Search

Background: In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), the treatment strategy for non-infarct-related artery (non-IRA) remains controversial. Quantitative flow ratio (QFR) is a new angiography-based physiological assessment index. However, there is little evidence on the practical clinical application of QFR. Methods: Two hundred and twenty-nine patients with STEMI and MVD were recruited for this study. Patients were randomly assigned to either receive QFR-guided complete revascularization (QFR-G-CR) of non-IRA or receive no further invasive treatment. The primary (1o) endpoint analyzed included death due to all causes, non-fatal myocardial infarction (MI), and ischemia-induced revascularization at 12 months post-surgery. Secondary (2o) endpoints included cardiovascular death, unstable angina, stent thrombosis, New York Heart Association (NYHA) class IV heart failure (HF), and stroke at 1 year post surgery. Massive bleeding and contrast-associated acute kidney injury (CAKI) were used as safety endpoints. Results: Around the 12 month follow up, the 1o outcome was recorded in 11/115 patients (9.6%) in the QFR-G-CR population, relative to 23/114 patients (20.1%) in the IRA-only PCI population (hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.22–0.92; p = 0.025). Unstable angina in 6 (5.2%) and 16 (14.0%) patients (HR: 0.36; 95% CI: 0.14–0.92; p = 0.026), respectively. No marked alterations were found in the massive bleeding and CAKI categories. Conclusions: In conclusion, STEMI and MVD patients can benefit from QFR-G-CR of non-IRA lesions in the initial stages of acute MI. This can help reduce incidences of major adverse cardiovascular events and unstable angina, relative to IRA treatment only. Chinese Clinical Trial Registration number: ChiCTR2100044120.

Background: The aim of this study was to describe the mechanism of subintimal shift (SIS), standardise diagnostic criteria and sensitise the interventional community to this phenomenon. The treatment of chronic total occlusions (CTO) by means of percutaneous coronary intervention (PCI) is complicated by bifurcation lesions involved in the CTO segment or adjacent to it. Extraplaque expansion of intracoronary devices during CTO PCI may extend the dissection plane over the bifurcation with the consequential side or main branch compression by an intimo-medial flap. This phenomenon is hereby described for the first time and named subintimal shift. Methods: Experienced CTO operators from 3 international high volume centers for CTO PCI retrospectively searched their personal records for paradigmatic cases of SIS, summarising key features and proposing diagnostic criteria. Results: The series comprised 7 demonstrative cases, illustrating SIS by intravascular imaging (2 cases) or indirect angiographic signs during CTO PCI (5 cases). Five cases were triggered by stent expansion, 1 by balloon inflation and 1 case was aborted after angiographic warning signs. In 4 cases, SIS resulted in total occlusion of a branch, refractory to ballooning whenever attempted. Four cases required bailout intervention and in 2 cases the branch was left occluded, resulting in a rise of cardiac markers. Conclusions: Subintimal shift is a noteworthy complication in CTO bifurcations, potentially resulting in occlusion of the relevant side or even the main branch. Intracoronary imaging prior to stenting is recommended to understand the tissue planes. Some counterintuitive peculiarities of this phenomenon, like its refractoriness to ballooning, must be known by CTO operators for its efficient resolution.

Background: With the advent of novel recanalization techniques and emerging devices, percutaneous coronary intervention (PCI) has become a promising leading treatment option for patients with chronic total occlusions (CTO). The present study aims to evaluate the acute outcomes of PCI in previously failed re-attempted vs. first-attempted CTO-lesions. Methods: Between 2012 and 2019, 619 patients were included and treated with PCI of at least one CTO. 253 patients were re-attempted lesions, while 366 were initially attempted lesions. Results: Re-attempted lesions were more complex, including higher Japanese-CTO (J-CTO) score and the need for a retrograde approach. The procedure time and fluoroscopy time were longer in this group. Nevertheless, overall success rates were comparable between both groups of patients. In-hospital events were rare and without significant differences. Conclusions: Re-attempted CTO lesions are more complex than first-attempt lesions and are associated with longer procedural times. However, they can be safely intervened by experienced operators with a similar success rate.

The management of acute ST-elevation myocardial infarction (STEMI) has transitioned from observation and reactive treatment of hemodynamic and arrhythmic complications to accelerated reperfusion and application of evidence-based treatment to minimize morbidity and mortality. International research established the importance of timely reperfusion therapy and the application of fibrinolysis, primary percutaneous coronary intervention (PCI), and subsequent development of the pharmacoinvasive approach. Clinician thought leaders developed and investigated comprehensive systems of care to optimize the outcomes of patients with STEMI, with a key focus in Canada being the integration of prehospital paramedics in diagnosis, triage, and treatment. This article will review highlights of these interventions and identify future challenges and opportunities in STEMI patient care.

Left atrial dissection (LatD), also known as left atrial intramural haematoma, is a rare condition that requires rapid diagnosis and frequently calls for timely surgical intervention. Diagnosis can be challenging because of a lack of definitive clinical criteria, and a patient’s situation can be complicated by co-morbidities, including unstable haemodynamics. We surgically repaired a case of LatD related to percutaneous coronary intervention (PCI). The operation went smoothly, and the patient was discharged one week after the operation. For LatD patients with co-morbidities, especially haemodynamic disorders, active surgical intervention is recommended.

Surgical aortic valve replacement with coronary artery bypass grafting (SAVR+CABG) is the recommended treatment for aortic stenosis and coronary artery disease; however, percutaneous coronary intervention at the time of transcatheter aortic valve replacement (TAVR+PCI) is used with increasing frequency.Using the National Inpatient Sample, we identified all adult admissions with a diagnosis of aortic stenosis. Subgroups of SAVR+CABG and TAVR+PCI formed the study group. Outcomes of interest included total hospitalization charges, temporal trends, in-hospital mortality, and complications.Between 2012 and 2017, a total of 97 955 admissions (95.9%) received SAVR+CABG, and 4240 (4.1%) received TAVR+PCI; the proportion of TAVR+PCI increased from 1% in 2012 to 9.2% in 2017 (P.001). Compared with patients receiving TAVR+PCI, admissions receiving SAVR+CABG were younger, more likely to be male, and had lower comorbidity (all P.001). Adjusted in-hospital mortality was comparable in both groups (odds ratio 0.94; 95% confidence interval, 0.79 to 1.11; P = .45). Higher rates of pacemaker implantation, cardiac arrest, and vascular complications were seen in the TAVR+PCI group, whereas SAVR+CABG was associated with a greater requirement for prolonged ventilation. Admissions receiving TAVR+PCI had shorter lengths of hospital stay and were more likely to be discharged home. Nevertheless, the TAVR+PCI group had higher hospitalization charges compared with the SAVR+CABG group (all P.001).There has been a steady increase in the use of percutaneous strategies for aortic stenosis and coronary artery disease management. In-hospital mortality was comparable in SAVR+CABG and TAVR+PCI groups, but despite shorter in-hospital stays, TAVR+PCI was associated with higher cardiac and vascular complication rates and hospitalization charges.

Ticagrelor is a part of dual antiplatelet therapy (DAPT) which has proven benefits in patients with acute coronary syndrome especially in those undergoing percutaneous coronary intervention (PCI). However, like most other drugs, it can lead to undesired and adverse effects such as dyspnoea, easy bruising and gastrointestinal bleeding. We present a case of 70-year-old woman who developed diarrhoea following initiation of DAPT comprising of aspirin and ticagrelor following PCI. After excluding more common causes, it was attributed to ticagrelor administration and completely resolved after it was replaced with another oral antiplatelet agent. On follow-up, the patient reported complete resolution of symptoms.

Disparities in cardiovascular outcomes between Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians persist. This has previously been attributed to a combination of differences in burden of cardiovascular disease risk factors, and inpatient access to guideline-recommended care.To assess differences in inpatient access to guideline-recommended acute coronary syndrome (GR-ACS) treatment between Aboriginal and Torres Strait Islander and non-indigenous patients admitted to Royal Darwin Hospital (RDH) with index ACS event.This retrospective study included index ACS admissions (n = 288) to RDH between January 2016 and June 2017. Outcomes included rates of coronary angiography, percutaneous coronary intervention (PCI), surgical revascularisation, GR-ACS medications prescribed on discharge and short-term outcomes (30-day mortality and ACS readmissions; 12-month all cardiac-related readmissions).Two hundred and eighty-eight patients, including 109 (37.85%) Aboriginal and Torres Strait Islander patients, were included. Compared with non-indigenous patients, they were younger (median age 48 years vs 60 years; P 0.01), with a greater burden of comorbidities, including diabetes (39% vs 19%; P 0.01), smoking (68% vs 35%; P 0.01) and chronic kidney disease (29% vs 5%; P 0.01). There were no differences in rates of coronary angiography (98% vs 96%; P = 0.24) or PCI (47% vs 57%; P = 0.12), although there was a trend towards surgical revascularisation in Aboriginal and Torres Strait Islander patients (16% vs 8%; P = 0.047). There were no differences in 30-day mortality (1.8% vs 1.7%; P = 0.72), 12-month ACS readmissions (7% vs 4%; P = 0.20) or 12-month cardiac-related readmissions (7% vs 13%; P = 0.11).Aboriginal and Torres Strait Islander patients received similar inpatient ACS care and secondary prevention medication at discharge, with similar short-term mortality outcomes as non-indigenous patients. While encouraging, these outcomes may not persist long term. Further outcomes research is required, with differences compelling consideration of other primary and secondary prevention contributors.

Aim Optimal dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) intends to balance ischemic and bleeding risks. Various DAPT de-escalation strategies, defined as switching from a full-dose potent to a reduced dose or less potent P2Y12 inhibitor, have been evaluated in several ACS-PCI trials. We aimed to compare DAPT de-escalation to standard DAPT with full-dose potent P2Y12 inhibitors in ACS patients who underwent PCI. Methods and results PubMed, Google Scholar, and Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials. Aspirin monotherapy trials were excluded. Five randomized trials (n = 10 779 patients) that assigned DAPT de-escalation (genetically guided to clopidogrel n = 1242; platelet function guided to clopidogrel n = 1304; unguided to clopidogrel n = 1672; unguided to lower dose n = 1170) vs. standard DAPT (control group n = 5391) were included in this analysis. DAPT de-escalation was associated with a significant reduction in Bleeding Academic Research Consortium ≥2 bleeding (HR 0.57, 95% CI 0.42–0.78; I2 = 77%) as well as major adverse cardiac events, represented in most trials by the composite of cardiovascular mortality, myocardial infarction, stent thrombosis, and stroke (HR 0.77, 95% CI 0.62–0.96; I2 = 0%). Notwithstanding the limited power, consistency was noted across various de-escalation strategies. Conclusion De-escalation of DAPT after PCI for ACS, both unguided and guided by genetic or platelet function testing (PFT), was associated with lower rates of clinically relevant bleeding and ischemic events as compared to standard DAPT with potent P2Y12 inhibitors based on five open-label RCTs reviewed.

Aim Recently, the atherogenic index of plasma (AIP) has been proposed as a novel, reliable plasma atherogenicity marker. This study aimed to investigate the association of AIP with the risk of in-stent restenosis (ISR) in patients with acute coronary syndrome (ACS). Methods This study retrospectively enrolled patients with ACS followed by angiography within 6 to 18 months after successful percutaneous coronary intervention (PCI) with a drug-eluting stent (DES). And the participants were divided into ISR or non-ISR groups based on the angiographic follow-up results. AIP was defined as the base 10 logarithm of the ratio of serum triglyceride (mmol/L) to high-density lipoprotein cholesterol (mmol/L). Results This study recruited 1319 patients with ACS, 199 of which had ISR. Compared with the non-ISR group, patients in the ISR group had higher level of AIP (0.199±0.290 vs 0.131±0.282, p=0.002). In the multiple logistic regression analysis, AIP was an independent risk factor for DES-ISR (OR=2.100, 95% CI 1.134 to 3.891, p=0.018). When we modulated AIP as a categorical variable, the risk of DES-ISR increased in quartile 4 compared to quartile 1 (OR=1.713, 95% CI 1.040 to 2.822, p=0.034). Furthermore, this association remains stable in various subgroups. Unexpectedly, the subgroup analysis suggested AIP and DES-ISR had a stronger positive association in individuals with low-density lipoprotein cholesterol (LDL-C) ＜1.8 mmol/L. Conclusions AIP and the risk of DES-ISR were positively and independently correlated in patients with ACS, especially in those with an LDL-C ＜1.8 mmol/L.

Bifurcation lesions are frequently found in chronic total occlusion (CTO) percutaneous coronary intervention and are associated with lower procedural success and higher rates of complications, including side branch loss. In this report, we describe a poorly understood mechanism for side branch loss in CTO PCI: subintimal shift. This involves the extension of a dissection plane caused by subintimal (extraplaque) crossing in the main branch at the level of the side branch ostium, causing exclusion of the latter upon vessel preparation or stent placement. Subintimal shift (as compared to carina shift in non-CTO bifurcation intervention) appears to be under-recognized, and CTO operators should be aware that, from a technical standpoint, ballooning of the side branch is unlikely to restore and maintain flow, and a two-stent strategy is indicated to preserve the bifurcation.

During an attempted PCI utilizing a femoral approach, a balloon became entrapped in the Left Circumflex Artery. Initial retrieval efforts including pulling the balloon and inflating a second balloon over the entrapment failed, the balloon fractured, and the distal end of the balloon apparatus migrated out of the guide catheter. We utilized a stepwise approach with a double helix wiring technique, snares and a change from a transfemoral to transradial approach to successfully retrieve the foreign bodies. This case highlights the importance of utilizing multiple techniques in series and understanding anatomical influences on equipment retrieval when single techniques and approaches fail.

The transradial access approach is a well-established route for coronary angiography and percutaneous intervention, given its lower complication rate over the transfemoral route. However, complications are still apparent, some of which can lead to serious injury. We report a case of delayed diagnosis of localized compartment syndrome , caused by haematoma and pseudoaneurysm formation following a radial procedure which resulted in long term disability. We emphasize the importance of early recognition and diagnosis of compartment syndrome to avoid long term sequalae.

Background: Pathological Q waves are correlated with infarct size, and Q-wave regression is associated with left ventricular ejection fraction improvement. There are limited data regarding the association of Q-wave regression and clinical outcomes. Our main objective was to assess the association of pathological Q wave evolution after re-perfusion with clinical outcomes after anterior STEMI.Methods: Standard 12-lead electrocardiograms (ECGs) were recorded in 780 anterior STEMI patients treated with primary percutaneous coronary intervention (PCI) from the CIRCUS trial. ECGs were recorded before and 90 min following PCI, as well as at hospitalization discharge and 12 months of follow-up. The number of classic ECG criteria Q waves was scored for each ECG. Patients were classified in the Q wave regression group if they had re-gression of at least one Q wave between the post-PCI, the discharge and/or one year ECGs. Patients were classified in the Q wave persistent group if they had the same number or greater between the post-PCI, the discharge and/ or 1 and one year ECGs. All-cause death and heart failure events were assessed for all patients at one year.Results: There were 323(43%) patients with persistent Q waves (PQ group), 378(49%) patients with Q wave re-gression (RQ group) and 60(8%) patients with non-Q wave MI (NQ group). Infarct size as measured by the peak creatine kinase was significantly greater in the PQ group compared to the RQ and NQ groups (4633 +/- 2784 IU/l vs. 3814 +/- 2595 IU/l vs. 1733 +/- 1583 IU/l respectively, p b 0.0001). At one year, there were 22 deaths (7%) in the PQ-group, 15 (4%) in the RQ-group and none in the NQ-group (p = 0.04). There was a 4-fold increase in the risk of death or heart failure in the PQ compared to the NQ group (HR 4.7 [1.1; 19.3]; p = 0.03), but there was no significant difference between NQ and RQ groups (HR 3.3 [0.8; 13.8]; p = 0.09).Conclusion: Ina population of anterior STEMI patients, persistent Q waves defined according to the classic ECG criteria after reperfusion was associated with a 4-fold increase in the risk of heart failure or death compared to non-Q-wave MI, while Q-wave regression was associated with significantly lower risk of events.(c) 2019 Elsevier Inc. All rights reserved.

Stent loss can occur during percutaneous coronary interventions (PCIs) and can lead to complications such as coronary occlusion, perforation or dissection. Stent retrieval is often attempted but may lead to additional complications. We describe a case of stent loss during chronic total occlusion PCI. The small balloon technique failed to retrieve the stent. The stent was snared but could still not be removed. Retrieval attempts were complicated by large vessel perforation. A covered stent was deployed covering the lost stent and successfully sealing the perforation.

Patient undergoing PCI can have distal embolization and microvascular obstruction despite normalization of epicardial blood flow. Aspiration thrombectomy has been studied previously to reduce infarct size, but prior methods of aspiration thrombectomy were associated with increased risk of stroke and is currently recommended as a bailout strategy. Penumbra CAT RX has been recently approved for aspiration thrombectomy, we evaluated the catheter's use in an academic cardiac catheterization lab. Patients undergoing cardiac catherization at an academic medical center who had deployment of the Penumbra CAT RX from 2017 through 2020 were included in the case series. TIMI flow pre and post procedure were determined by individual operator. Endpoints included 30-day cardiovascular death and post-procedural stroke. The Penumbra CAT RX catheter was used in a total of 34 patients, with 71% STEMI, 23% NSTEMI , 3% UA, and 3% new onset heart failure. TIMI 3 flow was achieved in 88% of cases. There were no cases of 30-day cardiovascular death or post procedural stroke. Aspiration thrombectomy continues to have clinical benefit in modern cardiac catherization laboratories with use in select cases. The Penumbra CAT RX appears to be safe and highly effective at thrombus removal in the acute setting without increased stroke risk as seen with manual aspiration thrombectomy.

Background Recent analyses of the volume-outcome relationship for percutaneous coronary intervention (PCI) have suggested a less robust association than previously reported. It is unknown if novel factors such as lifetime operator experience influence this relationship. Objectives To assess the relationship between annual volumes and outcomes for PCI and determine whether lifetime operator experience modulates the association. Methods Annual PCI volumes for facilities and operators within the Veterans Affairs Healthcare System and their relationship with 30-day mortality following PCI were described. The influence of operator lifetime experience on the volume-outcome relationship was assessed. Hierarchical logistic regression was used to adjust for patient and procedural factors. Results 57,608 PCIs performed from 2013 to 2018 by 382 operators and 63 institutions were analyzed. Operator annualized PCI volume averaged 47.6 (standard deviation [SD] 49.1) and site annualized volume averaged 189.2 (SD 105.2). Median operator experience was 9.0 years (interquartile range [IQR] 4.0–15.0). There was no independent relationship between operator annual volume, institutional volume, or operator lifetime experience with 30-day mortality (p > 0.10). However, the interaction between operator volume and lifetime experience was associated with a marginal decrease in mortality (odds ratio [OR] 0.9998, 95% CI 0.9996–0.9999). Conclusions There were no significant associations between facility or operator-level procedural volume and 30-day mortality following PCI in a nationally integrated healthcare system. There was a marginal association between the interaction of operator lifetime experience, operator annual volume, and 30-day mortality that is unlikely to be clinically relevant, though does suggest an opportunity to explore novel factors that may influence the volume-outcome relationship.

Background The Affordable Care Act of 2010 extended health insurance through expansion of Medicaid and subsidies for commercial insurance. Prior work has produced differing results in associating expanded insurance with improvements in health care processes and outcomes. Evaluating specific mechanisms of care processes and their association with insurance expansion may help reconcile those results. Methods and results We used inpatient hospitalization data in the Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 1/1/2008 to 9/30/2015. We included all hospitalizations for acute myocardial infarction (AMI). As a primary outcome, we defined percent rate of AMI hospitalizations receiving percutaneous coronary intervention (PCI) per month. In the non-Medicare (intervention) group, there was a relative decrease of 0.2% of the monthly trend before and after expansion (95% CI [-0.3%, -0.1%]). In the Medicare group, there was a relative decrease of 0.1% of the monthly trend before and after expansion (95% CI [-0.2%, 0%]). Conclusions We did not detect a relative difference in PCI for AMI associated with insurance expansion under health reform.

Background Use of percutaneous mechanical circulatory support has grown exponentially. Vascular complications remain a growing concern and best practices for device removal do not exist. We describe a novel post-closure technique for the next generation Impella CP removal and immediate hemostasis . Methods This study is a single center, retrospective, exploratory analysis of 11 consecutive patients receiving an Impella CP for either high-risk PCI or cardiogenic shock and then referred for post-closure compared to 20 patients receiving manual compression for Impella CP removal between 2017 and 2019. Results Mean age range was 62.7–65.4 years and 50–65% male between groups. Average duration of Impella CP treatment ranged from 3.4 to 5.2 days. Patients referred for post-closure had significantly lower rates of all-cause adverse vascular events (0% versus 40%; n = 0/11 versus n = 8/20; p = 0.01). There was no significant difference in BARC 3 or greater bleeding, transfusion requirement, hospitalization duration or intensive care duration between removal strategies. Conclusion The novel post-closure technique may significantly reduce vascular complications associated with device removal and may improve clinical outcomes for these critically ill patients.

BACKGROUND High levels of inflammation pre- and post-percutaneous coronary intervention (PCI) are associated with worse outcomes. Recent trials have suggested a benefit from treating inflammation with colchicine in coronary artery disease. In this randomised pilot COPE-PCI sub-study, we aimed to determine if administration of colchicine pre-PCI, would attenuate the inflammatory effect of PCI. METHODS PCI patients were randomised to colchicine or placebo, 6 to 24-hours pre-procedure. Study blood samples were taken immediately pre-PCI, and 24-hours post-procedure. Samples were tested for a broad array of inflammatory biomarkers including high-sensitive(hs)-CRP, leucocyte counts, and hs-troponin-. Periprocedural Myocardial Injury (PM-Injury) was defined as per the ESC Third Universal Definitions of Myocardial Infarction. RESULTS Thirty-six were randomised to colchicine and 39 to placebo. Treatment groups were similar for baseline variables. The median time from drug administration to pre-PCI blood sampling was 18-hours. Overall inflammation was low across the patient population, pre- & post-PCI hsCRP was

Background: Patients with prior coronary artery bypass graft (CABG) surgery often require percutaneous coronary intervention (PCI). Data are still limited in regards to the outcomes of native saphenous vein graft (SVG) PCI after CABG. Methods: We performed a retrospective study in a tertiary reference cardiac center of consecutive patients who underwent PCI after CABG. The data were collected for patients who underwent either native or graft PCI from January 2008 to December 2018. Arterial graft PCIs were excluded. Multivariable Cox regression analysis with propensity matching was performed, and major adverse cardiac events (MACE) outcomes including death or myocardial infarction (MI) or revascularization were assessed at 1-year after each index procedure. Results: A total of 435 PCI were performed in 401 patients (209 had native PCI and 192 had graft PCI). Target lesions were classified as following: 235 (54%) native coronary arteries and 200 (46%) SVG. Propensity matching resulted in 167 matched pairs. In multivariable Cox regression graft PCI relative to native PCI was an independent risk factor for MACE (hazard ratio [HR] 1.725, 95% confidence interval [CI] 1.049–2.837) which was primarily driven by increased incidence in revascularization (HR 2.218, 95% CI 1.193–4.122) and MI (HR 2.248, 95% CI 1.220–4.142) and with no significant difference in mortality (HR 1.118, 95% CI 0.435–2.870). Conclusions: Compared with native coronary PCI, bypass graft PCI was significantly associated with higher incidence of MACE at 1-year and this was mainly driven by MI and revascularization.

Background/Aims: Rapid percutaneous coronary intervention (PCI) is the cornerstone of treatment for ST-elevation myocardial infarction (STEMI). However, there have been conflicting results regarding the differences in clinical outcomes between on-hours and off-hours presentation in STEMI patients. We aimed to examine the difference in long-term outcomes between off-hours and on-hours PCI in patients with STEMI.Methods: The characteristics and clinical outcomes of 5,364 STEMI patients between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry were analyzed. Patients were divided into two groups: the off-hours group (weekdays from 6:01 PM to 7:59 AM, weekends, and legal holidays) and the on-hours group (weekdays from 8:00 AM to 6:00 PM). Major adverse cardiac and cerebrovascular events (MACCEs) were defined as a composite of allcause mortality, non-fatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis. The primary endpoint was the occurrence of MACCEs, and all other clinical outcomes were analyzed.Results: A total of 3,119 patients (58.1%) underwent primary PCI due to STEMI during off-hours and 2,245 patients (41.9%) during on-hours. At 36 months, the clinical outcomes of the off-hours group were similar to those of the on-hours group in both the unadjusted and propensity score weighting-adjusted analyses.Conclusions: Our analysis revealed that the long-term outcomes in STEMI patients admitted to hospitals during off-hours were similar to outcomes of those admitted during on-hours.

Objective To compare vascular complications in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) using ultrasound guidance (USG) versus fluoroscopy guidance (FSG) for femoral access. Background In patients undergoing PCI, using the arterial femoral access increases the risk of vascular complications compared using the radial access. USG reduces time to access, number of attempts, and vascular complications compared with FSG, but the efficacy of USG has never been tested in the setting of CTO-PCI. Methods A total of 197 patients undergoing CTO-PCI using at least a femoral vascular access from November 2015 to September 2020 were screened. The primary outcome was a composite of local hematoma, pseudoaneurysm , retroperitoneal hemorrhage , arteriovenous fistula or hemoglobin drop ≥3 g/dL during hospitalization. The independent association between USG and the primary outcome of interest was explored. Results The primary outcome occurred in 17.3% of patients. Patients in the USG group had a significantly lower incidence of vascular complications compared with patients in the FSG group (8.5% vs. 21.0%, p = 0.039), driven by a reduction of localized hematomas (3.4% vs 13.0%, p = 0.042). After adjustment for type of CTO approach and heparin dose, USG was significantly associated with a reduced relative risk of the composite primary outcome (adjusted odds ratio 0.16, 95% confidence interval 0.05 to 0.51; p = 0.002). Conclusion USG in CTO-PCI is associated with a decreased risk of vascular complications, primarily driven by a reduction in local hematomas, especially in complex CTO-PCI where the larger use of heparin increases the risk of vascular complications.

Aim: The coronavirus disease 2019 (COVID-19) pandemic has left negative spillover effects on the entire health care system. Previous studies have suggested significant declines in cases of acute coronary syndrome (ACS) and primary percutaneous coronary intervention (PCI) during the COVID-19 pandemic. Methods: We performed a quasi-experimental, retrospective cohort study of ACS hospitalisations by using a multi-institutional administrative claims database in Japan. We used interrupted time series analyses to ascertain impacts on cases, treatment approaches, and in-hospital mortality before and after Japan’s state of emergency to respond to COVID-19. The primary outcome was the change in ACS cases per week. Results: A total of 30, 198 ACS cases (including 21, 612 acute myocardial infarction and 8, 586 unstable angina) were confirmed between 1st July 2018 and 30th June 2020. After the state of emergency, an immediate decrease was observed in ACS cases per week (-18.3%; 95% confidence interval, -13.1 to -23.5%). No significant differences were found in the severity of Killip classification (P=0.51) or cases of fibrinolytic therapy (P=0.74). The impact of the COVID-19 pandemic on in-hospital mortality in ACS patients was no longer observed after adjustment for clinical characteristics (adjusted odds ratio, 0.93; 95% confidence interval, 0.78 to 1.12; P=0.49). Conclusions: We demonstrated the characteristics and trends of ACS cases in a Japanese population by applying interrupted time series analyses. Our findings provide significant insights into the association between COVID-19 and decreases in ACS hospitalisations during the pandemic.

Optimal antiplatelet therapy after percutaneous coronary intervention (PCI) has been changed in parallel with the improvements of coronary stent and antiplatelet therapy. Over the past 25 years, dual antiplatelet therapy (DAPT) with aspirin plus P2Y12inhibitor has been the standard of care used after coronary stent implantation. First-generation drug-eluting stent (DES) appeared to increase the risk of late stent thrombosis, and duration of DAPT was prolonged to 12 months. DAPT duration up to 12 months was the dominant strategy after DES implantation in the subsequent >10 years, although there was no dedicated randomized controlled trial supporting this recommendation. The current recommendation of DAPT duration is getting shorter due to the development of new-generation DES, use of a P2Y12inhibitor as a monotherapy, and the increasing prevalence of high-bleeding risk patients. Furthermore, an aspirin-free strategy is now emerging as one of the novel strategies of antiplatelet therapy after PCI. This review gives an overview of the history of antiplatelet therapy and provides current and future perspectives on antiplatelet therapy after PCI.

Background: The appropriateness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions has rarely been investigated. Methods and Results: The Japanese CTO-PCI Expert Registry enrolled consecutive patients undergoing CTO-PCI carried out by highly experienced Japanese CTO specialists who performed more than 50 CTO-PCIs per year and 300 CTO-PCIs in total. This study included patients undergoing CTO-PCI between January 2014 and December 2019. The appropriateness, trends, and differences among the procedures performed by the operators using the 2017 appropriate use criteria were analyzed. Furthermore, we performed a logistic regression analysis to assess whether the appropriateness was associated with in-hospital major adverse cardiovascular and cerebrovascular events (MACCE). Of the 5, 062 patients who underwent CTO-PCI, 4, 309 (85.1%) patients who did not undergo the non-invasive stress test were classified as having no myocardial ischemia. Of the total cases, 3, 150 (62.2%) were rated as “may be appropriate, ” and 642 (12.7%) as “rarely appropriate” CTO-PCI cases. The sensitivity analyses showed that the number (%) of “may be appropriate” ranged from 4, 125 (57.8%) to 4, 744 (66.4%) and the number of “rarely appropriate” ranged from 843 (11.8%) to 970 (13.6%) among best and worst scenarios. Conclusions: In a large Japanese CTO-PCI registry, approximately 13% of CTO-PCI procedures were classified as “rarely appropriate”. Substantial efforts would be required to decrease the number of “rarely appropriate” CTO-PCI procedures.

Background: Periprocedural myocardial injury (PMI) is a frequent complication of percutaneous coronary intervention (PCI) associated with poor prognosis. However, no effective method has been found to identify patients at risk of PMI before the procedure. MicroRNA-133a (miR-133a) has been reported as a novel biomarker in various cardiovascular diseases. Herein, it was sought to determine whether circulating miR-133a could predict PMI before the procedure. Methods: Eighty patients with negative preoperative values of cardiac troponin T (cTnT) receiving elective PCI for stable coronary artery disease (CAD) were recruited. Venous serum samples were collected on admission and within 16–24 hours post-PCI for miRNA measurements. PMI was defined as a cTnT value above the 99% upper reference limit (URL) after the procedure. The association between miR-133a and PMI was further assessed. Results: Periprocedural myocardial injury occurred in 48 patients. The circulating level of miR-133a was significantly higher in patients with PMI before and after the procedure (both p < 0.001). Receiver operating characteristic curve analysis of the preoperative miR-133a level revealed an area under the curve (AUC) of 0.891, with a sensitivity of 93.8% and a specificity of 71.9% to predict PMI. Additionally, a decrease was found in fibroblast growth factor receptor 1 (FGFR1) in parallel with an increase in miR-133a levels in patients with PMI. Conclusions: This study demonstrates for the first time that serum miR-133a can be used as a novel biomarker for early identification of stable CAD patients at risk of PMI undergoing elective PCI. The miR-133a-FGFR1 axis may be involved in the pathogenesis of PMI.

BACKGROUND: Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) is superior to angiography-guided PCI. The clinical uptake of FFR has been limited, however, by the need to advance a wire in the coronary artery, the additional time required and the need for hyperaemic agents which can cause patient discomfort. FFR derived from routine coronary angiography eliminates these issues. AIMS: The aim of this study was to assess the diagnostic performance and accuracy of three-dimensional quantitative coronary angiography (3D-QCA)-based vessel FFR (vFFR) compared to pressure wire-based FFR (≤0.80). METHODS: The FAST II (Fast Assessment of STenosis severity) study was a prospective observational multicentre study designed to evaluate the diagnostic accuracy of vFFR compared to the reference standard (pressure wire-based FFR ≤0.80). A total of 334 patients from six centres were enrolled. Both site-determined and blinded independent core lab vFFR measurements were compared to FFR. RESULTS: The core lab vFFR was 0.83±0.09 and pressure wire-based FFR 0.83±0.08. A good correlation was found between core lab vFFR and pressure wire-based FFR (R=0.74; p

Background Coronary vascular function of a chronic coronary total occlusion (CTO) immediately after recanalization is known to be poor and to be partially improved by pre-treatment with loading dose of ticagrelor vs. clopidogrel . It is unknown if this vascular dysfunction is maintained at long-term follow-up and may be improved by 1-year dual antiplatelet therapy (DAPT). Methods The TIGER is a prospective, open-label, two parallel-group controlled clinical trial , which 1:1 randomized 50 CTO patients to pre-PCI loading dose and subsequent 1-year DAPT with ticagrelor vs. clopidogrel. Coronary blood flow (CBF) under stepwise adenosine infusion was assessed after drug loading dose and at follow-up and compared between the two drug groups, adjusting for time of follow-up. Results Out of 50 patients with index CBF evaluation, 38 (76%) patients underwent angiographic follow-up (23 and 15 at 1 and 3-year, respectively) and Doppler data was available in 35 (70%). A high CBF area under the curve (AUC), already observed after loading dose in ticagrelor vs. clopidogrel group (p = 0.027), was maintained at follow-up (AUC 34815.22 ± 24,206.06 vs. AUC 22712.47 ± 13,768.95; p = 0.071). Specifically, whereas high ticagrelor loading dose-related CBF was sustained at follow-up (p = 0.933), clopidogrel loading dose-related CBF increased at follow-up (p = 0.039). Conclusion The TIGER trial showed that DAPT with ticagrelor maintained a non-significantly higher CBF in a recanalized CTO as compared to clopidogrel, whose treated patients exhibit a lower CBF immediately after PCI with a significant increase at follow-up. The clinical value of such sustained high coronary flow should be evaluated in a larger group of patients. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02211066 (ClinicalTrials.gov number NCT02211066 ).

Coronavirus disease-2019 (COVID-19) has a profound impact on the health care system worldwide. In the COVID-19 pandemic, hospitals are required to halt elective surgeries and procedures for preventing nosocomial infections and saving medical resources. In these situations, emergency procedures are required for life-threatening cardiovascular diseases such as acute coronary syndrome and cardiogenic shock. To prevent the spread of COVID-19, a social distance is essentially required. In ordinary percutaneous coronary intervention (PCI), operators manipulate the devices standing at the patient's tableside during the whole procedure, which may involve a certain risk of exposure to patients with COVID-19. A robotic-assisted PCI (R-PCI) allows operators to manipulate devices remotely, sitting at a cockpit located several meters away from the patient, and in addition, the assistant can be at the foot of the bed, much further from the access site. R-PCI can help to minimize the radiation exposure and the amount of person-to-person contact, and consequently may reduce the risk for the exposure to the virus., Graphical abstract Image, graphical abstract

Aims The ESC/EACTS myocardial revascularization guidelines recently standardized the definition of patients at high ischemic risk (HIR). However, the ability of ESC/EACTS-HIR criteria to stratify ischemic and bleeding risk in a contemporary real-world East Asian cohort remains unexplored. Methods A total of 10,167 consecutive patients undergoing PCI from prospective Fuwai PCI Registry (January 2013 to December 2013) were reviewed. ESC/EACTS-HIR features was defined as having at least one of the eight clinical and angiographic characteristics. The primary ischemic endpoint was target vessel failure (cardiac death, target vessel myocardial infarction [MI], or target vessel revascularization [TVR]); bleeding outcome was assessed using the BARC type 2, 3, or 5 bleeding. Median follow-up was 29 months. Results Compared with non-HIR patients, HIR patients (n=5,149, 50.6%) were associated with increased risk for target vessel failure (adjusted hazard ratio [HRadjust]: 1.48 [1.25-1.74]) and patient-oriented composite outcome (HRadjust: 1.44 [1.28-1.63]), as well as cardiac death, MI, and TVR. By contrast, the risk of clinically relevant bleeding was not significantly different between the two groups. (HRadjust: 0.84 [0.66-1.06]). Greater than or equal to three implanted stents and diabetic patients with diffuse multivessel coronary disease emerged as independent predictors for long-term adverse outcomes. There was no significant interaction between high bleeding risk (HBR) status and clinical outcomes associated with ESC/EACTS-HIR criteria (all Pinteraction ＞0.05). Conclusion The ESC/EACTS-HIR features identified patients at increased risk of thrombotic events, including cardiac death, but not for clinically relevant bleeding. Importantly, HBR did not modify cardiovascular risk subsequent to patients with ESC/EACTS-HIR features, suggesting its potential clinical applicability in tailoring antithrombotic therapy.

Thoracic endovascular aortic repair (TEVAR) has been increasingly used to treat complex thoracic aortic pathology. In the present study, we assessed the hospital volume's effects on the outcomes of patients who had undergone TEVAR.Patients who had undergone TEVAR from January 2015 to December 2019 were identified from the Vascular Quality Initiative database. The participating centers were stratified by volume as low-volume hospitals (LVHs) and high-volume hospitals (HVHs). We assessed the effects of hospital volume on 30-day mortality and major postoperative complications using multivariable logistic regression analysis.A total of 3584 TEVAR patients (1720 asymptomatic and 1864 symptomatic or ruptured) were identified at 147 centers. The median average annual number of TEVAR cases at the LVHs and HVHs was 6 and 17 cases, respectively. No significant differences were found in 30-day mortality between the LVHs and HVHs (asymptomatic, 3.7% vs 3.7% [P = .98]; symptomatic or ruptured, 9.3% vs 7.3% [P = .13]). After adjusting for multiple clinical and anatomic factors, treatment at a LVH was not associated with increased 30-day mortality (asymptomatic: odds ratio, 0.98; 95% confidence interval, 0.52-1.87; P = .96; symptomatic or ruptured: odds ratio, 1.15; 95% confidence interval, 0.75-1.77; P = .53) nor an increased risk of major complications, including renal, neurologic, cardiac, pulmonary, and femoral artery access complications (P.05 for all).Using a large national database, we have demonstrated that treatment at LVHs is not associated with inferior TEVAR outcomes compared with HVHs. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences.

Background Cardiac rupture (CR) is a catastrophic complication of acute myocardial infarction. Primary percutaneous coronary intervention (pPCI) reduces the incidence of CR. This study aimed to investigate the clinical risk factors and characteristics of CR after pPCI. Methods This was a retrospective, case-control, multicenter study. We enrolled 2444 consecutive patients with ST-elevation myocardial infarction (STEMI) who had undergone pPCI between 2009 and 2015; 33 patients experienced CR (1.35%): 19 were assigned as early CR (≤72 h) and 14 as late CR (>72 h). The 132 controls were randomly selected from the 2411 STEMI patients without CR, by matching institutions at a 1:4 ratio. Results : Multivariate logistic regression revealed that female sex, acute hyperglycemia, thrombocytopenia (platelets 1, and post-PCI TIMI 1 and thrombocytopenia were strongly associated with late CR. Early CR occurred more frequently between 12:00 and 21:00 h, whereas the peak incidence of late CR was bimodal between 6:00–12:00 and 21:00–24:00 h. Conclusions In STEMI patients after pPCI, acute hyperglycemia and thrombocytopenia are new risk factors for early and late CR, respectively. Clinical risk factors and time of occurrence of early and late CR may differ in the PCI era.

Aims This study sought to investigate patient and operator radiation dose in patients undergoing percutaneous coronary intervention (PCI) and the impact of body mass index (BMI) on patient and operator dose. Methods In patients undergoing PCI, radiation dose parameters, baseline characteristics and procedural data were collected in a tertiary centre for 3.5 years. Operators wore real time dosimeters. Patients were grouped by BMI. Dose area product (DAP) and operator radiation dose were compared across patient BMI categories. Multivariable analysis was performed to investigate the impact of patient BMI and other procedural variables on patient and operator dose. Results 2,043 patients underwent 2,197 PCI procedures. Each five-unit increase in BMI increased patient dose (expressed as DAP) by an average 31% (95% CI: 29–33%) and operator dose by 27% (95% CI: 20–33%). Patient dose was 2.3 times higher and operator dose was 2.4 times higher in patients with a BMI>40 than for normal BMI patients. Multivariable analysis indicated that there were many procedural factors that were predictors for increasing operator dose and patient dose but that patient BMI was a major contributor for both operator dose and patient dose. Conclusion Increasing BMI increases the DAP and operator dose for PCI procedures and BMI is demonstrated to be a major factor that contributes to both patient and operator radiation dose.

Problem definition: Among the most vexing issues in the U.S. healthcare ecosystem is inappropriate use of percutaneous coronary intervention (PCI) procedures, also known as overstenting. A key driver of overstenting is physician subjectivity in eyeballing a coronary angiogram. Advanced tests such as fractional flow reserve (FFR) provide more precise and objective measures of PCI appropriateness, yet the decision to perform these tests is endogenous and not immune to clinical ambiguity associated with eyeballing. Additionally, conflicts of interest, arising from revenue-generating incentives, play a role in overstenting. Academic/practical relevance: Conventional wisdom suggests more precise diagnostic testing will help reduce overtreatment. However, the literature rarely recognizes that the testing decision is itself endogenous. Our research highlights the role of endogeneity surrounding interventional cardiology decision making. Methodology: This study uses stochastic modeling and simulation. Results: Under a low conflict-of-interest level, the physician performs the advanced test for intermediate lesions. Under a high conflict-of-interest level, however, the physician would perform the advanced test only for high-grade lesions, because of a financial disincentive: Performing the advanced test may lower PCI revenue if the test results argue against the procedure. Surprisingly, despite this disincentive, a more revenue-driven physician can be more inclined to perform the advanced test. Managerial implications: Our model leads to implications for various efforts aimed at tackling overstenting: (1) Attention should be paid not only to the sheer quantity of FFR procedures but to which patients receive FFR procedures; (2) reducing the risk of the advanced test has a behavior-inducing effect, yet a modest risk reduction may lower patient welfare; and (3) offering a bonus to the physician for performing FFR procedures equal to a third of its reimbursement rate will cause only a 5% increase in average physician payment while inducing a 26% decline in overstenting. In addition, we show implementing a bundled payment scheme may discourage the use of FFR procedures and lead to more salient overstenting.

The treatment of chronic total coronary occlusions (CTO) carries the highest radiation exposure among percutaneous coronary interventions (PCI). In order to minimize radiation damage, we need to understand and optimize the contribution of all components of radiation exposure.A total of 1000 CTO procedures performed between 2011 and 2020 were compared according to implemented radiation modifications. Group 1 used the original set-up of the X-ray equipment (Artis Zee, Siemens). In group 2 a modified protocol aimed at reducing the fluoroscopy exposure, in group 3 further modifications aimed at reducing cineangiographic exposure.Despite an increased lesion complexity, Air Kerma (AK) was reduced from 2619 mGy (1653-4574) in group 1 to 2178 mGy (1332-3500; p0.001) in group 2 by mainly reducing fluoroscopic contribution by 54.1%, the cineangiographic contribution was lowered by only 6.6%. In group 3 AK dropped drastically to 746 mGy (480-1225; p0.001) mainly by reducing the cineangiographic contribution by 53.4%, still there was a further reduction of fluoroscopy contribution of 8.2%. This also led to a reduction of the skin entry dose from 1038 mGy (690-1589) in group 2 to 359 mGy (204-591; p0.001) in group 3. This was achieved both in normal weight and obese patients, and both in antegrade and retrograde procedures.The present study demonstrates that by modifying both the fluoroscopic and cineangiographic contribution to radiation exposure a drastic reduction of radiation risk can be achieved, even in obese patients. Currently accepted radiation thresholds may no longer be a limit for CTO PCI.

BACKGROUND: Absorb bioresorbable vascular scaffold (BVS)-related events have been reported between 1 and 3 years - the period of active scaffold bioresorption. Data on the performance of the Absorb BVS in daily clinical practice beyond this time point are scarce. AIMS: This report aimed to provide the final five-year clinical follow-up of the Absorb BVS in comparison with the XIENCE everolimus-eluting stent (EES). In addition, we evaluated the effect of prolonged dual antiplatelet therapy (DAPT) administration on events in the scaffold group. METHODS: AIDA was a multicentre, investigator-initiated, non-inferiority trial, in which 1,845 unselected patients with coronary artery disease were randomly assigned to either the Absorb BVS (n=924) or the XIENCE EES (n=921). Target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction or target vessel revascularisation, was the primary endpoint. Scaffold thrombosis cases were matched with controls and tested for the effect of prolonged DAPT. RESULTS: Up to five-year follow-up, there was no difference in TVF between the Absorb BVS (17.7%) and the XIENCE EES (16.1%) (hazard ratio [HR] 1.31, 95% confidence interval [CI]: 0.90-1.41; p=0.302). Definite or probable device thrombosis (DT) occurred in 43 patients (4.8%) in the scaffold group compared to 13 patients (1.5%) in the stent group (HR 3.32, 95% CI: 1.78-6.17; p

BACKGROUND: With the improvements of percutaneous coronary intervention (PCI) technology and post-PCI patient management, several registry studies reported temporal trends in post-PCI clinical outcomes. However, their results are inconclusive, potentially reflecting region-specific trends, based on site-reported events without external validity. AIMS: This study aimed to investigate temporal trends in post-PCI clinical outcomes in all-comers randomised controlled trials (RCTs) involving coronary stents. METHODS: We performed a systematic review identifying RCTs comparing a clinical outcome as a primary endpoint among different coronary stents with an all-comers design and independent clinical event adjudication, extracting the study start year, patient baseline characteristics, and one- and five-year clinical outcomes. Temporal trends in clinical outcomes (cardiac death, myocardial infarction [MI], target lesion revascularisation [TLR], stent thrombosis [ST]) were assessed using random-effects meta-regression analyses, estimating the relationship between clinical outcomes and study start year. RESULTS: Overall, 25 all-comers trials (51 device arms, 66,327 patients) conducted between 2003 and 2018 fulfilled the eligibility criteria. Random-effects meta-regression analysis revealed significant decreasing trends in one- and five-year cardiac death, one-year TLR, and five-year ST incidences (relative risk per 10-year increase: 0.69 [0.51-0.92], 0.66 [0.44-0.98], 0.60 [0.41-0.88], and 0.18 [0.07-0.44], respectively). There was no significant trend in myocardial infarction incidences. CONCLUSIONS: This is the first attempt to clarify and quantify the temporal trends of post-PCI outcome incidence. The 15-year improvements in PCI therapy and post-therapeutic patient management are associated with reduced incidences of cardiac death and PCI-related adverse events.

Background Cardiovascular procedural volumes can serve as metrics of hospital infrastructure and quality, and are the basis for thresholds for initiating transcatheter mitral valve repair (TMVr) programs. Whether hospital volumes of TMVr, surgical mitral valve replacement or repair (SMVRr), and percutaneous coronary intervention (PCI) are indicators of TMVr quality of care is not known. Methods We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TMVr procedures. Hospitals were divided into quartiles of TMVr volume. Associations of hospital TMVr, SMVRr, and PCI volumes, as well as SMVRr and PCI outcomes with TMVr outcomes were examined. Outcomes studied were risk-standardized in-hospital mortality rate (RSMR) and 30-day readmission rate (RSRR). Results The study included 3404 TMVr procedures performed across 150 hospitals in the US. The median hospital TMVr volume was 17 (IQR 10, 28). The mean hospital-level RSMR and RSRR for TMVr were 3.0% (95% CI 2.5%, 3.4%) and 14.8% (95% CI 14.5%, 15.0%), respectively. There was no significant association between hospital TMVr volume (as quartiles or as a continuous variable) and TMVr RSMR or RSRR (P > 0.05). Similarly, there was weak or no correlation between hospital SMVRr and PCI volumes and outcomes with TMVr RSMR or RSRR (Pearson correlation coefficients, r = −0.199 to 0.269). Conclusion In this study, we found no relationship between hospital TMVr, SMVRr, and PCI volume and TMVr outcomes. Further studies are needed to determine more appropriate structure and process measures to assess the performance of established and new TMVr centers.

Perfusion collateral index (PCI) has been recently defined as a promising measure of collateral status. We sought to compare collateral status assessed via CT-PCI in comparison to single-phase CTA and their relationship to outcome measures including final infarction volume, final recanalization status and functional outcome in ELVO patients.ELVO patients with anterior circulation large vessel occlusion who had baseline CTA and CT perfusion and underwent endovascular treatment were included. Collateral status was assessed on CTA. PCI from CT perfusion was calculated in each patient and an optimal threshold to separate good vs insufficient collaterals was identified using DSA as reference. The collateral status determined by CTA and PCI were assessed against 3 measured outcomes: 1) final infarction volume; 2) final recanalization status defined by TICI scores; 3) functional outcome measured by 90-day mRS.A total of 53 patients met inclusion criteria. Excellent recanalization defined by TICI ≥2C was achieved in 36 (68%) patients and 23 patients (43%) had good functional outcome (mRS ≤2). While having good collaterals on both CTA and CTP-PCI was associated with significantly (p0.05) smaller final infarction volume, only good collaterals status determined by CTP-PCI was associated with achieving excellent recanalization (p = 0.001) and good functional outcome (p = 0.003).CTP-based PCI outperforms CTA collateral scores in determination of excellent recanalization and good functional outcome and may be a promising imaging marker of collateral status in patients with delayed presentation of AIS.

Introduction: Trials investigating aspirin omission in patients taking oral anticoagulation (OAC) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) were not powered to assess rates of major bleeding or ischemic events.Methods: We performed an updated meta-analysis and network analysis of randomized trials comparing treatment with or without aspirin in patients taking OAC and a P2Y12-inhibitor after PCI or ACS. The primary outcome was TIMI major bleeding.Results: Five trials enrolling 11,542 patients allocated to antithrombotic regimens omitting (n = 5795) or including aspirin (n = 5747) were included. Aspirin omission was associated with a lower risk of TIMI major bleeding (RR = 0.56, 95% CI [0.44-0.71]; P < 0.001) but a trend towards a higher risk of MI (RR = 1.21, 95% CI [0.99-1.47]; P = 0.06), which was significantly higher when only non-vitamin K antagonist OAC (NOAC)-based trials were considered (Pinteraction = 0.02). The risk of stent thrombosis was comparable with both strategies (RR = 1.29, 95% CI [0.87-1.90]; P = 0.20), with a trend towards a higher risk of ST with aspirin omission when only NOAC-based trials were considered (Pinteraction = 0.06). Risks of stroke and death were similar with both strategies. Network meta-analysis ranked dabigatran (low dose) without aspirin as the best strategy for bleeding reduction (P-score = 0.86) and apixaban with aspirin as the best strategy for MI reduction (P-score = 0.66).Conclusions: In patients taking OAC after PCI or ACS, aspirin omission is associated with a lower risk of TIMI major bleeding, with a numerically increased risk of MI, which is statistically significant when only NOAC-based trials are considered. This supports individualization of the treatment regimen based on patient risk.

Aims Previous studies suggested that implantation with a 1st-generation DES was associated with coronary endothelial dysfunction, which was associated with Rho-kinase activation. Second-generation drug-eluting stents (DESs) may preserve coronary endothelial function in stented coronary arteries; however, because of methodological limitations, further study is needed to clarify the association between 2nd-generation DESs and coronary endothelial dysfunction. Methods We retrospectively analysed the CuVIC trial database, where we identified 112 patients who underwent coronary stenting in the left coronary arteries with either a bare metal stent (BMS, n=53) or 2nd-generation DES (n=59). We compared vasomotions of target vessels with stents and non-target vessels without stents. Furthermore, we measured the Rho-kinase activation detected in mononucleocytes from aortic and coronary sinus blood. Results ACh-induced vasoconstrictive responses of target vessels were not enhanced with a 2nd-generation DES (45±21% vs. 44±20%, P=0.56, paired t-test), but significantly enhanced in the coronary arteries with a BMS (50±18% vs. 42±20%, P=0.002). Rho-kinase activation did not differ between patients with a BMS and 2nd-generation DES. In the target vessels with a BMS, large late lumen loss and acute coronary syndrome (ACS) at the index percutaneous coronary intervention (PCI) were associated with ACh-induced enhanced coronary vasoconstrictive responses. Conclusions Evaluation of ACh-induced vasomotion of target vessels comparing with non-target vessels revealed that 2nd-generation DESs were not associated with coronary endothelial dysfunction in target vessels, nor activation of Rho-kinase in the coronary sinus blood 6-8 months after stenting.

Background : Cardiogenic shock (CS) is the leading cause of the death in patients with ST elevation myocardial infarction (STEMI). Thyroid dysfunction is related to prognosis of patients with myocardial infarction. Hence, the aim of this study is to explore the relationship between thyroid hormones (free triiodothyronine [FT3] and free thyroxine [FT4]) and CS. Method : A total of 1270 patients with STEMI treated with percutaneous coronary intervention (PCI) were consecutively enrolled in our study. Patients were classified into two groups according to with or without CS during hospitalization. Stepwise multivariate logistic analysis was conducted to investigate the association of thyroid hormones and CS. Restricted cubic spline method was employed to further explore relationship between CS and thyroid hormones. Results : Patients who developed CS (n=103) had lower FT3 and higher FT4 on admission. The stepwise logistic analysis showed both FT3 (P=0.038) and FT4 (P=0.024) were independently related to CS. Restricted cubic splines indicated that lower FT3 ( 1.25 ng/dl) was correlated with higher prevalence of CS. Over 2.5 years’ follow-up, patients (n=294) with low FT3 ( =0.88 ng/dl) had the highest all-cause mortality (18.2%), whereas patients (n=293) with high FT3 and low FT4 had the lowest all-cause mortality (3.8%) (P for trend Conclusions : Both FT3 and FT4 are independently associated with in-hospital CS development in patients with STEMI treated with PCI. Patients with lower range of FT3 and upper range of FT4 had the worst outcomes in a long-term follow-up.

SUMMARY This is a report of one of the many imposters of an irreducible inguinal hernia, a dermoid cyst. It is a rare entity that should be considered in the differential diagnosis of a groin lump when an atypical clinical presentation or groin examination occurs. Complete excision with histological evaluation remains the mainstay of surgical treatment. Keywords: dermoid cyst, inguinal hernia, inguinal canal, incarcerated, hernia surgery

BACKGROUND: Quantitative flow ratio (QFR) is a novel angiography-based physiological index for fast computation of fractional flow reserve without the use of a pressure wire or induction of hyperaemia. AIMS: We sought to investigate the prevalence and prognostic implications of achieving physiology-consistent percutaneous coronary intervention (PCI) according to the baseline angiographic QFR in an all-comers cohort. METHODS: QFR was retrospectively analysed from the angiograms of 1,391 patients enrolled in the randomised PANDA III trial. Patients in whom all functionally ischaemic vessels (baseline QFR ≤0.80) were treated and in whom all non-ischaemic vessels (baseline QFR>0.80) were deferred were termed as having had QFR-consistent treatment; otherwise, they were termed as having had QFR-inconsistent treatment. The major outcome was two-year major adverse cardiac events (MACE; a composite of all-cause death, all myocardial infarction (MI), or any ischaemia-driven revascularisation). RESULTS: Overall, 814 (58.5%) patients had QFR-consistent PCI, while 577 (41.5%) patients received QFR-inconsistent PCI. Patients with QFR-consistent versus those with QFR-inconsistent treatment had a lower risk of two-year MACE (8.4% vs 14.7%; hazard ratio [HR] 0.56, 95% confidence interval [CI]: 0.41-0.78). After adjusting for differences in baseline covariates, two-year rates of MACE remained significantly lower in the QFR-consistent group (8.8% vs 13.6%; adjusted HR 0.64, 95% CI: 0.44-0.93), due mainly to reduced ischaemia-driven revascularisation (2.9% vs 8.0%; adjusted HR 0.35, 95% CI: 0.20-0.60). CONCLUSIONS: In this post hoc analysis of an all-comers PCI trial, approximately 60% of patients were treated in accordance with what the QFR measurement would have recommended, the achievement of which was associated with improved two-year clinical outcomes. ClinicalTrials.gov identifier: NCT02017275

Background Gastrointestinal (GI) leaks after cytoreductive surgery and hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) is a known life-threatening complication that may alter patients’ outcomes. Our aim is to investigate risk factors associated with GI leaks and evaluate the impact of GI leaks on patient’s oncological outcomes. Methods A retrospective analysis of perioperative and oncological outcomes of patients with and without GI leaks after CRS/HIPEC. Results Out of 191 patients included in this study, GI leaks were identified in 17.8% (34/191) of patients. Small bowel anastomoses were the most common site (44%). Most of the GI leaks were managed conservatively and re-operation was needed in 44.1% of cases. Univariate analysis identified higher PCI (p = 0.03), higher number of packed cells transfused (p = 0.036), pelvic peritonectomy (p = 0.013), high number of anastomoses (p = 0.003) and colonic resection (p = 0.042) as factors associated with GI leaks. Multivariate analysis identified stapled anastomoses (OR 2.59, p = 0.001) and pelvic peritonectomy (OR 2.33, p = 0.044) as independent factors associated with GI leaks. Disease-free survival tended to be worse in the leak group but did not reach statistical significance (p = 0.235). The 3- and 5-year OS was 73.2% and 52.9% in the leak group compared to 75.8% and 73.2% in the non-leak group (p = 0.236). Conclusions GI leak showed no impact on overall and disease free survival after CRS/HIPEC.Avoidance of stapled reconstruction in high risk patients with high tumor burden and large number of anastomoses may yield improved outcomes.

Background The literature on outcomes of ST-elevation myocardial infarction (STEMI) amongst kidney transplant recipients (KTR) is limited. Objective To study the outcomes of STEMI among KTR. Methods Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA were analyzed for hospitalizations with STEMI among KTR for the years 2012-2018. Complications associated with STEMI were extracted using International Classification of Diseases codes. Results A total of 588,668 index KTR hospitalizations (mean age 57.67±14.22 years; female 44.5%) of which 3,496 (0.59%) had STEMI were recorded in the NRD for the years 2012-2018. A total of 11,676 (1.98%) patients died during the hospitalization. In-hospital mortality among STEMI was higher, 465 (13.3%), than without-STEMI 11,211 (1.92%). Among the complications, mechanical complications occurred among 1.0% vs 0.02%, cardiogenic shock 10.6 vs 0.3%, ventricular arrythmias 8.3% vs 0.8%, conduction block 6.9% vs 2%, stroke 4.1% vs 1.9%, and acute kidney injury 31.6% vs 28.3% among STEMI and without-STEMI respectively. Among coronary procedures, coronary angiography was performed among 1,999 (57.2%) of which 1,777 (50.8%) had percutaneous coronary intervention (PCI). On coarsened exact matching of baseline characteristics, PCI was less likely associated with mortality, odds ratio 0.39 (95% confidence interval 0.24-0.64; p=0.0002). The trends of mortality among STEMI were steady (p-trend 0.11). PCI trend increased (p-trend 0.008) and incidence of STEMI decreased over the study years 2012 (0.66%)-2018(0.474%). A total of 84,810 (14.4%) patients were readmitted in 30 days of which 696 (20%) patients were among the STEMI subgroup. Conclusion STEMI is not an uncommon complication among KTR and is associated with significant mechanical complications. Improvement in cardiovascular risk factors might improve the STEMI rates among KTR.

A 60-year-old man developed acute myocardial infarction from the total occlusion of the right coronary artery via metastatic squamous lung cancer and was treated with percutaneous coronary intervention (PCI). Computed tomography and transthoracic echocardiography (TTE) revealed a metastatic tumor, and three-dimensional TTE was useful for determining the size and location of the tumor in relation to the coronary artery. Six months after PCI, the patient died, and an autopsy confirmed extensive metastasis to the heart and nearby vessels as detected by three-dimensional TTE. Although rare, lung cancer metastasis to the heart may directly occlude the coronary artery.

Background The Scoreflex NC scoring angioplasty catheter is designed with a short rapid-exchange tip distal to a non-compliant, high-pressure balloon and an integral wire outside of the balloon, such that the guidewire and the integral wire act as scoring elements during balloon inflation. The external scoring elements enable a focal stress pattern facilitating expansion of resistant lesions at lower pressures using a focused force angioplasty effect. Methods Patients undergoing elective percutaneous coronary intervention (PCI) were enrolled in a prospective, single-arm study conducted at 12 centers in the United States. The primary endpoint was device procedural success, defined as the composite of successful device delivery to the target lesion with balloon inflation and deflation; absence of vessel perforation, flow-limiting dissection or reduction in TIMI flow from baseline; and achievement of final TIMI 3 flow. Results Among 200 patients (234 lesions), lesion complexities included: bifurcation disease (37.6%), moderate/severe calcification (36.6%), and total occlusions (5.0%). Successful delivery to the target lesion, inflation and removal of the balloon catheter was achieved in 95.5% of patients (191/200). Procedural success was achieved in 93.5% (187/200) of patients, and final TIMI 3 flow was observed in 99.0% of cases (198/200). No unanticipated device-related events occurred. In-hospital major adverse events were reported in 4.5% of patients (9/200), related to periprocedural myocardial infarction (8/200, 4.0%) and target lesion revascularization (1/200, 0.5%). Conclusions Among patients undergoing elective PCI and with varied lesion complexity, these results support the safety and effectiveness of a dilation strategy using the Scoreflex NC scoring catheter.

Background The use of drug-coated balloons (DCBs) in small-vessel coronary artery disease (SVD) remains controversial. Methods We performed a meta-analysis of all randomized controlled trials (RCTs) reporting the outcomes of DCB vs. DES in de-novo SVD. We included a total of 5 RCTs (1459 patients), with (DCB n = 734 and DES n = 725). Results Over a median follow-up duration of 6 months, DCB was associated with a smaller late lumen loss (LLL) compared with DES (mean difference − 0.12 mm (95% confidence interval (CI) [−0.21, −0.03 mm], p = 0.01). Over a median follow-up of 12 months, both modalities had a similar risk of major adverse cardiovascular events (MACE) (8.7% vs. 10.2%; odds ratio (OR): 0.94, 95% CI [0.49–1.79], p = 084), all-cause mortality (1.17% vs. 2.38%; OR: 0.53, 95% CI [0.16–1.75], p = 0.30), target lesion revascularization (TLR) (7.9% vs. 3.9%; OR: 1.26, 95% CI [0.51–3.14], p = 0.62), and target vessel revascularization (TVR) (8.2% vs. 7.8%; OR: 1.06, 95% CI [0.40–2.82], p = 0.91). DCBs were associated with a lower risk of myocardial infarction (MI) compared with DES (1.55% vs. 3.31%; OR: 0.48, 95% CI [0.23–1.00], p = 0.05, I2 = 0%). Conclusion PCI of SVD with DCBs is associated with a smaller LLL, a lower risk of MI, and a similar risk of MACE, death, TLR, and TVR compared with DES over one year. DCB appears as an attractive alternative to DES in patients with de-novo SVD, but long-term clinical data beyond are still needed.