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BackgroundImpact of commissural alignment (CA) strategies with self-expandable supra-annular transcatheter aortic valves (TAVR) has not been investigated yet.MethodsMulticentric ambispective study including patients who underwent self-expandable TAVR in 7 centers with the Evolut Pro/Pro+ (EP)(Medtronic, USA) and Acurate neo2 (AN2)(Boston Scientific, USA). Comparison of those with CA attempt vs. those with no CA attempt was performed. The degree of commissural misalignment (CMA) was assessed by computed tomography/angiography and 1-year transvalvular gradients/regurgitation evaluated by echocardiography. A matched comparison according to annular dimensions/eccentricity, prosthesis size/type, and baseline left ventricular function and gradients was performed.ResultsA total of 557 patients, mean age 80.7±6.6 years, 61.4% men, and STS score of 4.3±3.1% were analyzed. A CA technique was attempted in 215 patients (38.6%), including 113 patients with AN2 and 102 patients with EP. None/mild CMA was found in 158 (73.5% vs. 43.6% if no CA attempted, pConclusionsThe use of CA strategies significantly reduced the rate of CMA for the self-expandable TAVR devices ACN2 and EP which was associated to lower transvalvular gradients and intra-prosthetic regurgitation progression at 1-year although no criteria of structural deterioration were met at this follow up.Clinicaltrials.org:NCT05097183CONDENSED ABSTRACTCommissural alignment (CA) strategies with Evolut Pro and Acurate neo2 TAVR devices were similarly successful in ¾ of the patients, representing a significant increase compared to traditional implantation. Patients with moderate/severe commissural misalignment (CMA) had a significantly greater progression of both peak and mean gradients and higher rate of new central aortic regurgitation at 1-year, but not a greater proportion of patients with mean gradient above 10mmHg. Hence, even at only 1-year of follow up and despite the lack of formal structural deterioration criteria, some hints suggest a more rapid deterioration if moderate/severe CMA is present after supra-annular TAVR.

It is unknown whether the availability of long drug-eluting stents modify the PCI strategy of long CTO. To describe the contemporary PCI strategy of long chronic total occlusions (CTO) using overlapping (OS) or single long stents (SS) and to analyze its results.2842 consecutive CTO PCIs were included. T hose with an occlusion length ≥20 mm in which ≥ 1 DES was implanted were analyzed. We compared procedural characteristics and clinical outcomes of CTO treated with OS or SS.1088 CTO PCIs were analyzed (79.9% males; 64.7±10.6 years). Mean J-score was 2.8 ± 0.9. A SS was used in 38.5% of cases and OS in 61.5%. Total stent length was 64.1±29.9 mm; it was higher in the OS group (OS:79.9±25.5 mm vs SS:38.3±14.7 mm; p0.0001). Mean number of stents in the OS group was 2.3±1. Very long stents (≥40 mm) were used in 27.4% of cases, more frequently in the OS group (OS:32.4% vs SS:19.3%; p0.0001). After a mean follow-up of 19±15.9 months, the rate of adverse events (MACE) was 2% (cardiac death:1.6%, myocardial infarction:1.6%, target lesion revascularization:1.9% and stent thrombosis: 0.18%) with no significant differences between both groups. Overlapping was not an independent predictor of MACE.In long CTO PCIs, OS is more frequently used than single stenting, especially in more complex procedures. Clinical outcomes at a mid-term follow-up are favorable. Using newer generation DES, overlapping was not an independent predictor of MACE, however a trend toward a higher event rate was observed in the OS group.

Aim Patients with diabetes mellitus are at high risk of adverse events after percutaneous revascularization, with no differences in outcomes between most contemporary drug-eluting stents. The Cre8 EVO stent releases a formulation of sirolimus with an amphiphilic carrier from laser-dug wells, and has shown clinical benefits in diabetes. We aimed to compare Cre8 EVO stents to Resolute Onyx stents (a contemporary polymer-based zotarolimus-eluting stent) in patients with diabetes. Methods and results We did an investigator-initiated, randomized, controlled, assessor-blinded trial at 23 sites in Spain. Eligible patients had diabetes and required percutaneous coronary intervention. A total of 1175 patients were randomly assigned (1:1) to receive Cre8 EVO or Resolute Onyx stents. The primary endpoint was target-lesion failure, defined as a composite of cardiac death, target-vessel myocardial infarction, and clinically indicated target-lesion revascularization at 1-year follow-up. The trial had a non-inferiority design with a 4% margin for the primary endpoint. A superiority analysis was planned if non-inferiority was confirmed. There were 106 primary events, 42 (7.2%) in the Cre8 EVO group and 64 (10.9%) in the Resolute Onyx group [hazard ratio (HR): 0.65, 95% confidence interval (CI): 0.44–0.96; P non-inferiority < 0.001; P superiority = 0.030]. Among the secondary endpoints, Cre8 EVO stents had significantly lower rate than Resolute Onyx stents of target-vessel failure (7.5% vs. 11.1%, HR: 0.67, 95% CI: 0.46–0.99; P = 0.042). Probable or definite stent thrombosis and all-cause death were not significantly different between groups. Conclusion In patients with diabetes, Cre8 EVO stents were non-inferior to Resolute Onyx stents with regard to target-lesion failure composite outcome. An exploratory analysis for superiority at 1 year suggests that the Cre8 EVO stents might be superior to Resolute Onyx stents with regard to the same outcome. Clinical trial registration ClinicalTrials.gov: NCT03321032.

AIM: To investigate key aspects of the problem of myocardial revascularization failure (MRF) and repeat or secondary myocardial revascularization (SR) in contemporary practice.; METHODS: The registry of secondary revascularization (REVASEC) is an investigator-initiated, multicenter, prospective registry enhanced with data monitoring and independent event adjudication (ClinicalTrials.govNCT03349385). It includes patients with prior revascularization referred to coronary angiography for suspected MRF with broad inclusion criteria. The main objectives are to describe the characteristics of patients with prior revascularization referred for repeat angiography, to describe and the rate and mechanisms of MRF (stent or graft failure, coronary artery disease progression or residual coronary artery disease); to evaluate the management including medical treatment and SR of these patients; and to assess the prognosis according to the outlined causative mechanisms. The registry has one year follow up for the primary endpoint (Patient-oriented composite endpoint including all-cause death, any myocardial infarction or any new unplanned revascularization according to subsets of MRF), but extended follow-up will be carried out up to 5years.; CONCLUSION: The REVASEC Registry will provide updated data on the characteristics, patterns of treatment, and 1-year outcomes of patients with MRF and SR in contemporary clinical practice. Copyright © 2021. Published by Elsevier Inc.

Fractional flow reserve (FFR) is the "gold standard" for assessing the physiological significance of coronary disease. In the last decade, several alternative adenosine-free indexes have been proposed in order to facilitate the dissemination of the functional evaluation of coronary stenosis. Our aim was to investigate whether radiographic contrast plus intracoronary nitroglycerin (cFFR-NTG) can predict functional assessment of coronary stenosis offering superior diagnostic agreement with FFR compared to non-hyperemic indexes and contrast mediated FFR (cFFR).Three hundred twenty-nine lesions evaluated with pressure wire in 266 patients were prospectively included in this multicenter study.The ROC curves for cFFR-NTG using an FFR≤0.80 showed a higher accuracy in predicting FFR (AUC=0.97) than resting Pd/Pa (AUC=0.90, P0.01) and cFFR (AUC=0.93.5, P0.01). A significant (P0.01) strong correlation was found between FFR and the four analyzed indexes: Pd/Pa (r=0.78); iFR/RFR (r=0.73); cFFR(r=0.89) and cFFR-NTG (r=0.93). cFFR-NTG showed the closest agreement at Bland-Altman analysis. The cFFR-NTG cut off value0.84 showed the highest negative predictive value (88%), specificity (91%), sensitivity (94%) and accuracy (92%) of the studied indexes.Submaximal hyperemic adenosine-free indexes are an efficient alternative to adenosine for the physiological assessment of epicardial coronary disease. The most accurate index in predicting the functional significance of coronary stenosis using FFR as reference was cFFR-NTG.

Objectives We sought to investigate stent healing and neointimal hyperplasia with ihtDEStiny drug-eluting stent (DES) by optical coherence tomography (OCT) examination conducted 9 months after implantation. Background The currently used DES present certain features that have been linked separately to their better performance in terms of efficacy and safety. Methods First-in-man, prospective and multicenter study including patients treated with ihtDEStiny stent undergoing OCT examination at 9 months follow up. The ihtDEStiny stent is a sirolimus eluting stent with an oval shape ultrathin struts (68 μm) and an abluminal coating of a fluoropolymer containing the antiplatelet agent triflusal. Primary endpoint was the percentage of obstruction of the in-stent volume by the neointima. Results In 58 patients (63 lesions) in-stent late lumen loss was 0.11 ± 0.23 mm (95% CI 0.05-0.16) with only in 6% of stents being > 0.5 mm and in-segment binary stenosis was 1.6%. In OCT mean neointima volume obstruction was 10.5 ± 6.9% with a mean neointima thickness of 110.9 ± 89.8 μm. The proportion of uncovered struts was 2.5%, malapposed struts 1.1% and malapposed/uncovered struts 0.7% and no subclinical thrombi detected. Mean incomplete stent apposition area was 0.1 ± 0.1 mm2. At 12 months target lesion revascularization rate was 3% and no stent thrombosis was reported. Conclusions In this study the ihtDEStiny stent has shown a very low degree of neointimal proliferation associated with a low rate of uncovered/malapposed struts and total absence of subclinical thrombi at 9 months follow up.

Introduction and objectives The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. Methods Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. Results Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P

Resumen Introduccion Las lesiones largas suponen un desafio para los cardiologos intervencionistas dado el elevado riesgo de reestenosis y complicaciones. Evaluamos eventos clinicos pacientes en vida real con lesiones coronarias largas tratadas con stents liberadores de farmacos (DES) mayores de 40 mm. Metodos Estudio observacional prospectivo de pacientes consecutivos con una lesion coronaria muy larga (> 35 mm) revascularizados mediante stent Xience Xpedition liberador de everolimus (EES) o stent Biomime liberador de sirolimus (SES) ≥ 40 mm. Recogemos eventos cardiacos adversos mayores (ECAM) que agrupan muerte cardiaca, infarto no fatal y nueva revascularizacion de lesion diana (TLR). Resultados Analizamos a 94 pacientes con 113 lesiones (80% hombres, 63,8 ± 10 anos, 55% fumadores, 77% hipertensos, 41,5% diabeticos, 58% hiperlipidemicos). La presentacion fue sindrome coronario agudo en el 80%. El 44% fueron lesiones bifurcadas, ostiales 32%, calcificadas 87% y tromboticas 20,6%, y el 22,7% fueron oclusiones cronicas. La longitud media de la lesion fue de 57,9 ± 19 mm y la longitud media del stent fue 46 ± 2,5 mm. La longitud total de stents por lesion 64 ± 21 mm, con stents solapados en el 59%. Se implantaron 47 EES en 45 pacientes y 45 SES en 35 pacientes. Durante un seguimiento medio de 14,8 ± 11 meses, 4 (4,3%) pacientes fallecieron por causas cardiacas, 2 (2,1%) tuvieron infarto no fatal y 3 (3,2%) TLR. Un paciente presento una trombosis subaguda (2 stents SES solapados = 1,1%). La tasa de ECAM fue del 9,6%. Conclusiones Los pacientes con lesiones coronarias complejas muy largas tratados con DES ≥ 40 mm presentan excelentes resultados procedimentales y clinicos a largo plazo con una baja tasa de ECAM.

Resumen Introduccion y objetivos El stent Axxess es un stent autoexpandible de nitinol liberador de Biolimus, que se despliega en la carina y ofrece facil acceso a las ramas distales. El objetivo de este estudio fue evaluar los resultados del dispositivo de forma aguda, en un seguimiento a medio-largo plazo y el tipo de estrategia realizada. Metodos y resultados Se incluyeron 33 pacientes (34 lesiones) consecutivos de forma ambispectiva (69 ± 9 anos, 76% hombres, 60% fumadores/exfumadores, 46% diabeticos, 76% hipertensos, 54% dislipidemicos, 27% con fibrilacion auricular, 36% con cardiopatia isquemica previa y el 24% con ACTP previa). Presentaban algun grado de disfuncion VI el 33%. La presentacion clinica fue SCA en todos los casos (45,5% AI, 36,4% SCASEST, 18,2% SCACEST). El acceso fue en el 97% por via radial (7 F o 6 F). La bifurcacion tratada fue en un 70,6% ADA-Diagonal; 11,8% ACx-OM; 2,9% ACD-TPL; 14,7% TCI-ADA-ACx. El 80,6% fueron bifurcaciones verdaderas y la mayoria fueron 1,1,1 de la clasificacion de Medina (74%). El angulo de bifurcacion fue Conclusiones El uso del stent Axxess fue favorable en la mayoria de las ocasiones, ofreciendo un enfoque unico para el tratamiento de las bifurcaciones y buenos resultados a medio-largo plazo..

Summary We present a clinical case about a patient with a previuous angioplasty with lactic acid bioresorbible vascular scaffold on proximal left anterior descending artery. The patient suffered recurrent angina four year later. During catheterization, coronary spasm was observed by optical coherence tomography (OCT) and solved with intracoronary nitroglicerine. The OCT showed a singular pattern in medial and luminal area.

A 44-year-old man presented with an anterior ST-segment elevation myocardial infarction. The culprit artery was the proximal left anterior descending coronary artery ([Figure 1A][1]), which was successfully treated with a 3.00 × 15 mm magnesium bioresorbable scaffold (BRS) (Magmaris, Biotronik, B

Coronary pseudoaneurysms are rare complications of coronary perforation or dissection that can progress to rupture and cardiac tamponade. There is no optimal standard treatment, and their management is often guided by individual criteria including the risk of rupture, location in the coronary tree, size and flow in it. All of them must be taken into account when deciding the best treatment strategy. We report a case in which an Amplatzer Vascular Plug II (AVP II) was used successfully to occlude a distal coronary pseudoaneurysm that developed early after rescue angioplasty in a woman with a myocardial infarction due to spontaneous coronary dissection.

La angiografía coronaria permanece como "gold standard" para el diagnóstico y toma de decisiones en la enfermedad coronaria. Sin embargo, la significación de lesiones con estenosis de 50-70% es difícil. La medición de la reserva de flujo fraccional (FFR) es una herramienta útil para dilucidar esta interrogante. Generalmente se usa adenosina (A) en bolo intracoronario para inducir máxima vasodilatación y hay poca evidencia para drogas alternativas con este objeto. En este estudio evaluamos el uso de nitroprusiato (N) como droga alternativa. Métodos y Resultados: Se efectuó un estudio clínico aleatorizado. A (120 ug IC) y posteriormente N (50 ug IC), o vice-versa, se usaron para evaluar cada lesión. Se evaluaron 60 lesiones en 44 pacientes (24 hombres) de 63.5 ± 9.6 años, con masa corporal 28.95 ± 3.32 kg/m2. Las lesiones se localizaron en arteria descendente anterior en 46.7%, coronaria derecha en 26.7%, circunfleja en 11.7% y 13.9% en las otras arterias. La estenosis coronaria promedio evaluada por angiografía cuantitativa fue 49.5% (95% CI: 46.5 - 52.5%). La presión arterial media (PAM) basal fue similar en ambos grupos (pre - A: 106.5 ± 18.2 mmHg, pre - N: 105.6 ± 18.8 mmHg, NS) o después de A, pero se observó un descenso transitorio después de NP (descenso promedio de 12.5 mmHg, 95% CI: 9.2 a15.7 mmHg, 2p < 0.001). Este efecto estaba asociado a la hiperemia prolongada lograda con N. (duración de hiperemia con N: 39.2 ± 8.7 s., y con A of 15.3 ± 3.2 s. 2p < 0.001). Hubo excelente correlación entre los resultados de A y de N respecto de FFR (r 0.986). Se observó sólo 1 caso de hipotensión sintomática con N. cuatro pacientes con A y 2 con N desarrollaron angina. Además, 10 pacientes desarrollaron bloqueo A-V transitorio con A y ninguno con N. Conclusion: El N en bolo intracoronario es una intervención segura y confiable para la determinación del FFR coronario. La vasodilatación más sostenida después del N puede simplificar el procedimiento y evitar algunas de las limitaciones observadas con A.

A B S T R A C T Introduction and objectives: Coronary angiography is the gold standard for the study of coronary artery disease. This technique requires several orthogonal projections. Rotational angiography is a new technique which involves pre-set rotation of the X-ray tube around the patient and allows visualization of each coronary artery in different views, using a single contrast injection. The purpose of this study was to compare conventional coronary angiography (A) vs rotational angiography (B), focusing on radiation dose, amount of contrast administered, and total procedure time for both diagnostic and therapeutic percutaneous coronary interventions. Methods: Prospective study of 104 consecutive patients undergoing coronary angiography who were randomized to one of these techniques. Results: We found a significant reduction in the amount of contrast administered (A vs B, 93.1 (41.7) vs 50.9 (14.7) mL; P

Resumen Introduccion y objetivos La coronariografia es la tecnica de eleccion para estudiar la enfermedad coronaria. El estudio con esta tecnica requiere varias proyecciones ortogonales. La angiografia rotacional es una nueva tecnica que realiza una rotacion del tubo de rayos alrededor del paciente sobre un doble eje que permite la visualizacion desde diferentes angulos de cada coronaria con una unica inyeccion de contraste. El objetivo es comparar la angiografia convencional (A) con la angiografia rotacional (B) analizando dosis de radiacion, cantidad de contraste administrado y tiempo de procedimiento, tanto en el procedimiento diagnostico como en el terapeutico. Metodos Estudio prospectivo de 104 pacientes consecutivos aleatorizados a ambos grupos. Resultados Encontramos reduccion significativa de contraste (A frente a B, 93,1 ± 41,7 frente a 50,9 ± 14,7 ml; p 2 ; p Conclusiones La angiografia rotacional permite una reduccion significativa de la dosis de radiacion y la cantidad de contraste administrado en procedimientos diagnosticos respecto a la angiografia convencional. En los pacientes a los que se realiza intervencionismo percutaneo, la reduccion de contraste persiste significativamente.