Long-term prognostic value of quantitative-flow-ratio-concordant revascularization in stable coronary artery disease.

OBJECTIVES: Confirming the prognostic value of global QFR and evaluating the long-term prognosis of QFR-concordant therapy in stable coronary artery disease. BACKGROUND: Wire-based functional evaluation of coronary disease is linked to patient's prognosis. Quantitative Flow Ratio (QFR) is a newer index of computational physiology, linked to clinical outcomes and prognosis at 1 year follow-up. Long-term prognosis of QFR-concordant revascularization in stable coronary artery disease is however unknown hitherto. METHODS: Consecutive patients with stable coronary disease undergoing coronary angiography were included. Centralized and blinded QFR analysis of three coronary territories was performed. Three vessel QFR (3vQFR) was defined as the sum of the basal QFR of each coronary territory. QFR-concordant revascularization was met if all significant lesions (QFR ≤ 0.80) were revascularized and all non-significant lesions (QFR > 0.80) were not; otherwise, the case was defined as QFR-discordant revascularization. Patient-oriented composite end-point (POCE) of cardiac death, myocardial infarction and unscheduled revascularization was the primary endpoint. RESULTS: A total of 803 patients from six high-volume centers were included. Canadian Cardiovascular Society (CCS) class II angina was the most frequent (48.9%) clinical presentation. Median of follow-up was 68.8 months. 3vQFR was an independent predictor of POCE (HR 1.79 CI95% 1.01-3.18), with 2.75 as optimal cut-off value, irrespective of the therapy received. QFR-discordant revascularization (QFR+/Revascularization- or QFR-/Revascularization+) was an independent predictor of POCE in multivariate analysis (HR 1.65, CI 95% 1.03-2.64). CONCLUSION: Global burden of epicardial coronary atherosclerosis, as evaluated by 3vQFR, as well as QFR-discordant therapy are independent predictors of adverse clinical outcome at long-term follow-up in stable coronary artery disease.

Agreement between Murray law-based quantitative flow ratio (µQFR) and three-dimensional quantitative flow ratio (3D-QFR) in non-selected angiographic stenosis: A multicenter study.

BACKGROUND: The agreement between single-projection Murray-based quantitative flow ratio (mQFR) and conventional three-dimensional quantitative flow ratio (3D-QFR) has not been reported hitherto. METHODS: Patients from a multinational database were randomly selected for the study of agreement, according to sample size calculation. Both conventional 3D-QFR and mQFR were analyzed for all available arteries at a central corelab by independent analysts, blinded to each other's results. RESULTS: Ninety-eight coronary arteries from 35 patients were finally analyzed. Median 3D-QFR was 0.82 (interquartile range 0.78-0.87). The intraclass correlation coefficient for the absolute agreement between 3D-QFR and mQFR was 0.996 (95% confidence interval [CI]: 0.993-0.997); Lin's coefficient 0.996 (95% CI: 0.993-0.997), without constant or proportional bias (intercept = 0 and slope = 1 in orthogonal regression). As dichotomous variable, there was absolute agreement between mQFR and 3D-QFR, resulting in no single false positive or negative. Kappa index was 1 and the diagnostic accuracy 100%. CONCLUSIONS: mQFR using a single angiographic projection showed almost perfect agreement with standard 3D-QFR. These results encourage the interchangeable use of mQFR and 3D-QFR, which can be interesting to improve QFR feasibility in retrospective studies, wherein appropriate double angiographic projections might be challenging to obtain.

Thrombosis of second-generation drug-eluting stents in real practice results from the multicenter Spanish registry ESTROFA-2 (Estudio Español Sobre Trombosis de Stents Farmacoactivos de Segunda Generacion-2).

OBJECTIVES: This study sought to evaluate second-generation drug-eluting stent (DES) thrombosis in clinical practice. BACKGROUND: First-generation DES are associated with a significant incidence of late thrombosis. There is paucity of data regarding real practice late thrombosis incidence and predictors with second-generation DES, zotarolimus-eluting stent (ZES), and everolimus-eluting stents (EES). METHODS: A prospective, large-scale, non-industry-linked multicenter registry was designed. Complete clinical-procedural data and systematic follow-up of all patients treated with these stents was reported in a dedicated registry supported by the Spanish Working Group on Interventional Cardiology. RESULTS: From 2005 to 2008, 4,768 patients were included in 34 centers: 2,549 treated with ZES, and 2,219 with EES. The cumulative incidence of definite/probable thrombosis for ZES was 1.3% at 1 year and 1.7% at 2 years and for EES 1.4% at 1 year and 1.7% at 2 years (p = 0.8). The increment of definite thrombosis between the first and second year was 0.2% and 0.25%, respectively. In a propensity score analysis, the incidence remained very similar. Ejection fraction (adjusted hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.95 to -0.99; p = 0.008), stent diameter (adjusted HR: 0.37; 95% CI: 0.17to 0.81; p = 0.01) and bifurcations (adjusted HR: 2.1; 95% CI: 1.14 to 3.7; p = 0.02) emerged as independent predictors of thrombosis. In the subgroup of patients with bifurcations, the use of ZES was independently associated with a higher thrombosis rate (adjusted HR: 4; 95% CI: 1.1 to 13; p = 0.03). CONCLUSIONS: In a real practice setting, the incidence of thrombosis at 2 years with ZES and EES was low and quite similar. The incidence of very late thrombosis resulted lower than was reported in registries of first-generation DES. In the subset of bifurcations, the use of ZES significantly increased the risk of thrombosis.

Drug-eluting stent thrombosis: results from the multicenter Spanish registry ESTROFA (Estudio ESpañol sobre TROmbosis de stents FArmacoactivos).

OBJECTIVES: This study sought to assess the incidence, predictors, and outcome of drug-eluting stent(DES) thrombosis in real-world clinical practice. BACKGROUND: The DES thromboses in randomized trials could not be comparable to those observed in clinical practice, frequently including off-label indications. METHODS: We designed a large-scale, nonindustry-linked multicentered registry, with 20 centers in Spain. The participant centers provided follow-up data for their patients treated with DES, reporting a detailed standardized form in the event of any angiography-documented DES-associated thrombosis occurring. RESULTS: Of 23,500 patients treated with DES, definite stent thrombosis(ST) developed in 301: 24 acute, 125 subacute, and 152 late. Of the late, 62 occurred >1 year(very late ST). The cumulative incidence was 2% at 3 years. Antiplatelet treatment had been discontinued in 95 cases(31.6%). No differences in incidences were found among stent types. Independent predictors for subacute ST analyzed in a subgroup of 14,120 cases were diabetes, renal failure, acute coronary syndrome, ST-segment elevation myocardial infarction, stent length, and left anterior descending artery stenting, and for late ST were ST-segment elevation myocardial infarction, stenting in left anterior descending artery, and stent length. Mortality at 1-year follow-up was 16% and ST recurrence 4.6%. Older age, left ventricular ejection fraction <45%, nonrestoration of Thrombolysis In Myocardial Infarction flow grade 3, and additional stenting were independent predictors for mortality. CONCLUSIONS: The cumulative incidence of ST after DES implantation was 2% at 3 years. No differences were found among stent types. Patient profiles differed between early and late ST. Short-term prognosis is poor, especially when restoration of normal flow fails.

[The importance of investigating the internal thoracic artery before coronary artery surgery in Leriche's syndrome]. / Importancia del sondaje de la arteria mamaria antes de cirugía coronaria en el síndrome de Leriche.

Frequently, both peripheral and coronary artery disease are present in the same patient. In patients with abdominal aortic occlusion (i.e., Leriche's syndrome) or femoroiliac occlusion, collateral circulation to the lower extremities can originate in branches of the abdominal aorta or even in the internal thoracic artery (depending on the level of the occlusion). It is important to identify the origin of this circulation during diagnostic procedures, especially in patients who may need to undergo coronary revascularization surgery since, in cases where the majority of the collateral circulation originates in the internal thoracic artery, using the artery as a coronary graft could lead to acute ischemia of the lower extremities. We present three patients with Leriche's syndrome in whom the internal thoracic artery was the origin of the collateral circulation to the ipsilateral femoral artery.

Importancia del sondaje de la arteria mamaria antes de cirugía coronaria en el síndrome de Leriche / The importance of investigating the internal thoracic artery before coronary artery surgery in Leriche's syndrome

La enfermedad arterial periférica y la enfermedad coronaria frecuentemente coexisten en un mismo paciente. En los pacientes con oclusión de la aorta abdominal (síndrome de Leriche) o del eje femoroiliaco, la circulación colateral a extremidades inferiores puede originarse en ramas de la aorta abdominal o incluso en la arteria mamaria interna (en función del grado de la oclusión). Es importante filiar, durante el procedimiento diagnóstico, el origen de esta circulación, especialmente en los pacientes que pueden necesitar revascularización coronaria quirúrgica, ya que en los casos con circulación colateral procedente en su mayoría de la arteria mamaria interna, su uso como injerto coronario puede ocasionar isquemia aguda en las extremidades inferiores. Presentamos los casos de 3 pacientes con síndrome de Leriche y circulación colateral desde las arterias mamarias a las femorales homolaterales (AU)

Frequently, both peripheral and coronary artery disease are present in the same patient. In patients with abdominal aortic occlusion (i.e., Leriche's syndrome) or femoroiliac occlusion, collateral circulation to the lower extremities can originate in branches of the abdominal aorta or even in the internal thoracic artery (depending on the level of the occlusion). It is important to identify the origin of this circulation during diagnostic procedures, especially in patients who may need to undergo coronary revascularization surgery since, in cases where the majority of the collateral circulation originates in the internal thoracic artery, using the artery as a coronary graft could lead to acute ischemia of the lower extremities. We present three patients with Leriche's syndrome in whom the internal thoracic artery was the origin of the collateral circulation to the ipsilateral femoral artery (AU)

[Does intracoronary abciximab improve the outcome of percutaneous coronary interventions? A randomized controlled trial]. / 'Mejora el uso de abciximab intracoronario el resultado del intervencionismo percutáneo? Estudio prospectivo y aleatorizado.

INTRODUCTION AND OBJECTIVES: It has been clearly demonstrated that abciximab is useful in percutaneous coronary interventions. However, it is not known if intracoronary administration of the initial abciximab bolus improves outcome. Moreover, there may be safety concerns. METHODS: The study was a single-center prospective randomized trial that included all patients undergoing coronary angioplasty involving the use of abciximab. Patients were randomized to either intracoronary or intravenous administration of the abciximab bolus. The primary endpoint was the incidence of major adverse cardiac events (i.e., death, myocardial infarction, or the need for revascularization); secondary endpoints were hemorrhagic complications and the troponin-I level. RESULTS: The study included 137 patients; 72 received an intracoronary abciximab bolus and 65, an intravenous bolus. Clinical characteristics and baseline angiographic findings were similar in the two groups. All patients underwent coronary stent implantation. No difference was observed between the intracoronary bolus group and the intravenous bolus group in type of stent used (drug eluting stent 47.2% vs 50.8%, respectively), total stent length, or final TIMI flow grade (3 vs 2.97, respectively). The intervention success rates were also similar (98.5% vs. 99%, respectively). No complication associated with the administration route was reported. However, the level of the myocardial injury marker troponin I increased significantly in the intravenous bolus group. Clinical follow-up at 1 year did not reveal any difference in the incidence of major adverse cardiac events: 8.5% in the intracoronary bolus group versus 6.2% in the intravenous bolus group. CONCLUSIONS: Intracoronary administration of an abciximab bolus did not appear to be less safe or effective than intravenous administration. Less post-procedural myocardial damage was observed in the intracoronary bolus group.

¿Mejora el uso de abciximab intracoronario el resultado del intervencionismo percutáneo? Estudio prospectivo y aleatorizado / Does intracoronary abciximab improve the outcome of percutaneous coronary interventions? A randomized controlled trial

Introducción y objetivos. La utilidad del abciximab en el intervencionismo coronario percutáneo se ha demostrado plenamente. Sin embargo, se desconoce si la administración intracoronaria del bolo inicial puede aportar ventajas. Igualmente, podría haber dudas acerca de su seguridad. Métodos. Estudio en un solo centro, prospectivo y aleatorizado, en el que se incluyó a todos los pacientes en los que se realizó un intervencionismo coronario percutáneo con abciximab. Se aleatorizó a los pacientes para recibir un bolo de abciximab (ABX) intracoronario o intravenoso. Se analizaron la incidencia de MACE (muerte, reinfarto y necesidad de revascularización) como variable principal y las complicaciones hemorrágicas y las concentraciones de troponina I como variables secundarias. Resultados. Se incluyó a 137 pacientes (72 con ABX intracoronario y 65 con ABX intravenoso). Las características clínicas y los hallazgos angiográficos fueron similares en ambos grupos. Todos recibieron stents. No hubo diferencias en el tipo de stent utilizado (recubierto activo del 47,2 frente al 50,8%), la longitud total del stent y el flujo TIMI final (3 frente a 2,97). Los resultados del intervencionismo coronario percutáneo fueron similares: se realizó con éxito en el 98,5% de los pacientes del grupo ABX intracoronario y en el 99% del grupo ABX intravenoso. No se detectaron complicaciones derivadas de la vía de administración. En el grupo ABX intravenoso se observó una elevación significativa posprocedimiento de la troponina I. En el seguimiento clínico al año no se hallaron diferencias significativas en la incidencia de MACE (el 8,5% en el grupo ABX intracoronario frente al 6,2% en el grupo ABX intravenoso). Conclusiones. La administración intracoronaria del bolo de abciximab no parece menos segura que la intravenosa y es, al menos, igualmente eficaz. Se observó un menor grado de daño miocárdico posprocedimiento en el grupo ABX intracoronario

Introduction and objectives. It has been clearly demonstrated that abciximab is useful in percutaneous coronary interventions. However, it is not known if intracoronary administration of the initial abciximab bolus improves outcome. Moreover, there may be safety concerns. Methods. The study was a single-center prospective randomized trial that included all patients undergoing coronary angioplasty involving the use of abciximab. Patients were randomized to either intracoronary or intravenous administration of the abciximab bolus. The primary endpoint was the incidence of major adverse cardiac events (i.e., death, myocardial infarction, or the need for revascularization); secondary endpoints were hemorrhagic complications and the troponin-I level. Results. The study included 137 patients; 72 received an intracoronary abciximab bolus and 65, an intravenous bolus. Clinical characteristics and baseline angiographic findings were similar in the two groups. All patients underwent coronary stent implantation. No difference was observed between the intracoronary bolus group and the intravenous bolus group in type of stent used (drug eluting stent 47.2% vs 50.8%, respectively), total stent length, or final TIMI flow grade (3 vs 2.97, respectively). The intervention success rates were also similar (98.5% vs. 99%, respectively). No complication associated with the administration route was reported. However, the level of the myocardial injury marker troponin I increased significantly in the intravenous bolus group. Clinical follow-up at 1 year did not reveal any difference in the incidence of major adverse cardiac events: 8.5% in the intracoronary bolus group versus 6.2% in the intravenous bolus group. Conclusions. Intracoronary administration of anabciximab bolus did not appear to be less safe or effective than intravenous administration. Less postprocedural myocardial damage was observed in the intracoronary bolus group