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)

Healthcare Professionals' Perspectives on the Implementation of the Integrated Care Models for Chronic Patients.

Objective This study aimed to assess the understanding, adoption, and barriers to implementing integrated care for chronic diseases among healthcare professionals in Greece. By gathering insights from healthcare professionals directly involved in the care of patients with chronic conditions, this study sought to identify areas for improvement and inform future policy and strategic initiatives to enhance the quality of care and patient outcomes in Greece. Specific objectives included assessing healthcare professionals' knowledge and understanding of integrated care concepts, principles, and components in chronic disease management and exploring healthcare professionals' experiences in providing or participating in integrated care activities for patients with chronic diseases. Methods This study employed a census-based survey design to assess healthcare professionals' understanding, adoption, and barriers to the implementation of integrated care for chronic diseases in the Greek healthcare system. The sampling technique has been used to ensure the representation of different healthcare professions and regions in Greece. The survey questionnaire was structured based on the internationally recognized Chronic Care Model Elements Survey, specifically tailored to capture insights on integrated care for chronic illnesses in Greece. Healthcare professionals from diverse settings, including primary healthcare centers, public and private hospitals, specialty clinics, rehabilitation centers, home-based care services, and private sector practitioners, were targeted to gather comprehensive perspectives. Both urban and rural areas were included to ensure a representative sample, enabling an understanding of integrated care implementation in Greece. Results A total of 246 responses from healthcare professionals in Greece were collected and analyzed. An applicability index was constructed to evaluate the suitability of the integrated care system in Greece, utilizing variables collected during the survey. The reliability of the index was assessed using Cronbach's Alpha coefficient, which demonstrated a high value of 0.940, indicating strong internal consistency and correlation among the questions related to integrated care. However, the data collected for Greece exhibited a departure from a normal distribution using the Shapiro-Wilk test, suggesting the presence of barriers to the implementation of integrated care within the Greek healthcare system. Conclusions The study revealed several obstacles to integrated care implementation, encompassing organizational and individual factors, such as financial constraints, cultural differences, and regulatory challenges. Tackling these barriers will require a collective approach and close collaboration among multiple stakeholders to create an enabling context for adopting integrated care. Possible strategies involve resource allocation, fostering communication and cooperation among healthcare providers, and revising regulatory frameworks to facilitate integrated care practices. In order to achieve the national objectives of improving public health, the survey increases the focus on evidence-based public health.

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.

Rationale and design of a prospective, observational study for the QUantitative EStimation of Thrombus burden in patients with ST-Elevation Myocardial Infarction using micro-computed tomography: the QUEST-STEMI trial.

BACKGROUND: Although the presence of thrombus in patients with ST-elevation myocardial infarction (STEMI) has been linked to adverse outcomes, routine thrombus aspiration has not been proven effective. A potential explanation is that these patients should be risk-stratified. Traditional clinical, laboratory and angiographic parameters used in clinical trials have been proven inadequate to classify patients. Aspirated thrombotic material characteristics might be an additional important parameter that has not yet been addressed. In this report, we aim to describe a methodological analysis of thrombus aspirated from coronary arteries during primary PCI using micro-Computed Τomography (micro-CT). These data will be combined with traditional factors to develop a risk-stratification system with high discriminative power for these patients. METHODS: Eighty-seven patients with STEMI undergoing thrombus aspiration in AHEPA University Hospital, Greece, will be enrolled in the study. The first patient was enrolled in June 2018. After being aspirated, thrombi are preserved in formalin and their volume and density are calculated with micro-CT. Micro-CT allows us to create 3D models of thrombi from a series of x-ray projection images. These models are further analyzed to find the volume and density of extracted thrombi and to assess potential differences in their structure. Association of these variables with clinical parameters and angiographic outcomes will be explored. DISCUSSION: QUEST-STEMI is-to our knowledge-the first study of volumetric coronary thrombus assessment by micro-CT. This method could be used in larger, clinically-oriented trials to help stratify patients with thrombus burden according to their risk for adverse outcomes. TRIAL REGISTRATION: QUEST-STEMI trial ClinicalTrials.gov number: NCT03429608 Date of registration: February 12, 2018. The study was prospectively registered (registered prior to enrollment of the first participant).

Percutaneous recanalisation of chronic total occlusions: 2019 consensus document from the EuroCTO Club.

Since its inception in December 2006, the EuroCTO Club has strived to provide the framework for state-of-the-art chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in Europe and nearby regions. Among its initiatives, the EuroCTO Club has published a set of recommendations regarding the technical aspects of CTO PCI, whose last edition dates to 2012. The EuroCTO Club consensus document discusses CTO PCI clinical indications, techniques and equipment use, as well as the qualifications of operators/centres. Given the considerable amount of progress made by this subspecialty in recent years, there is a need for an updated document that includes data from recent clinical trials and registries, information on novel devices and techniques, and an up-to-date revision on the training requirements to approach CTO PCI. The current updated consensus document of the EuroCTO Club reflects the expertise of European operators to promote the widespread application of state-of-the-art CTO PCI, not only in Europe but also across neighbouring communities.

Temporal Trends in Chronic Total Occlusion Interventions in Europe.

BACKGROUND: The study focuses on the evolution of practice, procedural outcomes, and in-hospital complications of chronic total occlusion percutaneous coronary intervention in Europe. METHODS AND RESULTS: Data from 17 626 procedures enrolled in European Registry of Chronic Total Occlusion between January 2008 and June 2015 were assessed. The mean patient age was 63.9±10.9 years; 85% were men. Procedural success increased from 79.7% to 89.3% through the study period. Patients enrolled during the years had increasing comorbidities and lesion complexity (J-CTO score [Multicenter CTO Registry of Japan] increased from 1.76±1.03 in 2008 to 2.17±0.91 in 2015; P for trend, <0.001). Retrograde approach utilization steadily increased from 10.1% in 2008 to 29.9% in 2015 ( P for trend, <0.001). Antegrade dissection reentry adoption was low, not exceeding 5.5%. In-hospital mortality decreased during the study period from 0.4% to 0.1% ( P for trend, <0.001), whereas in-hospital complication rates remained essentially unchanged, in the range 4.4% to 5.2% ( P for trend, 0.390). CONCLUSIONS: Chronic total occlusion percutaneous coronary intervention has shown a steady increase in procedural success rate over time, with unchanged complication rates, despite the increasing complexity of the lesions attempted. The J-CTO score predictive value for procedural success was low for the entire registry and had no predictive ability for the retrograde approach.

Theory and practical based approach to chronic total occlusions.

Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90%, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries.

Thrombus aspiration in primary angioplasty for ST-segment elevation myocardial infarction.

Mechanical reperfusion with primary percutaneous coronary intervention in acute ST-segment-elevation myocardial infarction is superior to fibrinolysis in terms of short-term and long-term outcome, provided that it can be delivered on time and by an experienced team. Balloon angioplasty and stent implantation of an occluded epicardial vessel during ST-segment-elevation myocardial infarction can cause disruption of the frail thrombus containing lesions associated with suboptimal myocardial reperfusion and microcirculatory obstruction. Distal embolization of atherothrombotic material can be prevented by thrombus aspiration during primary angioplasty. Mechanical aspiration via end-hole large-lumen thrombectomy catheters has been shown to improve Thrombolysis in Myocardial Infarction (TIMI) flow and result in a more consistent early resolution of ST-segment elevation in multiple registries. More recently, a more sophisticated quantification of the myocardial damage has been applied using myocardial scintigraphy and magnetic resonance, with no difference between patients treated with thrombectomy and patients treated with conventional therapy. The expectations in terms of lasting mortality benefit raised by the first Dutch single-center randomized trial of thrombectomy versus predilation with plain old balloon angioplasty (Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction, TAPAS) were not confirmed by a much larger Swedish trial (Thrombus Aspiration ST-Segment Elevation Myocardial Infarction, TASTE) showing no outcome changes. Although we are waiting for new trials to clarify these controversial results, thrombectomy is still used in selected patients with high thrombus load or with persistent occlusion of the infarct-related artery after wire passage. Here we review the various systems available and discuss their relative merits and the reported results.

Double Chronic Total Occlusion Recanalisation with Antegrade and Retrograde Techniques and the Use of a Novel Drug-eluting Stent with Biodegradable Polymer.

Percutaneous recanalisation of coronary chronic total occlusions (CTOs) has proved an efficient and safe treatment option with steadily ascending success rates, especially since the advent and constant refinement of the retrograde approach. Uptake remains low, even though experienced operators have in the last five years reached an unprecedented maturity level, producing success rates in the range of 90 %, clearly comparable to non-occlusive coronary artery disease treatment. Antegrade and retrograde techniques are currently considered complementary components of a CTO procedure, rather than discrete treatment strategies. We report on the case of a successful CTO recanalisation procedure on a young patient with two chronically occluded coronary arteries and a large ischaemic burden. Both CTOs were addressed in the same session employing a range of dedicated CTO recanalisation techniques, without compromising on safety issues related to contrast dye consumption and radiation exposure. A novel drug-eluting stent (DES) with biodegradable polymer was used to treat the lesions.