE rates were significantly more common in the CF group as compared with the CA group (16.2% vs. 4.3%, p = 0.009). At multivariable analysis, CA was associated with reduced MACE risk (HR 0.13, 95% CI 0.1-0.7, p = 0.028). Of note, this was mainly driven by higher cardiac death rate in those undergoing CF than in those undergoing CA (p = 0.01)., Conclusions: CA after complex PCI, such as ULM PCI, is associated with reduced MACE. Such an observation calls for appropriately designed randomized trials.

Background: Left main (LM) atherosclerotic lesions affect clinical outcomes. Frequency domain-optical coherence tomography (FD-OCT) allows detailed characterization of non-ostial coronary atherosclerotic lesions. The clinical impact of FD-OCT assessment of LM bifurcation disease on the revascularization decision is unknown., Methods: Patients who underwent FD-OCT assessment to guide management of angiographically intermediate distal LM stenosis were retrospectively selected. The FD-OCT LM criteria for percutaneous or surgical revascularization were: Clinical follow-up was obtained to evaluate the occurrence of target vessel failure (TVF) defined as cardiac death and/or acute myocardial infarction (AMI) not related to other vessel and/or target vessel revascularization., Results: Out of 131 patients underwent FD-OCT assessment of LM, 122 patients (93%) entered the study. Based on FD-OCT features, 58 (48%) patients were conservatively managed, while the remaining 64 (52%) were revascularized by stenting (n=48) or surgery (n=16). After a mean follow-up of 18months, TVF-free survival was not different between patients undergoing conservative management vs. revascularization (HR 0.40, CI 95% 0.10-1.61, P=0.20). Of note, two patients only in the conservative management group had TVF (elective LM stenting, no death or myocardial infarction)., Conclusions: This preliminary experience suggests that a FD-OCT based management for patients with angiographically-intermediate LM bifurcation stenosis may help identify patients in whom revascularization could be deferred. Such observation calls for further evaluations by appropriately designed trials., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Aims: Microvascular obstruction (MVO) is associated with a worse prognosis in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI). However, data about incidence, clinical outcome and correlates of MVO in latecomers after STEMI are still lacking., Methods: We prospectively enrolled consecutive patients that were latecomers after STEMI (symptoms onset >12h) undergoing PCI. We performed an angiographic analysis to assess the occurrence of MVO [defined as TIMI flow grade ≤2 or 3 with a myocardial blush grade <2]. Moreover, we performed a clinical and echocardiographic follow-up to assess the occurrence of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, myocardial infarction and rehospitalization for heart failure, and to evaluate left ventricle remodelling., Results: Seventy-eight patients were enrolled [mean age 67.58±11.72years, 57 (73%) male; mean time of symptom onset 23.14±16.06h] with a mean follow-up time of 29.7±14.1months. MVO occurred in 39 (50%) patients. Patients with MVO had a higher rate of MACE [18 (46%) vs. 3 (8%), p<0.001] and LV remodelling [25 (64%) vs. 6 (15%), p<0.001] compared with patients without MVO. By multivariable Cox regression MVO and left anterior descending artery were independent predictors of MACE., Conclusions: Latecomers after STEMI have a high risk to develop MVO that is related to an adverse prognosis. Appropriate management and follow-up strategies should be implemented in such high-risk patients group., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Radial approach is the emerging arterial access for percutaneous coronary interventions (PCIs) in patients with coronary artery disease. Among the different subset of complex targets for PCI, chronic total occlusion (CTO) still represent a challenge for the interventional cardiologist. Is radial approach suitable for PCI on CTO? A series of data collected in selected centers with high volume of transradial procedures supported the change from elective transfemoral approach to systematic transradial approach. In this paper, we tried to provide an update on the technical aspects and the theoretical data which may be useful during the planning of CTO procedures. Overall, a full knowledge of upper limb vascular anatomy, arterial sheaths/guiding catheters selections, transradial PCI technique and CTO lesion management skill is pivotal to safely offer CTO patients the potential benefit of reduced bleeding risks through radial access adoption.

Background: Diffuse coronary artery disease treatment still remains a challenge for interventional cardiologists and cardiac surgeons. There are few data on full metal jacket (FMJ) stenting, especially with new-generation drug-eluting stents. We aimed to assess the efficacy and safety of FMJ with new-generation Zotarolimus-eluting stents (n-ZES)., Methods and Results: All patients who underwent FMJ with n-ZES (≥60mm stent length) in eleven Italian interventional centers participating in the Clinical Service® project were included in this analysis. The project population consisted of 120 patients and 122 lesions. Mean age was 67±10years and 95 (79.2%) patients were male. A chronic total occlusion was present in 34 lesions (27.9%). The number of stents implanted per lesion was 2.9±0.8, and the diameter of the stents was 3.0±0.5mm. Predilation and post-dilatation were performed in 107 (87.7%) and 92 (75.4%) patients, respectively. At 41±21month follow-up there were 2 patients with subacute definite stent thrombosis, 6 patients (5.0%) had cardiac death and 5 patients (4.2%) had non-fatal myocardial infarction. Seven patients (5.8%) underwent clinically-driven target lesion revascularization. Fourteen patients (11.7%) had at least one major adverse cardiac event., Conclusion: The treatment of diffuse coronary artery disease with FMJ stenting with n-ZES appears to be effective and safe. Late and very-late ST does not seem to be an issue and the rate of restenosis and of major cardiac adverse events after more than 3-year follow-up is rather low., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

In this study, we aim to assess whether remote ischemic preconditioning (RIPC) reduces platelet activation during coronary angiography (CA) and/or percutaneous coronary interventions. We studied 30 patients who underwent CA because of a suspect of stable angina. Patients were randomized to RIPC (3 short episodes of forearm ischemia) or sham RIPC (controls) before the procedure. Blood samples were collected at baseline, at the end of the procedure, and 24 hours later. Monocyte-platelet aggregate (MPA) formation and platelet CD41 in the MPA gate and CD41 and CD62 expression in the platelet gate were assessed by flow cytometry, in the absence and in the presence of adenosine diphosphate (ADP) stimulation. A significant increase in platelet activation occurred during the invasive procedure in controls, which persisted at 24 hours. However, compared with controls, RIPC group showed no or a lower increase in platelet variables, including MPA formation (p <0.0001) and CD41 (p = 0.002) in the MPA gate and CD41 (p <0.0001) and CD62 (p = 0.002) in the platelet gate. ADP increased platelet activation at baseline, but did not further increase platelet reactivity during the invasive procedure in either groups. Percutaneous coronary interventions, performed in 10 patients (6 in the RIPC group and 4 in controls), did not have any further significant effect on platelet activation and reactivity compared with CA alone. In conclusion, RIPC reduces platelet activation occurring during CA. In contrast, no effects were observed on platelet response to ADP stimulation, probably related to the administration of an ADP antagonist in all patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Transradial approach (TRA), when compared with transfemoral, improves the safety of percutaneous coronary procedures. Arterial axis variants are known to hinder the performance of transradial approach percutaneous coronary procedures. Data on the occurrence of arterial axis variants in the right and left arm arterial axes of individual patients are lacking., Methods and Results: From a single-center prospective registry, we selected all patients in whom bilateral upper limb arterial anatomy was assessed based on the performance of left and right radial catheterization obtained during the same or during repeat coronary diagnostic or interventional procedure(s). The occurrence of upper right and left limb arterial axis variants was classified according to the previously described operative ABC classification. A total of 610 patients were identified. An ABC upper limb arterial axis variant was detected in 156 (25.6%) patients. Variants were right-sided only in 65 (11.0%), left-sided only in 40 (6.6%), and bilateral in 46 (7.5%) patients. Thus, arterial axis variants were significantly more common in the right side (P=0.02). Bilateral arterial variants were significantly associated with age, female sex, and valvulopathy. Both A (radial/brachial) and B (axillary/subclavian/innominate) variants exhibited concordance across the 2 sides (odds ratio, 7.2; 95% confidence interval, 4.1-12.7 and 8.0; 95% confidence interval, 2.1-30.9, respectively)., Conclusions: The occurrence of an anatomic variant potentially hindering transradial approach coronary diagnostic or interventional procedures is bilateral in <8% of cases and is more common in the right arm. Such information may guide, during the clinical practice, the access selection in the case of repeat procedures or need for additional accesses., (© 2015 American Heart Association, Inc.)

About 30% of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing recanalisation of the infarct-related coronary artery do not achieve valid myocardial reperfusion (no-reflow phenomenon or coronary microvascular obstruction [MVO]). The mechanisms of MVO are incompletely understood. In this study we investigated the role platelet activation in the pathogenesis of coronary MVO in STEMI patients. We enrolled 48 STEMI patients (age 56.2 ± 11 years; 31 men), treated by primary percutaneous coronary intervention (PCI) followed by double anti-platelet treatment, and 20 control patients with stable coronary artery disease (CAD) on single anti-platelet treatment (age 57.5 ± 6 years, 12 men). STEMI patients were divided into two groups: 35 patients with complete myocardial reperfusion (MR) and 13 patients with coronary MVO despite successful PCI. Platelet activation was assessed on admission and at one-month follow-up by measuring platelet receptor expression and monocyte-platelet aggregates (MPAs). Platelet receptor expression, platelet receptor conformational change for fibrinogen binding availability and MPA formation were increased in STEMI patients with MVO compared to both STEMI patients with MR and stable CAD patients, both on admission and at one-month follow-up (p<0.05 for all).Among STEMI patients, platelet activation is greater in those who display coronary MVO, compared to those with MR, after successful PCI, both on admission and one month after STEMI, suggesting that enhanced platelet activation might be involved in the pathogenesis of MVO. The persistence of enhanced platelet activation despite double classical anti-platelet therapy suggests that new anti-platelet strategies should be considered in patients with coronary MVO.

Bleeding complications in patients with acute coronary syndromes are a significant predictor of mortality. Trans-radial approach (TRA) is a promising strategy to reduce bleedings in patients undergoing invasive coronary procedures. Recently, two multicentre prospective randomized trials aimed to test whether TRA, compared to trans-femoral approach (TFA), may improve clinical outcome in patients with ST-elevation myocardial infarction: the RIFLE STEAC and STEMI-RADIAL. In the RIFLE STEACS, the primary endpoint of 30-day NACEs occurred in 68 patients (13.6%) in the TRA arm and 105 patients (21.0%) in the TFA arm (p = 0.003). In particular, compared with TFA, TRA was associated with significantly lower rates of cardiac mortality (5.2% vs. 9.2% , p = 0.020), bleeding (7.8% vs. 12.2%, p = 0.026), and shorter hospital stay (5 days, [range, 4 to 7 days]; vs. 6 [range, 5 to 8 days]; p = 0.03). In the STEMI-RADIAL, the primary endpoint of major bleeding or access site complications occurred in 7.2 percent of the TFA patients and 1.4 percent of the TRA patients (p=0.0001). The rate of MACE at 30 days was 4.2 percent in the TFA group, and 3.5 percent in the TRA group (p=0.7). The results of two recent trials support the systematic adoption of TRA instead of TFA approach to improve the clinical outcome of STEMI patients. In the present paper, we overview the results of these two trials and put them in the context of previous scientific evidences collected in this field.

Aim: The aim of our study is to assess the predictors and the prognostic role of left ventricle ejection fraction (LVEF) recovery after Impella-supported percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (AMI). Methods: This retrospective, observational study included patients admitted for AMI who underwent Impella-supported PCI in two Italian high-volume cardiac catheterization laboratories. Only patients who underwent an echocardiographic assessment of left ventricle ejection fraction (LVEF) before the procedure (acute LVEF) and during follow-up (follow-up LVEF) were included in the present analysis. Patients with a baseline LVEF ≥40% were excluded from the present analysis. LVEF recovery was calculated as the difference between follow-up LVEF and acute LVEF. A delta ≥5% was considered significant and was used to define the responder group. Results: From April 2007 to December 2020, 64 consecutive patients were included in our study. A total of 55 patients (86%) received hemodynamic support with Impella 2.5, and 9 patients (14%) with Impella CP. Median LVEF at follow-up was significantly higher compared to baseline (36% (30–42) vs. 30% (24–33), p < 0.001). Based on LVEF recovery, 37 patients (57.8%) were deemed responders. According to multivariate analysis, complete functional revascularization was an independent predictor of a significant EF recovery (OR: 0.159; 95% CI: 0.038–0.668; p = 0.012). At three-year follow-up, lack of LVEF recovery was the only predictor of mortality (HR: 5.315; 95% CI: 1.100–25.676; p = 0.038). Conclusions: Functional complete revascularization is an independent predictor of the recovery of LVEF in patients presenting with AMI who underwent Impella-supported PCI. The recovery of LV function is associated with improved prognosis and could be used to stratify the risk of future events at long-term follow-up. [ABSTRACT FROM AUTHOR]

Background Transaxillary route for structural and coronary percutaneous interventions represents a valid alternative access in patients with obstructive peripheral disease. Nevertheless, its widespread use is limited by a less manageable haemostasis procedure. Case summary In this case, we describe a minimalistic high-risk transcatheter aortic valve implantation (TAVI) procedure (TAVI Score 6.42%) conducted with a double arm approach (radial and axillary accesses) in an 88-year-old patient with severe aortic stenosis and multiple co-morbidities preventing both surgical (Society of Thoracic Surgeons mortality 7.9%) and percutaneous transfemoral approach (extensive peripheral artery disease). We also described the successful management of a complicated transaxillary haemostasis with this technique. Discussion In our cases, a minimalist double-arm approach was successfully used for TAVI procedure as an alternative to transfemoral approach assuring effective and safe management of vascular access haemostasis. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to evaluate the 30-day and long-term clinical outcomes of patients with carotid obstructive disease (COD) and concomitant coronary artery disease (CAD) undergoing a combined percutaneous revascularization, in 4 high-volume centers skilled for the treatment of multilevel vascular disease. Background: The optimal management of patients with COD and concomitant CAD remains controversial. A variety of therapeutic strategies, including coronary artery bypass grafting, alone or in combination with carotid artery revascularization, have been reported. Methods: Between January 2006 and April 2010, 239 consecutive patients with COD (symptomatic carotid stenosis in 20.5%) and concomitant CAD were treated with staged or simultaneous carotid artery stenting and percutaneous coronary intervention, and enrolled in this prospective registry. The primary endpoint was the incidence of major cardiac and cerebrovascular events, including any death, myocardial infarction, or stroke occurring between the first revascularization procedure and 30 days after treatment of the second vascular territory affected. Results: The incidence of the primary endpoint at 30 days was 4.2% (95% confidence interval [CI]: 2.02 to 7.56). The rate of death, myocardial infarction, and stroke at long-term follow-up (median 520 days) was 4.2%, 2.1%, and 3.8%, respectively. At long-term follow-up, patients with previous cardiovascular disease had significantly higher rates of major cardiac and cerebrovascular events than did patients with a first clinical episode (17% vs. 6%, hazard ratio: 3.34; 95% CI: 1.46 to 7.63; p = 0.004). Conclusions: In patients with COD and concomitant CAD, a combined percutaneous treatment compares favorably with previous surgical or hybrid experiences. Such strategy may be particularly suited to complex patients at high surgical risk. [ABSTRACT FROM AUTHOR]

Contrast fractional flow reserve (cFFR) is a relatively new tool for the assessment of intermediate coronary artery stenosis and represents a reliable surrogate of FFR with the advantage of potentially simplifying functional evaluation. We aimed to compare the incidence of major adverse cardiac events (MACE) in patients undergoing functional evaluation with both FFR and cFFR based on the results of the two indexes. We retrospectively analyzed outcomes in 488 patients who underwent functional evaluation with FFR and cFFR. Patients were divided into four groups using the cutoff values of 0.80 for FFR and 0.85 for cFFR: −/− (n = 298), +/+ (n = 134), −/+(n = 31) and +/− (n = 25). All patients were treated according to FFR value. MACE rate was assessed in each group, including death, myocardial infarction and urgent target vessel revascularization (TVR). Mean follow-up time was 22 ± 15 months. Incidence of MACE at follow-up was 8.3% in FFR−/cFFR−, 14.0% in FFR+/cFFR+, 16.0% in FFR−/cFFR+ and 8.0% in FFR+/cFFR− without a significant difference amongst the 4 groups (p = 0.2). Nevertheless, a significant difference in the rate of TVR comparing FFR−/cFFR− (n = 17) and FFR−/cFFR+ (n = 5) was found at 24 months (5.7% vs 16.0%; p = 0.027). cFFR is accurate in predicting FFR and consequently reliable in guiding coronary revascularization. In the rare case of discordance, while FFR+/cFFR- patients show a prognosis similar to FFR-/cFFR- patients, FFR-/cFFR+ patients show a prognosis similar to FFR+/cFFR+ patients. • cFFR is a new tool in the assessment of intermediate coronary stenosis. • cFFR is accurate in predicting FFR and reliable in guiding revascularization. • In case of discordance, no significant difference in outcome choosing cFFR. • In patients with FFR > 0.80 and cFFR ≤ 0.85 TVR is higher. • cFFR could be a more sensitive index. [ABSTRACT FROM AUTHOR]

Dual quantitative coronary angiography (QCA) has been recently tested for assessment of intracoronary thrombus volume in experimental models. The present study aimed to validate dual QCA in vivo for the assessment of thrombus burden by exploring the correlations between dual QCA-thrombus volume and optical coherence tomography (OCT)-derived indices of thrombotic burden. Fifty-one patients with ACS and angiographic evidence of thrombus undergoing OCT of the culprit lesion before stenting were included. Dual QCA-thrombus volume was calculated as difference between edge-detection and video-densitometry area functions along the target segment. Culprit lesion was categorized using the Ambrose's and AHA/ACC angiographic classifications. Thrombus volume (mean thrombus area × thrombus length), thrombus burden [(mean thrombus area/mean lumen area) x100] and Prati thrombus score (number of quadrants with thrombus) were measured by OCT, and the presence of plaque rupture (PR) or intact fibrous cap (IFC) was assessed. Dual QCA-thrombus volume correlated significantly with OCT-thrombus volume (R = 0.791), thrombus burden (R = 0.767) and Prati thrombus score (R = 0.600) (all p < 0.001). Dual-QCA thrombus volume was significantly higher in patients with PR compared with those with IFC (3.48 mm3 [1.45–11.26] vs. 1.69 mm3 [0.09–5.02], p = 0.013). Compared with IFC, PR showed higher prevalence of eccentric type II Ambrose lesion (41.7% vs. 7.4%, p = 0.004), complex B2/C lesion (87.5% vs. 55.6%, p = 0.012), and heavy calcification (29.2% vs. 3.7%, p = 0.013). Dual QCA analysis appears to be a promising tool for quantification of intracoronary thrombus in vivo. This novel methodology may be useful to guide intracoronary thrombus removal during percutaneous coronary intervention and to aid prognostic stratification in patients with ACS. Unlabelled Image • Dual quantitative coronary angiography (QCA) has been tested for the assessment of thrombus volume in experimental models. • In this in vivo study, dual QCA-thrombus volume was correlated with optical coherence tomography indices of thrombus burden. • A combination of angiographic features may enable the discrimination of patients with plaque rupture and intact fibrous cap. • Dual QCA may be useful to guide thrombus removal and aid prognostic stratification in patients with acute coronary syndrome. [ABSTRACT FROM AUTHOR]

Background The decision-making process of patients with angiographically-intermediate coronary lesions (ICL) is clinically challenging and may benefit from adjunctive invasive techniques. Fractional-flow-reserve (FFR) represents the gold standard to evaluate ICL but frequency-domain optical-coherence-tomography (OCT) is a novel, promising, high resolution coronary imaging technique, which allows physiopathologic assessment of coronary plaque. We investigated the possible relation between OCT and FFR in selected ICL patients. Methods Stable or unstable patients with ICL who underwent both FFR and OCT assessment at two large tertiary centers were retrospectively enrolled. FFR was performed according to standard methodology. OCT images were (on blind to clinical and FFR results) analyzed to assess minimal lumen area (MLA), percentage area stenosis (AS), thrombus and plaque ulceration. Results Forty patients were identified (62 ± 10 years, 93% symptomatic, 35% acute presentation, 93% left-anterior-descending artery ICL). Percentage diameter stenosis at quantitative coronary angiography was 40 ± 12% and FFR was 0.85 ± 0.07. MLA ( p = 0.009), AS ( p < 0.001) and plaque ulceration ( p = 0.02) were significantly associated with FFR values. An integrated assessment of AS (≥ or < 70%), MLA (≥ or < 2.5 mm 2 ) and presence or absence of thrombus and plaque ulceration was found to have the potential to accurately (sensitivity 91%, specificity 93%) predict FFR results. Conclusion In patients with ICL, a combination of different OCT parameters may help predict FFR results. These findings suggest that only a comprehensive assessment of lesion features by OCT can allow an accurate prediction of lesion severity assessed by FFR. [ABSTRACT FROM AUTHOR]

The clinical challenge of percutaneous coronary interventions (PCI) is highly dependent on the recognition of the coronary anatomy of each individual. The classic imaging modality used for PCI is angiography, but advanced imaging techniques that are routinely performed during PCI, like optical coherence tomography (OCT), may provide detailed knowledge of the pre-intervention vessel anatomy as well as the post-procedural assessment of the specific stent-to-vessel interactions. Computational fluid dynamics (CFD) is an emerging investigational tool in the setting of optimization of PCI results. In this study, an OCT-based reconstruction method was developed for the execution of CFD simulations of patient-specific coronary artery models which include the actual geometry of the implanted stent. The method was applied to a rigid phantom resembling a stented segment of the left anterior descending coronary artery. The segmentation algorithm was validated against manual segmentation. A strong correlation was found between automatic and manual segmentation of lumen in terms of area values. Similarity indices resulted >96% for the lumen segmentation and >77% for the stent strut segmentation. The 3D reconstruction achieved for the stented phantom was also assessed with the geometry provided by X-ray computed micro tomography scan, used as ground truth, and showed the incidence of distortion from catheter-based imaging techniques. The 3D reconstruction was successfully used to perform CFD analyses, demonstrating a great potential for patient-specific investigations. In conclusion, OCT may represent a reliable source for patient-specific CFD analyses which may be optimized using dedicated automatic segmentation algorithms. [ABSTRACT FROM AUTHOR]