Intervención de lesiones en bifurcación relacionadas con oclusión coronaria crónica total: incidencia, tratamiento y resultados hospitalarios / Interventions in chronic total occlusions with bifurcation lesions: incidence, treatment, and in-hospital outcome

Introducción y objetivos: Las oclusiones coronarias crónicas totales (OCT) que afectan a lesiones en bifurcación representan un subconjunto de lesiones difíciles de tratar y poco estudiadas en la literatura. Este estudio analiza la incidencia, la estrategia de tratamiento, los resultados hospitalarios y las complicaciones de la intervención coronaria percutánea (ICP) de las OCT en bifurcación (OCT-BIF). Métodos: Se evaluaron los datos de 607 pacientes consecutivos con OCT tratados en el Institut Cardiovasculaire Paris Sud (ICPS), Massy, Francia, entre enero de 2015 y febrero de 2020. Se compararon 2 subgrupos de pacientes (OCT-BIF, n=245; OCT-no BIF, n=362) en cuanto a estrategia de procedimiento, resultado hospitalario y tasa de complicaciones. Resultados: La media de edad de los pacientes fue 63,2±10,6 años; el 79,6% eran varones. Las lesiones en bifurcación estuvieron implicadas en el 40,4% de los procedimientos. La complejidad general de la lesión fue alta (valores medios de las puntuaciones J-CTO, 2,30 ± 1,16, y PROGRESS CTO, 1,37±0,94). El stent condicional fue la estrategia preferida para el tratamiento de las lesiones en bifurcación (93,5%). Los pacientes OCT-BIF presentaban una mayor complejidad de la lesión según la puntuación J-CTO (2,42±1,02 frente a 2,21±1,23 de los pacientes OCT-no BIF; p=0,025) y la puntuación PROGRESS CTO (1,60±0,95 frente a 1,22±0,90 de los pacientes OCT-no BIF; p<0,001). El éxito de la intervención fue del 78,9% y no se vio afectado por la presencia de bifurcación (el 80,4% en el grupo de OCT-BIF y el 77,8% en el grupo de OCT-no BIF; p=0,447) ni por el lugar de la bifurcación (OCT-BIF en segmento proximal, el 76,9%; OCT-no BIF en segmento medio, el 83,8%; OCT-BIF en segmento distal, el 85%; p=0,204). Las tasas de complicaciones fueron similares en ambos grupos...(AU)

Introduction and objectives: Coronary chronic total occlusions (CTO) involving bifurcation lesions are a challenging lesion subset that is understudied in the literature. This study analyzed the incidence, procedural strategy, in-hospital outcomes and complications of percutaneous coronary interventions (PCI) for bifurcation-CTO (BIF-CTO). Methods: We assessed data from 607 consecutive CTO patients treated at the Institut Cardiovasculaire Paris Sud (ICPS), Massy, France between January 2015 and February 2020. Procedural strategy, in-hospital outcomes and complication rates were compared between 2 patient subgroups: BIF-CTO (n=245=and non–BIF-CTO (n=362). Results: The mean patient age was 63.2±10.6 years; 79.6% were men. Bifurcation lesions were involved in 40.4% of the procedures. Overall lesion complexity was high (mean J-CTO score 2.30±1.16, mean PROGRESS-CTO score 1.37±0.94). The preferred bifurcation treatment strategy was a provisional approach (93.5%). BIF-CTO patients presented with higher lesion complexity, as assessed by J-CTO score (2.42±1.02 vs 2.21±1.23 in the non–BIF-CTO patients, P=.025) and PROGRESS-CTO score (1.60±0.95 vs 1.22±0.90 in the non–BIF-CTO patients, P<.001). Procedural success was 78.9% and was not affected by the presence of bifurcation lesions (80.4% in the BIF-CTO group, 77.8% in the non–BIF-CTO-CTO group, P=.447) or the bifurcation site (proximal BIF-CTO 76.9%, mid–BIF-CTO 83.8%, distal BIF-CTO 85%, P=.204). Complication rates were similar in BIF-CTO and non–BIF-CTO. Conclusions: The incidence of bifurcation lesions is high in contemporary CTO PCI. Patients with BIF-CTO present with higher lesion complexity, with no impact on procedural success or complication rates when the predominant strategy is provisional stenting.(AU)

Safety and incremental prognostic value of stress cardiovascular magnetic resonance in patients with known chronic kidney disease.

BACKGROUND: Cardiovascular disease (CVD) is the main cause of mortality in patients with chronic kidney disease (CKD). Although several studies have demonstrated the consistently high prognostic value of stress cardiovascular magnetic resonance (CMR), its prognostic value in patients with CKD is not well established. We aimed to assess the safety and the incremental prognostic value of vasodilator stress perfusion CMR in consecutive symptomatic patients with known CKD. METHODS: Between 2008 and 2021, we conducted a retrospective dual center study with all consecutive symptomatic patients with known stage 3 CKD, defined by estimated glomerular filtration rate (eGFR) between 30 and 60 ml/min/1.73 m2, referred for vasodilator stress CMR. All patients with eGFR < 30 ml/min/1.73 m2 (n = 62) were excluded due the risk of nephrogenic systemic fibrosis. All patients were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or recurrent nonfatal myocardial infarction (MI). Cox regression analysis was used to determine the prognostic value of stress CMR parameters. RESULTS: Of 825 patients with known CKD (71.4 ± 8.8 years, 70% men), 769 (93%) completed the CMR protocol. Follow-up was available in 702 (91%) (median follow-up 6.4 (4.0-8.2) years). Stress CMR was well tolerated without occurrence of death or severe adverse event related to the injection of gadolinium or cases of nephrogenic systemic fibrosis. The presence of inducible ischemia was associated with the occurrence of MACE (hazard ratio [HR] 12.50; 95% confidence interval [CI] 7.50-20.8; p < 0.001). In multivariable analysis, ischemia and late gadolinium enhancement were independent predictors of MACE (HR 15.5; 95% CI 7.72 to 30.9; and HR 4.67 [95% CI 2.83-7.68]; respectively, both p < 0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI = 0.477; IDI = 0.049). CONCLUSIONS: In patients with known stage 3 CKD, stress CMR is safe and its findings have an incremental prognostic value to predict MACE over traditional risk factors.

Interventions in chronic total occlusions with bifurcation lesions: incidence, treatment, and in-hospital outcome.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTO) involving bifurcation lesions are a challenging lesion subset that is understudied in the literature. This study analyzed the incidence, procedural strategy, in-hospital outcomes and complications of percutaneous coronary interventions (PCI) for bifurcation-CTO (BIF-CTO). METHODS: We assessed data from 607 consecutive CTO patients treated at the Institut Cardiovasculaire Paris Sud (ICPS), Massy, France between January 2015 and February 2020. Procedural strategy, in-hospital outcomes and complication rates were compared between 2 patient subgroups: BIF-CTO (n=245=and non-BIF-CTO (n=362). RESULTS: The mean patient age was 63.2±10.6 years; 79.6% were men. Bifurcation lesions were involved in 40.4% of the procedures. Overall lesion complexity was high (mean J-CTO score 2.30±1.16, mean PROGRESS-CTO score 1.37±0.94). The preferred bifurcation treatment strategy was a provisional approach (93.5%). BIF-CTO patients presented with higher lesion complexity, as assessed by J-CTO score (2.42±1.02 vs 2.21±1.23 in the non-BIF-CTO patients, P=.025) and PROGRESS-CTO score (1.60±0.95 vs 1.22±0.90 in the non-BIF-CTO patients, P<.001). Procedural success was 78.9% and was not affected by the presence of bifurcation lesions (80.4% in the BIF-CTO group, 77.8% in the non-BIF-CTO-CTO group, P=.447) or the bifurcation site (proximal BIF-CTO 76.9%, mid-BIF-CTO 83.8%, distal BIF-CTO 85%, P=.204). Complication rates were similar in BIF-CTO and non-BIF-CTO. CONCLUSIONS: The incidence of bifurcation lesions is high in contemporary CTO PCI. Patients with BIF-CTO present with higher lesion complexity, with no impact on procedural success or complication rates when the predominant strategy is provisional stenting.

Prognostic impact of artificial intelligence-based fully automated global circumferential strain in patients undergoing stress CMR.

AIMS: To determine whether fully automated artificial intelligence-based global circumferential strain (GCS) assessed during vasodilator stress cardiovascular (CV) magnetic resonance (CMR) can provide incremental prognostic value. METHODS AND RESULTS: Between 2016 and 2018, a longitudinal study included all consecutive patients with abnormal stress CMR defined by the presence of inducible ischaemia and/or late gadolinium enhancement. Control subjects with normal stress CMR were selected using a propensity score-matching. Stress-GCS was assessed using a fully automatic machine-learning algorithm based on featured-tracking imaging from short-axis cine images. The primary outcome was the occurrence of major adverse clinical events (MACE) defined as CV mortality or nonfatal myocardial infarction. Cox regressions evaluated the association between stress-GCS and the primary outcome after adjustment for traditional prognosticators. In 2152 patients [66 ± 12 years, 77% men, 1:1 matched patients (1076 with normal and 1076 with abnormal CMR)], stress-GCS was associated with MACE [median follow-up 5.2 (4.8-5.5) years] after adjustment for risk factors in the propensity-matched population [adjusted hazard ratio (HR), 1.12 (95% CI, 1.06-1.18)], and patients with normal CMR [adjusted HR, 1.35 (95% CI, 1.19-1.53), both P < 0.001], but not in patients with abnormal CMR (P = 0.058). In patients with normal CMR, an increased stress-GCS showed the best improvement in model discrimination and reclassification above traditional and stress CMR findings (C-statistic improvement: 0.14; NRI = 0.430; IDI = 0.089, all P < 0.001; LR-test P < 0.001). CONCLUSION: Stress-GCS is not a predictor of MACE in patients with ischaemia, but has an incremental prognostic value in those with a normal CMR although the absolute event rate remains low.

AI-Based Fully Automated Left Atrioventricular Coupling Index as a Prognostic Marker in Patients Undergoing Stress CMR.

BACKGROUND: The left atrioventricular coupling index (LACI) is a strong and independent predictor of heart failure (HF) in individuals without clinical cardiovascular disease. Its prognostic value is not established in patients with cardiovascular disease. OBJECTIVES: This study sought to determine in patients undergoing stress cardiac magnetic resonance (CMR) whether fully automated artificial intelligence-based LACI can provide incremental prognostic value to predict HF. METHODS: Between 2016 and 2018, the authors conducted a longitudinal study including all consecutive patients with abnormal (inducible ischemia or late gadolinium enhancement) vasodilator stress CMR. Control subjects with normal stress CMR were selected using propensity score matching. LACI was defined as the ratio of left atrial to left ventricular end-diastolic volumes. The primary outcome included hospitalization for acute HF or cardiovascular death. Cox regression was used to evaluate the association of LACI with the primary outcome after adjustment for traditional risk factors. RESULTS: In 2,134 patients (65 ± 12 years, 77% men, 1:1 matched patients [1,067 with normal and 1,067 with abnormal CMR]), LACI was positively associated with the primary outcome (median follow-up: 5.2 years [IQR: 4.8-5.5 years]) before and after adjustment for risk factors in the overall propensity-matched population (adjusted HR: 1.18 [95% CI: 1.13-1.24]), in patients with abnormal CMR (adjusted HR per 0.1% increment: 1.22 [95% CI: 1.14-1.30]), and in patients with normal CMR (adjusted HR per 0.1% increment: 1.12 [95% CI: 1.05-1.20]) (all P < 0.001). After adjustment, a higher LACI of ≥25% showed the greatest improvement in model discrimination and reclassification over and above traditional risk factors and stress CMR findings (C-index improvement: 0.16; net reclassification improvement = 0.388; integrative discrimination index = 0.153, all P < 0.001; likelihood ratio test P < 0.001). CONCLUSIONS: LACI is independently associated with hospitalization for HF and cardiovascular death in patients undergoing stress CMR, with an incremental prognostic value over traditional risk factors including inducible ischemia and late gadolinium enhancement.

Clustering of patients with inconclusive non-invasive stress testing referred for vasodilator stress cardiovascular magnetic resonance.

BACKGROUND: Inconclusive non-invasive stress testing is associated with impaired outcome. This population is very heterogeneous, and its characteristics are not well depicted by conventional methods. AIMS: To identify patient subgroups by phenotypic unsupervised clustering, integrating clinical and cardiovascular magnetic resonance data to unveil pathophysiological differences between subgroups of patients with inconclusive stress tests. METHODS: Between 2008 and 2020, consecutive patients with a first inconclusive non-invasive stress test referred for stress cardiovascular magnetic resonance were followed for the occurrence of major adverse cardiovascular events (defined as cardiovascular death or myocardial infarction). A cluster analysis was performed on clinical and cardiovascular magnetic resonance variables. RESULTS: Of 1402 patients (67% male; mean age 70±11years) who completed the follow-up (median 6.5years, interquartile range 5.6-7.5years), 197 experienced major adverse cardiovascular events (14.1%). Three distinct phenogroups were identified based upon unsupervised hierarchical clustering of principal components: phenogroup 1=history of percutaneous coronary intervention with viable myocardial infarction and preserved left ventricular ejection fraction; phenogroup 2=atrial fibrillation with preserved left ventricular ejection fraction; and phenogroup 3=coronary artery bypass graft with non-viable myocardial scar and reduced left ventricular ejection fraction. Using survival analysis, the occurrence of major adverse cardiovascular events (P=0.007), cardiovascular mortality (P=0.002) and all-cause mortality (P<0.001) differed among the three phenogroups. Phenogroup 3 presented the worse prognosis. In each phenogroup, ischaemia was associated with major adverse cardiovascular events (phenogroup 1: hazard ratio 2.79, 95% confidence interval 1.61-4.84; phenogroup 2: hazard ratio 2.59, 95% confidence interval 1.69-3.97; phenogroup 3: hazard ratio 3.16, 95% confidence interval 1.82-5.49; all P<0.001). CONCLUSIONS: Cluster analysis of clinical and cardiovascular magnetic resonance variables identified three phenogroups of patients with inconclusive stress testing, with distinct prognostic profiles.

Additional prognostic value of stress cardiovascular magnetic resonance for cardiovascular risk stratification after a cryptogenic ischemic stroke.

Background: One-third of ischemic strokes are "cryptogenic" without clearly identified etiology. Although coronary artery disease (CAD) is the main cause of death after stroke, the interest in CAD screening in patients with cryptogenic stroke is still debated. Aim: The aim of the study was to assess the incremental prognostic value of stress cardiovascular magnetic resonance (CMR) beyond traditional risk factors for predicting cardiovascular events in patients with a prior cryptogenic ischemic stroke. Materials and methods: Between 2008 and 2021, consecutive patients with prior cryptogenic strokes referred for stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACEs), defined by cardiovascular death or non-fatal myocardial infarction (MI). Univariable and multivariable Cox regressions were performed to determine the prognostic value of unrecognized MI and silent ischemia. Results: Of 542 patients (55.2% male, mean age 71.4 ± 8.8 years) who completed the follow-up (median 5.9 years), 66 (12.2%) experienced MACE. Silent ischemia and unrecognized MI were detected in 18 and 17% of patients, respectively. Using Kaplan-Meier analysis, silent ischemia and unrecognized MI were associated with the occurrence of MACE [hazard ratio, HR: 8.43 (95% CI: 5.11-13.9); HR: 7.87 (95% CI: 4.80-12.9), respectively, p < 0.001]. In multivariable analysis, silent ischemia and unrecognized MI were independent predictors of MACE [HR: 8.08 (95% CI: 4.21-15.5); HR: 6.65 (95% CI: 3.49-12.7), respectively, p < 0.001]. After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI = 0.428; IDI = 0.048). Conclusion: In patients with prior cryptogenic stroke, stress CMR findings have an incremental prognostic value to predict MACE over traditional risk factors.

Prognostic Value of Stress CMR in Symptomatic Patients With Coronary Stenosis on CCTA.

BACKGROUND: Noninvasive functional imaging is often performed in patients with obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CTA). However, the prognostic value of stress cardiac magnetic resonance (CMR) is unknown in patients with coronary stenosis of unknown significance on coronary CTA. OBJECTIVES: This study assessed the prognostic value of stress CMR in symptomatic patients with obstructive CAD of unknown significance on coronary CTA. METHODS: Between 2008 and 2020, consecutive symptomatic patients without known CAD referred for coronary CTA were screened. Patients with obstructive CAD (at least 1 ≥50% stenosis on coronary CTA) were further referred for stress CMR and followed for the occurrence of major adverse cardiovascular events (MACEs), defined as cardiovascular death or nonfatal myocardial infarction. RESULTS: Of 2,210 patients who completed CMR, 2,038 (46.5% men; mean age 69.8 ± 12.2 years) completed follow-up (median 6.8 years; IQR: 5.9-9.2 years); 281 experienced a MACE (13.8%). Inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with MACEs (HR: 4.51 [95% CI: 3.55-5.74], and HR: 3.32 [95% CI: 2.55-4.32], respectively; P < 0.001). In multivariable Cox regression, the number of segments with >70% stenosis, with noncalcified plaques and the number of vessels with obstructive CAD were prognosticators (P < 0.001). The presence of inducible ischemia and LGE were independent predictors of MACEs (HR: 3.97 [95% CI: 3.43-5.13]; HR: 2.30 [95% CI: 1.52-3.33]; P < 0.001). After adjustment, stress CMR showed the best improvement in model discrimination and reclassification above traditional risk factors and coronary CTA (C-statistic improvement: 0.04; net reclassification improvement = 0.421; integrative discrimination index = 0.047). CONCLUSIONS: In symptomatic patients with obstructive CAD of unknown significance on coronary CTA, stress CMR had incremental prognostic value to predict MACEs.

On-line estimated peak skin dose during percutaneous coronary intervention for chronic total occlusion using new patient dose mapping technology.

BACKGROUND: X-ray exposure during complex percutaneous coronary intervention is a very important issue. AIM: To reduce patient peak skin dose during percutaneous coronary intervention procedures for chronic total occlusion using on-line estimated peak skin dose software (Dose Map). METHODS: Throughout the procedure, Dose Map provided a map of local cumulative peak skin dose. This map was displayed in-room from 1Gy cumulative air kerma, and was updated every 0.5Gy. The operator's actions to minimize deterministic risks following map notification were collected. Skin reaction was evaluated 3 months after the procedure. A comparison with our historical X-ray exposure data (207 patients from January 2013 to July 2014) was performed. RESULTS: From November 2015 to October 2016, 97 patients (Japanese chronic total occlusion score 2.1±1.1; 100 percutaneous coronary intervention procedures for chronic total occlusion) were prospectively enrolled. Fluoroscopy time was 40.8 (21.6-60.3) minutes, cumulative air kerma 1884 (1144-3231) mGy, estimated peak skin dose 962 (604-1474) mGy and kerma area product 115.8 (71.5-206.7) Gy.cm2. Cumulative air kerma was>3Gy in 28% of cases, and>5Gy in 11% of cases. In 68% of cases, at least one action was taken by the operator after map notification to optimize skin dose distribution. Main changes included: gantry angulation (52%); field of view (25%); and collimation (13%). No skin injuries were observed at follow-up. In comparison with our chronic total occlusion historical radiation data, median cumulative air kerma and kerma area product were reduced by 31% and 33%, respectively (P<0.005. CONCLUSION: Online skin dose mapping software allows the distribution of patient skin dose during complex percutaneous coronary intervention procedures, and may minimize X-ray exposure.

Machine-Learning Score Using Stress CMR for Death Prediction in Patients With Suspected or Known CAD.

BACKGROUND: In patients with suspected or known coronary artery disease, traditional prognostic risk assessment is based on a limited selection of clinical and imaging findings. Machine learning (ML) methods can take into account a greater number and complexity of variables. OBJECTIVES: This study sought to investigate the feasibility and accuracy of ML using stress cardiac magnetic resonance (CMR) and clinical data to predict 10-year all-cause mortality in patients with suspected or known coronary artery disease, and compared its performance with existing clinical or CMR scores. METHODS: Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 (IQR: 5.0-8.0) years included all consecutive patients referred for stress CMR. Twenty-three clinical and 11 stress CMR parameters were evaluated. ML involved automated feature selection by random survival forest, model building with a multiple fractional polynomial algorithm, and 5 repetitions of 10-fold stratified cross-validation. The primary outcome was all-cause death based on the electronic National Death Registry. The external validation cohort of the ML score was performed in another center. RESULTS: Of 31,752 consecutive patients (mean age: 63.7 ± 12.1 years, and 65.7% male), 2,679 (8.4%) died with 206,453 patient-years of follow-up. The ML score (ranging from 0 to 10 points) exhibited a higher area under the curve compared with Clinical and Stress Cardiac Magnetic Resonance score, European Systematic Coronary Risk Estimation score, QRISK3 score, Framingham Risk Score, and stress CMR data alone for prediction of 10-year all-cause mortality (ML score: 0.76 vs Clinical and Stress Cardiac Magnetic Resonance score: 0.68, European Systematic Coronary Risk Estimation score: 0.66, QRISK3 score: 0.64, Framingham Risk Score: 0.63, extent of inducible ischemia: 0.66, extent of late gadolinium enhancement: 0.65; all P < 0.001). The ML score also exhibited a good area under the curve in the external cohort (0.75). CONCLUSIONS: The ML score including clinical and stress CMR data exhibited a higher prognostic value to predict 10-year death compared with all traditional clinical or CMR scores.

Safety and efficacy of 48 mm Xience Xpedition everolimus-eluting stent for the treatment of long coronary lesions.

INTRODUCTION: Long drug-eluting stents may limit the issue of overlapping multiple stents when treating long coronary lesions. AIM: The aim of the study was to assess the safety and efficacy of the 48 mm Xience Xpedition everolimus-eluting stent (48mm-EES) for the treatment of long coronary lesions, in an all-comer population. METHODS: Patients receiving at least one 48mm-EES were prospectively included from March 2014 to December 2018. The primary endpoint was target lesion failure (TLF), defined as a composite of cardiac death, target vessel myocardial infarction, and clinically driven target lesion revascularization (TLR) at 1 year. The main secondary endpoint was the patient-oriented composite endpoint (POCE) defined as a composite of death, stroke, myocardial infarction, and reintervention. RESULTS: A total of 268 patients with 276 long coronary lesions, including 94 chronic total occlusions (CTO), were successfully treated using at least one 48mm-EES. The total stent length per lesion was 66 ± 22 mm. A single 48mm-EES was suitable to successfully treat the target lesion in 48% of cases (60% for non-CTO lesions). One-year follow-up rate was 96.3%. TLF occurred in 13 patients (5.3%), mainly driven by TLR (4.1%). Two cardiac death occurred (0.7%). POCE occurred in 30 patients (11.6%) mainly driven by repeat revascularization (9.7%). Definite stent thrombosis was observed in two patients (0.7%). No difference was observed in one-year outcomes between single 48mm-EES and multiple stents implantation as well as between CTO and non-CTO lesions. CONCLUSION: The 48mm-EES is safe and effective to treat long coronary lesions, including CTOs, and provides attractive cost-effectiveness by limiting multiple stenting.

Angiographic Predictors of Septal Collateral Tracking During Retrograde Percutaneous Coronary Intervention for Chronic Total Occlusion: Anatomical Analysis or Rolling the Dice?

OBJECTIVES: The aim of this study was to identify independent angiographic predictors of collateral channel (CC) tracking success, microcatheter tracking failure, and complications in chronic total occlusion (CTO) retrograde approach. We also developed a "crossability score," comparing its predictive performance with pre-existing scores. BACKGROUND: The retrograde approach was introduced for recanalization of challenging CTOs. The passage of guidewires through CCs is a key step of the procedure. Two scoring systems have been recently developed to predict CC tracking success. METHODS: A total of 180 patients and 297 CCs were retrospectively analyzed in an unselected retrograde CTO population. RESULTS: Guidewire crossing was successful in 203 collaterals (68.3%). The only independent predictor of successful CC tracking was Werner score 2. Conversely, Werner score 0, severe tortuosity (>180°), acute exit angle (<90°), and length of collateral were independently associated with tracking failure. We assigned a score to each "significant" variable to create a model that showed a greater accuracy than pre-existing scores (area under the receiver-operator characteristics curve, 0.72 vs 0.65 and 0.69). Moreover, CC length was also associated with microcatheter tracking failure and complications. CONCLUSIONS: Werner score 0, tortuosity, acute exit angle, and CC length were independently associated with CC tracking failure, whereas Werner score 2 was a predictor of crossing success. Length of CC is associated with a higher rate of microcatheter crossing failure and complications. We combined these findings into the R-ICPS score, which showed an adequate accuracy for collateral crossing prediction.

Phenotypic Clustering of Patients With Newly Diagnosed Coronary Artery Disease Using Cardiovascular Magnetic Resonance and Coronary Computed Tomography Angiography.

Background: Epidemiological characteristics and prognostic profiles of patients with newly diagnosed coronary artery disease (CAD) are heterogeneous. Therefore, providing individualized cardiovascular (CV) risk stratification and tailored prevention is crucial. Objective: Phenotypic unsupervised clustering integrating clinical, coronary computed tomography angiography (CCTA), and cardiac magnetic resonance (CMR) data were used to unveil pathophysiological differences between subgroups of patients with newly diagnosed CAD. Materials and Methods: Between 2008 and 2020, consecutive patients with newly diagnosed obstructive CAD on CCTA and further referred for vasodilator stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or non-fatal myocardial infarction. For this exploratory work, a cluster analysis was performed on clinical, CCTA, and CMR variables, and associations between phenogroups and outcomes were assessed. Results: Among 2,210 patients who underwent both CCTA and CMR, 2,015 (46% men, mean 70 ± 12 years) completed follow-up [median 6.8 (IQR 5.9-9.2) years], in which 277 experienced a MACE (13.7%). Three mutually exclusive and clinically distinct phenogroups (PG) were identified based upon unsupervised hierarchical clustering of principal components: (PG1) CAD in elderly patients with few traditional risk factors; (PG2) women with metabolic syndrome, calcified plaques on CCTA, and preserved left ventricular ejection fraction (LVEF); (PG3) younger men smokers with proximal non-calcified plaques on CCTA, myocardial scar, and reduced LVEF. Using survival analysis, the occurrence of MACE, cardiovascular mortality, and all-cause mortality (all p < 0.001) differed among the three PG, in which PG3 had the worse prognosis. In each PG, inducible ischemia was associated with MACE [PG1, Hazards Ratio (HR) = 3.09, 95% CI, 1.70-5.62; PG2, HR = 3.62, 95% CI, 2.31-5.7; PG3, HR = 3.55, 95% CI, 2.3-5.49; all p < 0.001]. The study presented some key limitations that may impact generalizability. Conclusions: Cluster analysis of clinical, CCTA, and CMR variables identified three phenogroups of patients with newly diagnosed CAD that were associated with distinct clinical and prognostic profiles. Inducible ischemia assessed by stress CMR remained associated with the occurrence of MACE within each phenogroup. Whether automated unsupervised phenogrouping of CAD patients may improve clinical decision-making should be further explored in prospective studies.

Prognostic value of pre-hospitalization stress perfusion cardiovascular magnetic resonance to predict death in patients hospitalized for COVID-19.

BACKGROUND: Inducible ischaemia is a strong marker of vascular vulnerability. Knowing the important role of the vascular tropism of COVID-19 to explain its severity, the presence of a prior inducible ischaemia may be a key pathogenetic determinant of COVID-19 severity. AIMS: To investigate the prognostic value of prior inducible ischaemia on stress cardiovascular magnetic resonance (CMR) to predict death in patients hospitalized for COVID-19. METHODS: We retrospectively analysed consecutive patients referred for stress perfusion CMR during 1/1/18-1/1/20 who were later hospitalized for COVID-19. The primary outcome was all-cause death, including in-hospital and post-hospitalization deaths, based on the electronic national death registry. RESULTS: Among the patients referred for stress CMR, 481 were hospitalized for COVID-19 (mean age 68.4±9.6years, 61.3% male) and completed the follow-up (median [interquartile range] 73 [36-101] days). There were 93 (19.3%) all-cause deaths, of which 13.7% occurred in hospital and 5.6% were post-hospitalization deaths. Age, male sex, hypertension, diabetes, known coronary artery disease (CAD), the presence of prior inducible ischaemia, the number of ischaemic segments, the presence of late gadolinium enhancement and left ventricular ejection fraction were significantly associated with all-cause death. In multivariable stepwise Cox regression analysis, age (hazard ratio [HR]: 1.04, 95% confidence interval [CI]: 1.01-1.07; P=0.023), hypertension (HR: 2.77; 95% CI: 1.71-4.51; P<0.001), diabetes (HR: 1.72; 95% CI: 1.08-2.74; P=0.022), known CAD (HR: 1.78; 95% CI: 1.07-2.94; P=0.025) and prior inducible ischaemia (HR 2.05; 95% CI: 1.27-3.33; P=0.004) were independent predictors of all-cause death. CONCLUSIONS: In COVID-19 patients, prior inducible ischaemia by stress CMR during the 2years preceding the COVID-19 pandemic was independently associated with all-cause death.

[Methergin pour le diagnostic de l'angor spastique : voie intraveineuse ou intracoronaire ?] / Comparative performance of intravenous and intracoronary ergonovine provocation in vasospastic angina.

BACKGROUND: Vasospastic angina is an infrequent underlying cause of angina and is under-diagnosed. Ergonovine provocation tests can be performed via intravenous or intracoronary injections. Although the safety profile of intracoronary injection has been well documented, no study has yet compared the intracoronary and intravenous injections regarding the positivity rate of the test. AIMS: This study sought to compare the positivity rate of intravenous versus intracoronary injection of ergonovine in the diagnosis of vasospastic angina. METHODS: Between January 2010 and February 2018, 427 patients with suspected vasospastic angina underwent an ergonovine provocation test in 2 tertiary hospitals in France and were retrospectively included in this study. Injection was performed via the intravenous or the intracoronary route. The primary endpoint was the positivity rate of the test. Propensity score matching was used to account for confounding factors. RESULTS: 427 patients were included in the study. Mean age was 60.3 (+/- 12.4) years. There were 247 (58%) females and 97 (23%) smokers. The intracoronary route was used in 199 (47%) patients. The indication for the test was acute coronary syndrome for 121 (28%). No rhythmic complications or deaths were reported. After propensity-matching, the baseline characteristics of the 2 groups (148 patients in each) were comparable. The positivity rate was 24% in the intracoronary group and 9% in the intravenous group (OR [95%CI]: 3.2 [1.6, 6.4]). CONCLUSIONS: Intracoronary injection of ergonovine is safe and associated with a positivity rate of the test three times higher compared to intravenous injection.

Long-Term Prognostic Value of Stress Cardiovascular Magnetic Resonance-Related Coronary Revascularization to Predict Death: A Large Registry With >200 000 Patient-Years of Follow-Up.

BACKGROUND: Although the benefit of coronary revascularization in patients with stable coronary disease is debated, data assessing the potential interest of stress cardiovascular magnetic resonance (CMR) to guide coronary revascularization are limited. We aimed to assess the long-term prognostic value of stress CMR-related coronary revascularization in consecutive patients from a large registry. METHODS: Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range, 5.0-8.0) included all consecutive patients referred for stress CMR. CMR-related coronary revascularization was defined by any coronary revascularization performed within 90 days after CMR. The primary outcome was all-cause death based on the National Death Registry. RESULTS: Among the 31 762 consecutive patients (mean age 63.7±12.1 years and 65.7% males), 2679 (8.4%) died at 206 453 patient-years of follow-up. Inducible ischemia and late gadolinium enhancement by CMR were associated with death (both P<0.001). In multivariable Cox regression, inducible ischemia and late gadolinium enhancement were independent predictors of death (hazard ratio, 1.61 [99.5% CI, 1.41-1.84]; hazard ratio, 1.62 [99.5% CI, 1.41-1.86], respectively; P<0.001). In the overall population, CMR-related coronary revascularization was an independent predictor of greater survival (hazard ratio, 0.58 [99.5% CI, 0.46-0.74]; P<0.001). In 1680, 1:1 matched patients using a limited number of variables (840 revascularized, 840 nonrevascularized), CMR-related revascularization was associated with a lower incidence of death in patients with severe inducible ischemia (≥6 segments, P<0.001) but showed no benefit in patients with mild or moderate ischemia (<6 segments, P=0.109). Using multivariable analysis in the propensity-matched population, CMR-related revascularization remained an independent predictor of a lower incidence of all-cause mortality (hazard ratio, 0.66 [99.5% CI, 0.54-0.80], P<0.001). CONCLUSIONS: In this large observational series of consecutive patients, stress perfusion CMR had important incremental long-term prognostic value to predict death over traditional risk factors. CMR-related revascularization was associated with a lower incidence of death in patients with severe ischemia.

Long-term prognostic value of ischaemia and cardiovascular magnetic resonance-related revascularization for stable coronary disease, irrespective of patient's sex: a large retrospective study.

AIMS: To assess the sex-specific, long-term prognostic value of myocardial ischaemia induced by stress cardiovascular magnetic resonance (CMR) and early CMR-related revascularization in consecutive patients from a large registry. METHODS AND RESULTS: Between 2008 and 2010, all consecutive patients referred for stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular mortality or recurrent non-fatal myocardial infarction (MI). Early CMR-related revascularization was defined as any revascularization within 90 days after CMR. Among 3664 patients (56.9% male, mean age 69.9 ± 11.8 years), 472 (12.9%) had MACE (163 women and 309 men) after a median follow-up of 8.8 (IQR 6.9-9.5) years. Inducible ischaemia and late gadolinium enhancement (LGE) by CMR were associated with MACE in women and men (all P < 0.001). In multivariable Cox regression, inducible ischaemia, LGE, and CMR-related revascularization were independent predictors of MACE both in women [heart rate (HR) 4.79, 95% confidence interval (CI) 2.17-9.10; HR 1.82, 95% CI 1.22-2.71; HR 0.71, 95% CI 0.54-0.92, respectively; all P < 0.001] and men (HR 3.88, 95% CI 2.33-5.98; HR 1.48, 95% CI 1.16-1.89; HR 0.78, 95% CI 0.65-0.97, respectively; all P < 0.001). The addition of CMR-parameters led to improved model discrimination for MACE (C-statistic 0.61 vs. 0.71; NRI = 0.212; IDI = 0.032) for both women and men. CMR-related revascularization was associated with a lower incidence of MACE in patients with left ventricular ejection fraction (LVEF)<50%. CONCLUSION: Inducible ischaemia and early CMR-related revascularization were good long-term predictors of MACE irrespective of sex. CMR-related revascularization was associated with a lower MACE incidence in the sole sub-set of patients with LVEF < 50%.

Long-Term Prognostic Value of Stress CMR in Patients With Heart Failure and Preserved Ejection Fraction.

OBJECTIVES: The objectives of this study were to investigate the long-term prognostic value of inducible myocardial ischemia assessed by vasodilator stress cardiovascular magnetic resonance (CMR) in patients with HFpEF. BACKGROUND: Some studies suggest that ischemia could play a key role in HF in patients with preserved ejection fraction (HFpEF). METHODS: Between 2008 and 2019, consecutive patients prospectively referred for stress CMR with HFpEF as defined by current guidelines, without known coronary artery disease (CAD), were followed for the occurrence of major adverse cardiovascular events (MACE), as defined by cardiovascular mortality or nonfatal myocardial infarction (MI). Secondary composite outcomes included cardiovascular mortality or hospitalization for acute HF. Cox regression analysis was performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR. RESULTS: Among the 1,203 patients with HFpEF (73 ± 13 years of age; 29% males) who underwent stress CMR and completed follow-up (6.9 years interquartile range [IQR]: 6.7 to 7.7 years]), 108 experienced a MACE (9%). Kaplan-Meier analysis showed inducible ischemia and LGE were significantly associated with MACE (HR: 6.63; 95% confidence interval [CI]: 4.54 to 9.69; and HR: 2.56; 95% CI: 1.60 to 4.09, respectively; both p < 0.001) and secondary outcomes (HR: 8.40; 95% CI: 6.31 to 11.20; p < 0.001; and HR: 1.87; 95% CI: 1.27 to 2.76, respectively; p = 0.002). In multivariate analysis, inducible ischemia and LGE were independent predictors of MACE (HR: 6.10; 95% CI: 4.14 to 9.00; p < 0.001 and HR: 1.62; 95% CI: 1.06 to 2.49; p = 0.039; respectively). CONCLUSIONS: Stress CMR-inducible myocardial ischemia and LGE have accurate discriminative long-term prognostic value in HFpEF patients without known CAD to predict the occurrence of MACE.